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Effect of Pharmacy-Supported Transition-of-Care Interventions on 30-Day Readmissions: A Systematic Review and Meta-analysis.

Joe Martin, MD - Wed, 01/30/2019 - 08:23
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Effect of Pharmacy-Supported Transition-of-Care Interventions on 30-Day Readmissions: A Systematic Review and Meta-analysis.

Ann Pharmacother. 2017 Oct;51(10):866-889

Authors: Rodrigues CR, Harrington AR, Murdock N, Holmes JT, Borzadek EZ, Calabro K, Martin J, Slack MK

Abstract
OBJECTIVE: To describe pharmacy-supported transition-of-care (TOC) interventions and determine their effect on 30-day all-cause readmissions.
DATA SOURCES: MEDLINE/PubMed, EMBASE, International Pharmaceutical Abstracts, ABI Inform Complete, PsychINFO, Web of Science, Academic Search Complete, CINHAL, Cochrane library, OIASTER, ProQuest Dissertations & Theses, ClinicalTrials.gov , and relevant websites were searched from January 1, 1995, to December 31, 2015.
STUDY SELECTION AND DATA EXTRACTION: PICOS+E criteria were utilized. Eligible studies reported pharmacy-supported TOC interventions compared with usual care in adult patients discharged to home within the United States. Studies were required to evaluate postdischarge outcomes (eg, rate of readmissions, hospital utilization). Randomized controlled trials, cohort studies, or controlled before-and-after studies were included. Two reviewers independently extracted data and evaluated study quality.
DATA SYNTHESIS: A total of 56 articles were included in the systematic review (n = 61 858), of which 32 reported 30-day all-cause readmissions and were included in the meta-analysis. A taxonomy was developed to categorize targeted patients, intervention types, and pharmacy personnel as sole intervener. The meta-analysis demonstrated about a 32% reduction in the odds of readmission (odds ratio [OR] = 0.68; 95% CI = 0.61 to 0.75) observed for pharmacy-supported TOC interventions compared with usual care. Heterogeneity was identified ( I2 = 55%; P < 0.001). A stratified meta-analysis showed that interventions with patient-centered follow-up reduced 30-day readmissions relative to studies without follow-up (OR = 0.70; CI = 0.63 to 0.78).
CONCLUSIONS: Pharmacy-supported TOC programs were associated with a significant reduction in the odds of 30-day readmissions.

PMID: 28599601 [PubMed - indexed for MEDLINE]

Unifying interdisciplinary education: designing and implementing an intern simulation educational curriculum to increase confidence in critical care from PGY1 to PGY2.

Jo Leuck - Wed, 01/30/2019 - 08:23
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Unifying interdisciplinary education: designing and implementing an intern simulation educational curriculum to increase confidence in critical care from PGY1 to PGY2.

BMC Res Notes. 2017 Nov 06;10(1):563

Authors: Bullard MJ, Leuck JA, Howley LD

Abstract
BACKGROUND: A longitudinal, multidisciplinary critical care simulation curriculum was developed and implemented within a teaching hospital to address the need for consistent, safe, efficient, and unified critical care training within graduate medical education. Primary goals were to increase learner confidence in critical care topics and procedural skills across all specialties. Secondary goals included improving communication skills and obtaining a high level of learner satisfaction. All interns caring for adult patients within our hospital participated in three 4-h simulation-based sessions scheduled over the second half of their intern year. Pre- and postcurricular surveys evaluated self-confidence in critical care topics, procedures, and communication skills. The Debriefing Assessment for Simulation in Healthcare Student Version (DASH-SV) Short Form was used to evaluate facilitator debriefing. Data were compared with Wilcoxon rank sum and signed rank test.
RESULTS: Pre- and postcurricular surveys were collected from 51 of 52 interns (98% response rate) in curricular year 1 and 59 of 59 interns (100% response rate) in curricular year 2 in six programs within the hospital. Resident confidence significantly improved in all areas (p < .05). DASH-SV demonstrated overall effective facilitator debriefing and > 75% of interns in both curricular years 1 and 2 expressed a desire for future educational sessions.
CONCLUSIONS: The implemented curriculum increased learner confidence in select critical care topics, procedures, and communication skills and demonstrated a high level of learner satisfaction. The curriculum has expanded to learners from three other teaching hospitals within our system to unify critical care education for all interns caring for adult patients.

PMID: 29110695 [PubMed - indexed for MEDLINE]

The role of patient perception of crowding in the determination of real-time patient satisfaction at Emergency Department.

Jo Leuck - Wed, 01/30/2019 - 08:23
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The role of patient perception of crowding in the determination of real-time patient satisfaction at Emergency Department.

Int J Qual Health Care. 2017 Oct 01;29(5):722-727

Authors: Wang H, Kline JA, Jackson BE, Robinson RD, Sullivan M, Holmes M, Watson KA, Cowden CD, Phillips JL, Schrader CD, Leuck J, Zenarosa NR

Abstract
Objective: To evaluate the associations between real-time overall patient satisfaction and Emergency Department (ED) crowding as determined by patient percepton and crowding estimation tool score in a high-volume ED.
Design: A prospective observational study.
Setting: A tertiary acute hospital ED and a Level 1 trauma center.
Participants: ED patients.
Intervention(s): Crowding status was measured by two crowding tools [National Emergency Department Overcrowding Scale (NEDOCS) and Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool (SONET)] and patient perception of crowding surveys administered at discharge.
Main outcome measure(s): ED crowding and patient real-time satisfaction.
Results: From 29 November 2015 through 11 January 2016, we enrolled 1345 participants. We observed considerable agreement between the NEDOCS and SONET assessment of ED crowding (bias = 0.22; 95% limits of agreement (LOAs): -1.67, 2.12). However, agreement was more variable between patient perceptions of ED crowding with NEDOCS (bias = 0.62; 95% LOA: -5.85, 7.09) and SONET (bias = 0.40; 95% LOA: -5.81, 6.61). Compared to not overcrowded, there were overall inverse associations between ED overcrowding and patient satisfaction (Patient perception OR = 0.49, 95% confidence limit (CL): 0.38, 0.63; NEDOCS OR = 0.78, 95% CL: 0.65, 0.95; SONET OR = 0.82, 95% CL: 0.69, 0.98).
Conclusions: While heterogeneity exists in the degree of agreement between objective and patient perceived assessments of ED crowding, in our study we observed that higher degrees of ED crowding at admission might be associated with lower real-time patient satisfaction.

PMID: 28992161 [PubMed - indexed for MEDLINE]

Optimal Measurement Interval for Emergency Department Crowding Estimation Tools.

Jo Leuck - Wed, 01/30/2019 - 08:23
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Optimal Measurement Interval for Emergency Department Crowding Estimation Tools.

Ann Emerg Med. 2017 Nov;70(5):632-639.e4

Authors: Wang H, Ojha RP, Robinson RD, Jackson BE, Shaikh SA, Cowden CD, Shyamanand R, Leuck J, Schrader CD, Zenarosa NR

Abstract
STUDY OBJECTIVE: Emergency department (ED) crowding is a barrier to timely care. Several crowding estimation tools have been developed to facilitate early identification of and intervention for crowding. Nevertheless, the ideal frequency is unclear for measuring ED crowding by using these tools. Short intervals may be resource intensive, whereas long ones may not be suitable for early identification. Therefore, we aim to assess whether outcomes vary by measurement interval for 4 crowding estimation tools.
METHODS: Our eligible population included all patients between July 1, 2015, and June 30, 2016, who were admitted to the JPS Health Network ED, which serves an urban population. We generated 1-, 2-, 3-, and 4-hour ED crowding scores for each patient, using 4 crowding estimation tools (National Emergency Department Overcrowding Scale [NEDOCS], Severely Overcrowded, Overcrowded, and Not Overcrowded Estimation Tool [SONET], Emergency Department Work Index [EDWIN], and ED Occupancy Rate). Our outcomes of interest included ED length of stay (minutes) and left without being seen or eloped within 4 hours. We used accelerated failure time models to estimate interval-specific time ratios and corresponding 95% confidence limits for length of stay, in which the 1-hour interval was the reference. In addition, we used binomial regression with a log link to estimate risk ratios (RRs) and corresponding confidence limit for left without being seen.
RESULTS: Our study population comprised 117,442 patients. The time ratios for length of stay were similar across intervals for each crowding estimation tool (time ratio=1.37 to 1.30 for NEDOCS, 1.44 to 1.37 for SONET, 1.32 to 1.27 for EDWIN, and 1.28 to 1.23 for ED Occupancy Rate). The RRs of left without being seen differences were also similar across intervals for each tool (RR=2.92 to 2.56 for NEDOCS, 3.61 to 3.36 for SONET, 2.65 to 2.40 for EDWIN, and 2.44 to 2.14 for ED Occupancy Rate).
CONCLUSION: Our findings suggest limited variation in length of stay or left without being seen between intervals (1 to 4 hours) regardless of which of the 4 crowding estimation tools were used. Consequently, 4 hours may be a reasonable interval for assessing crowding with these tools, which could substantially reduce the burden on ED personnel by requiring less frequent assessment of crowding.

PMID: 28688771 [PubMed - indexed for MEDLINE]

Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions.

Jo Leuck - Wed, 01/30/2019 - 08:23
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Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions.

BMC Health Serv Res. 2016 10 10;16(1):564

Authors: Wang H, Johnson C, Robinson RD, Nejtek VA, Schrader CD, Leuck J, Umejiego J, Trop A, Delaney KA, Zenarosa NR

Abstract
BACKGROUND: Risks prediction models of 30-day all-cause hospital readmissions are multi-factorial. Severity of illness (SOI) and risk of mortality (ROM) categorized by All Patient Refined Diagnosis Related Groups (APR-DRG) seem to predict hospital readmission but lack large sample validation. Effects of risk reduction interventions including providing post-discharge outpatient visits remain uncertain. We aim to determine the accuracy of using SOI and ROM to predict readmission and further investigate the role of outpatient visits in association with hospital readmission.
METHODS: Hospital readmission data were reviewed retrospectively from September 2012 through June 2015. Patient demographics and clinical variables including insurance type, homeless status, substance abuse, psychiatric problems, length of stay, SOI, ROM, ICD-10 diagnoses and medications prescribed at discharge, and prescription ratio at discharge (number of medications prescribed divided by number of ICD-10 diagnoses) were analyzed using logistic regression. Relationships among SOI, type of hospital visits, time between hospital visits, and readmissions were also investigated.
RESULTS: A total of 6011 readmissions occurred from 55,532 index admissions. The adjusted odds ratios of SOI and ROM predicting readmissions were 1.31 (SOI: 95 % CI 1.25-1.38) and 1.09 (ROM: 95 % CI 1.05-1.14) separately. Ninety percent (5381/6011) of patients were readmitted from the Emergency Department (ED) or Urgent Care Center (UCC). Average time interval from index discharge date to ED/UCC visit was 9 days in both the no readmission and readmission groups (p > 0.05). Similar hospital readmission rates were noted during the first 10 days from index discharge regardless of whether post-index discharge patient clinic visits occurred when time-to-event analysis was performed.
CONCLUSIONS: SOI and ROM significantly predict hospital readmission risk in general. Most readmissions occurred among patients presenting for ED/UCC visits after index discharge. Simply providing early post-discharge follow-up clinic visits does not seem to prevent hospital readmissions.

PMID: 27724889 [PubMed - indexed for MEDLINE]

A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients.

Jo Leuck - Wed, 01/30/2019 - 08:23
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A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients.

J Clin Med Res. 2016 Aug;8(8):591-7

Authors: Wang H, Umejiego J, Robinson RD, Schrader CD, Leuck J, Barra M, Buca S, Shedd A, Bui A, Zenarosa NR

Abstract
BACKGROUND: There is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated.
METHODS: Local trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data.
RESULTS: A total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05).
CONCLUSIONS: An early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation.

PMID: 27429680 [PubMed]

Measuring Provider Compliance with an Institution-Based Clinical Pathway for Diverticulitis Using Radiologic Criteria.

Jeffrey Tessier, MD - Wed, 01/30/2019 - 08:22
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Measuring Provider Compliance with an Institution-Based Clinical Pathway for Diverticulitis Using Radiologic Criteria.

Surg Infect (Larchmt). 2018 Oct;19(7):655-660

Authors: Gonzalez G, Montemayor E, Sanders JM, Burton M, Tessier JM, Duane TM

Abstract
BACKGROUND: Diverticulitis remains a common disease encountered in the acute care setting. Management strategies have been developed to guide treatment decisions based on imaging. By using a multi-faceted clinical pathway approach, a standardized method of diagnosing and categorizing disease severity can be performed in order to guide appropriate management. This study evaluated provider compliance with an institutional clinical pathway designed to guide management of diverticulitis.
METHODS: An institutional clinical pathway was developed to manage diverticulitis, including radiologic classification, primary service line assignment, interventional strategies, and antimicrobial treatment. To assess provider compliance with the algorithm, we queried the institutional acute diverticulitis database for patients admitted from May 19, 2016 to February 8, 2017, which identified 83 patients. Provider compliance with the pathway was assessed using subgroup analysis of radiologic documentation (modified Neff [mNeff] classification), primary service assignment, and interventions (i.e., interventional radiology [IR] and antimicrobial agents).
RESULTS: The cohort represented a diverse group of mNeff classifications, predominantly Stage 0. Surgical interventions occurred in 10.8% of the cohort. Antimicrobial agents were administered to 88.0% and 78.3% of the outpatients and inpatients, respectively. Patients received a total duration of antimicrobial therapy (mean ± standard deviation [SD]) of 10.2 ± 5.1 days. Overall compliance occurred in 10% of the patients. Compliance with radiologic documentation, antimicrobial choice, and antimicrobial duration were 90.4%, 20.5%, and 69.9%, respectively.
CONCLUSIONS: Overall compliance with the clinical pathway was poor, except as it related to compliance with radiologic documentation, appropriate assignment to surgical service line, and antimicrobial duration. These results suggest areas for future improvement to augment compliance with the clinical pathway.

PMID: 30179571 [PubMed - indexed for MEDLINE]

Construct and concurrent validity of the Dementia Rating Scale-2 Alternate Form.

Janet Lieto, DO - Wed, 01/30/2019 - 08:21
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Construct and concurrent validity of the Dementia Rating Scale-2 Alternate Form.

J Clin Exp Neuropsychol. 2006 Jul;28(5):646-54

Authors: Schmidt KS, Lieto JM, Kiryankova E, Salvucci A

Abstract
The Dementia Rating Scale-2: Alternate Form (DRS-2: AF) was developed by Schmidt (2004) for use in serial neuropsychological assessments with the original DRS-2 (Jurica, Leitten, & Mattis, 2001). Results from two preliminary validation studies of the DRS-2: AF are presented here. In Study 1, the DRS-2: AF and four additional neuropsychological measures were administered to 49 healthy, community-dwelling participants without dementia; convergent and discriminant correlational analyses provide evidence for the construct validity of four DRS-2: AF subscales (Attention, Initiation/ Perseveration, Conceptualization, Memory). In Study 2, the DRS-2: AF and Mini-Mental State Examination (MMSE) were administered to a sample of 65 residents living in a continuing care retirement community (30 residents with dementia, 35 residents without dementia) to demonstrate the construct and concurrent validity of the DRS-2: AF Total Score. A strong correlation was found between the MMSE and DRS-2: AF Total Score. When DRS-2: AF Total Scores were subjected to a discriminant function analysis, Total Scores accurately classified 61 of the 65 participants into the appropriate patient group (dementia vs. comparison). The results of these preliminary validation studies are robust, and suggest that the DRS-2: AF may be a useful measure when serial assessments with the DRS-2 are needed.

PMID: 16723314 [PubMed - indexed for MEDLINE]

Validity of the Medication Administration Test among older adults with and without dementia.

Janet Lieto, DO - Wed, 01/30/2019 - 08:21
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Validity of the Medication Administration Test among older adults with and without dementia.

Am J Geriatr Pharmacother. 2005 Dec;3(4):255-61

Authors: Schmidt KS, Lieto JM

Abstract
BACKGROUND: Impairments in everyday activities (ie, using the telephone, driving, managing medication) have been associated with increasing age as well as dementia severity. One of the initial functional losses among older adults both with and without dementia is impaired medication self-management skills. In fact, reduced ability to self administer medication has been identified as a significant predictor of an assisted living (AL) placement (vs an independent living [IL] placement) among older adults. We recently developed a Medication Administration Test (MAT) to aid in placement decisions regarding level of care (eg, IL, AL).
OBJECTIVE: The purpose of this study was to examine the construct and concurrent validity of the MAT in a sample of older adults residing in a continuing care retirement facility.
METHODS: IL and AL participants were administered the MAT along with a brief neuropsychological battery that included the Naturalistic Action Test, the Mini-Mental State Examination, and the Instrumental Activities of Daily Living scale. The construct validity of the MAT was assessed by correlating MAT scores with the other neuropsychological instruments of cognition and function. With respect to the MAT's concurrent validity, a discriminant function analysis was run to determine the classification accuracy (IL vs AL) of the newly developed MAT.
RESULTS: Sixty-two white participants were included in the study (mean age, 85.56 years); 34 participants were residing in an AL setting and 28 were residing in an IL setting. Evidence for construct validity was relatively robust, as performance on the MAT was moderately correlated with scores on the Mini-Mental State Examination, the Naturalistic Action Test, and the Instrumental Activities of Daily Living scale. When MAT scores were subjected to a discriminant function analysis to assess concurrent validity, MAT performance accurately classified 79.03% of the participants into the appropriate level of care (IL or AL).
CONCLUSION: This project provides preliminary evidence for the validity of the MAT when used for placement decisions within continuing care retirement communities. Given the current need for objective measures to aid in level of care decision making, the MAT may be useful in both clinical and research arenas.

PMID: 16503321 [PubMed - indexed for MEDLINE]

Reduced ability to self-administer medication is associated with assisted living placement in a continuing care retirement community.

Janet Lieto, DO - Wed, 01/30/2019 - 08:21
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Reduced ability to self-administer medication is associated with assisted living placement in a continuing care retirement community.

J Am Med Dir Assoc. 2005 Jul-Aug;6(4):246-9

Authors: Lieto JM, Schmidt KS

Abstract
OBJECTIVE: To examine whether reduced ability to self-administer medication can accurately classify living placement (independent or assisted living) in a continuing care retirement community (CCRC).
DESIGN: Convenience sample of consecutive patients seen in a medical clinic.
SETTING: An outpatient medical clinic at a CCRC.
PARTICIPANTS: A group of 78 consecutive patients (aged 68-98 years) scheduled for a geriatric medical evaluation between May 1, 2001, and August 31, 2001, residing in an independent (IL) or assisted living (AL) apartment.
MEASUREMENTS: Ability to self-administer medication was assessed by asking residents to respond to a medication administration question based on a 5-point Likert scale. Residents were also given measures of cognitive status (MMSE), activities of daily living (ADL), and depression (GDS). Further, age of residents as well as number of falls within the previous 6 months were recorded.
RESULTS: A discriminant function analysis accurately classified living placement (IL or AL) in 89.7% of the cases based on the ability of residents to self-administer medication. The additions of MMSE score, ADL performance, GDS score, number of falls, and age of the residents to the analyses did not improve the number of cases that were correctly classified.
CONCLUSION: Ability to self-administer medication emerged as the main predictor of current living environment within the CCRC in the present study. These results underscore the importance of considering a resident's ability to independently manage his or her medications when placement decisions are being made within CCRCs.

PMID: 16005410 [PubMed - indexed for MEDLINE]

Utilizing the Dementia Rating Scale-2 Alternate Form to differentiate independent and assisted living in a continuing care retirement community.

Janet Lieto, DO - Wed, 01/30/2019 - 08:21
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Utilizing the Dementia Rating Scale-2 Alternate Form to differentiate independent and assisted living in a continuing care retirement community.

J Am Osteopath Assoc. 2005 Jan;105(1):23-4

Authors: Kiryankova E, Schmidt K, Lieto JM

PMID: 15710667 [PubMed - indexed for MEDLINE]

Lymphatic pump treatment augments lymphatic flux of lymphocytes in rats.

Jamie Huff, DO - Wed, 01/30/2019 - 08:21
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Lymphatic pump treatment augments lymphatic flux of lymphocytes in rats.

Lymphat Res Biol. 2010 Dec;8(4):183-7

Authors: Huff JB, Schander A, Downey HF, Hodge LM

Abstract
BACKGROUND: Lymphatic pump techniques (LPT) are used by osteopathic practitioners for the treatment of edema and infection; however, the mechanisms by which LPT enhances the lymphatic and immune systems are poorly understood.
METHODS AND RESULTS: To measure the effect of LPT on the rat, the cisterna chyli (CC) of 10 rats were cannulated and lymph was collected during 4 min of 1) pre-LPT baseline, 2) 4 min LPT, and 3) 10 min post-LPT recovery. LPT increased significantly (p < 0.05) lymph flow from a baseline of 24 ± 5 μl/min to 89 ± 30 μl/min. The baseline CC lymphocyte flux was 0.65 ± 0.21 × 10⁶ lymphocytes/min, and LPT increased CC lymphocyte flux to 6.10 ± 0.99 × 10⁶ lymphocytes/min (p < 0.01). LPT had no preferential effect on any lymphocyte population, since total lymphocytes, CD4+ T cells, CD8+ T cells, and B cell numbers were similarly increased. To determine if LPT mobilized gut-associated lymphocytes into the CC lymph, gut-associated lymphocytes in the CC lymph were identified by staining CC lymphocytes for the gut homing receptor integrin α4β7. LPT significantly increased (p < 0.01) the flux of α4β7 positive CC lymphocytes from a baseline of 0.70 ± 0.03 × 10⁵ lymphocytes/min to 6.50 ± 0.10 × 10⁵ lymphocytes/min during LPT. Finally, lymphocyte flux during recovery was similar to baseline, indicating the effects of LPT are transient.
CONCLUSIONS: Collectively, these results suggest that LPT may enhance immune surveillance by increasing the numbers of lymphocytes released in to lymphatic circulation, especially from the gut associated lymphoid tissue. The rat provides a useful model to further investigate the effect of LPT on the lymphatic and immune systems.

PMID: 21190489 [PubMed - indexed for MEDLINE]

Lymphatic pump treatment mobilizes leukocytes from the gut associated lymphoid tissue into lymph.

Jamie Huff, DO - Wed, 01/30/2019 - 08:21
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Lymphatic pump treatment mobilizes leukocytes from the gut associated lymphoid tissue into lymph.

Lymphat Res Biol. 2010 Jun;8(2):103-10

Authors: Hodge LM, Bearden MK, Schander A, Huff JB, Williams A, King HH, Downey HF

Abstract
BACKGROUND: Lymphatic pump techniques (LPT) are used clinically by osteopathic practitioners for the treatment of edema and infection; however, the mechanisms by which LPT enhances lymphatic circulation and provides protection during infection are not understood. Rhythmic compressions on the abdomen during LPT compress the abdominal area, including the gut-associated lymphoid tissues (GALT), which may facilitate the release of leukocytes from these tissues into the lymphatic circulation. This study is the first to document LPT-induced mobilization of leukocytes from the GALT into the lymphatic circulation.
METHODS AND RESULTS: Catheters were inserted into either the thoracic or mesenteric lymph ducts of dogs. To determine if LPT enhanced the release of leukocytes from the mesenteric lymph nodes (MLN) into lymph, the MLN were fluorescently labeled in situ. Lymph was collected during 4 min pre-LPT, 4 min LPT, and 10 min following cessation of LPT. LPT significantly increased lymph flow and leukocytes in both mesenteric and thoracic duct lymph. LPT had no preferential effect on any specific leukocyte population, since neutrophil, monocyte, CD4+ T cell, CD8+ T cell, IgG+B cell, and IgA+B cell numbers were similarly increased. In addition, LPT significantly increased the mobilization of leukocytes from the MLN into lymph. Lymph flow and leukocyte counts fell following LPT treatment, indicating that the effects of LPT are transient.
CONCLUSIONS: LPT mobilizes leukocytes from GALT, and these leukocytes are transported by the lymphatic circulation. This enhanced release of leukocytes from GALT may provide scientific rationale for the clinical use of LPT to improve immune function.

PMID: 20583872 [PubMed - indexed for MEDLINE]

Association between emergency physician self-reported empathy and patient satisfaction.

James d'Etienne, MD - Wed, 01/30/2019 - 08:21
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Association between emergency physician self-reported empathy and patient satisfaction.

PLoS One. 2018;13(9):e0204113

Authors: Wang H, Kline JA, Jackson BE, Laureano-Phillips J, Robinson RD, Cowden CD, d'Etienne JP, Arze SE, Zenarosa NR

Abstract
BACKGROUND: Higher physician self-reported empathy has been associated with higher overall patient satisfaction. However, more evidence-based research is needed to determine such association in an emergent care setting.
OBJECTIVE: To evaluate the association between physician self-reported empathy and after-care instant patient-to-provider satisfaction among Emergency Department (ED) healthcare providers with varying years of medical practice experience.
RESEARCH DESIGN: A prospective observational study conducted in a tertiary care hospital ED.
METHODS: Forty-one providers interacted with 1,308 patients across 1,572 encounters from July 1 through October 31, 2016. The Jefferson Scale of Empathy (JSE) was used to assess provider empathy. An after-care instant patient satisfaction survey, with questionnaires regarding patient-to-provider satisfaction specifically, was conducted prior to the patient moving out of the ED. The relation between physician empathy and patient satisfaction was estimated using risk ratios (RR) and their corresponding 95% confidence limits (CL) from log-binomial regression models.
RESULTS: Emergency Medicine (EM) residents had the lowest JSE scores (median 111; interquartile range [IQR]: 107-122) and senior physicians had the highest scores (median 119.5; IQR: 111-129). Similarly, EM residents had the lowest percentage of "very satisfied" responses (65%) and senior physicians had the highest reported percentage of "very satisfied" responses (69%). There was a modest positive association between JSE and satisfaction (RR = 1.04; 95% CL: 1.00, 1.07).
CONCLUSION: This study provides evidence of a positive association between ED provider self-reported empathy and after-care instant patient-to-provider satisfaction. Overall higher empathy scores were associated with higher patient satisfaction, though minor heterogeneity occurred between different provider characteristics.

PMID: 30212564 [PubMed - in process]

Risks predicting prolonged hospital discharge boarding in a regional acute care hospital.

Hao Wang, MD - Wed, 01/30/2019 - 08:20
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Risks predicting prolonged hospital discharge boarding in a regional acute care hospital.

BMC Health Serv Res. 2018 01 30;18(1):59

Authors: Shaikh SA, Robinson RD, Cheeti R, Rath S, Cowden CD, Rosinia F, Zenarosa NR, Wang H

Abstract
BACKGROUND: Prolonged hospital discharge boarding can impact patient flow resulting in upstream Emergency Department crowding. We aim to determine the risks predicting prolonged hospital discharge boarding and their direct and indirect effects on patient flow.
METHODS: Retrospective review of a single hospital discharge database was conducted. Variables including type of disposition, disposition boarding time, case management consultation, discharge medications prescriptions, severity of illness, and patient homeless status were analyzed in a multivariate logistic regression model. Hospital charges, potential savings of hospital bed hours, and whether detailed discharge instructions provided adequate explanations to patients were also analyzed.
RESULTS: A total of 11,527 admissions was entered into final analysis. The median discharge boarding time was approximately 2 h. Adjusted Odds Ratio (AOR) of patients transferring to other hospitals was 7.45 (95% CI 5.35-10.37), to court or law enforcement custody was 2.51 (95% CI 1.84-3.42), and to a skilled nursing facility was 2.48 (95% CI 2.10-2.93). AOR was 0.57 (95% CI 0.47-0.71) if the disposition order was placed during normal office hours (0800-1700). AOR of early case management consultation was 1.52 (95% CI 1.37-1.68) versus 1.73 (95% CI 1.03-2.89) for late consultation. Eighty-eight percent of patients experiencing discharge boarding times within 2 h of disposition expressed positive responses when questioned about the quality of explanations of discharge instructions and follow-up plans based on satisfaction surveys. Similar results (86% positive response) were noted among patients whose discharge boarding times were prolonged (> 2 h, p = 0.44). An average charge of $6/bed/h was noted in all hospital discharges. Maximizing early discharge boarding (≤ 2 h) would have resulted in 16,376 hospital bed hours saved thereby averting $98,256.00 in unnecessary dwell time charges in this study population alone.
CONCLUSION: Type of disposition, case management timely consultation, and disposition to discharge dwell time affect boarding and patient flow in a tertiary acute care hospital. Efficiency of the discharge process did not affect patient satisfaction relative to the perceived quality of discharge instruction and follow-up plan explanations. Prolonged disposition to discharge intervals result in unnecessary hospital bed occupancy thereby negatively impacting hospital finances while delivering no direct benefit to patients.

PMID: 29378577 [PubMed - indexed for MEDLINE]

Endometrial ablation for severe menorrhagia in a patient with hereditary hemorrhagic Telangiectasia. A case report.

Frank D. DeLeon, MD, FACOG - Wed, 01/30/2019 - 08:19
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Endometrial ablation for severe menorrhagia in a patient with hereditary hemorrhagic Telangiectasia. A case report.

J Reprod Med. 1996 Mar;41(3):183-5

Authors: Berry DL, DeLeon FD

Abstract
BACKGROUND: Hereditary hemorrhagic telangiectasia is a rare, inherited disease characterized by abnormal visceral and superficial blood vessel anastomoses. These telangiectasias predispose the patient to a lifelong history of recurrent bleeding for the nasal and gastrointestinal mucosa. Less commonly involved organs include the liver, brain and lung. To date there is no cure for this disease. Management requires many palliative minor surgical procedures to stop actively bleeding sites. Major surgery is often contraindicated in these patients due do coexisting medical sequelae of their underlying disease.
CASE: Menorrhagia was diagnosed in a 42 year-old multipara with known history of hereditary hemorrhagic telangiectasia. The bleeding was unresponsive to hormonal therapy. Substantial preexisting conditions, including profound anemia, history of multiple strokes, a seizure disorder and ventricular arrhythmias, precluded major surgical intervention, including hysterectomy. Serial injections of leuprolide acetate injections were followed by hysteroscopic "rollerball" electrocoagulation of the endometrium under regional anesthesia. On long-term follow up, the patient was cured of her menorrhagia.
CONCLUSION: Endometrial ablation provides patients who have significant medical complications with an effective, minimally invasive alternative to hysterectomy for control of menorrhagia.

PMID: 8778418 [PubMed - indexed for MEDLINE]

The accuracy of interqual criteria in determining the need for observation versus hospitalization in emergency department patients with chronic heart failure.

Ferran Ros, DO - Wed, 01/30/2019 - 08:18
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The accuracy of interqual criteria in determining the need for observation versus hospitalization in emergency department patients with chronic heart failure.

Crit Pathw Cardiol. 2013 Dec;12(4):192-6

Authors: Wang H, Robinson RD, Coppola M, Fernandez D, Ros F, Zenarosa NR, Burton MJ, Delaney KA

Abstract
McKesson's Interqual criteria are one of the medical screening criteria that are widely used in emergency departments (EDs) to determine if patients qualify for observation or inpatient admission. Chronic heart failure (CHF) is one of the most common yet severe cardiovascular diseases seen in the ED with a relatively higher admission rate. This study is to evaluate the accuracy of Interqual criteria in determining observation versus hospitalization need in CHF patients. From January 2009 till December 2010, data from 503 CHF patients were reviewed. One hundred twenty-two patients were observed and 381 patients were admitted. Only one variable (blood urea nitrogen, ≥30 mg/dL; odds ratio, 2.44) from Interqual criteria had reached statistical significant difference between observation and hospitalization groups. Our results showed that based on the initial review at ED, clinical variables from Interqual criteria did not appear to help accurately predict the level of care in CHF patient in our patient population. Other clinical variables may need to be added in the criteria for better prediction.

PMID: 24240548 [PubMed - indexed for MEDLINE]

Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department.

Elizabeth Fagan, MD - Wed, 01/30/2019 - 08:18
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Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department.

J Clin Med Res. 2017 Nov;9(11):911-916

Authors: Phillips JL, Jackson BE, Fagan EL, Arze SE, Major B, Zenarosa NR, Wang H

Abstract
BACKGROUND: Crowding occurs commonly in high volume emergency departments (ED) and has been associated with negative patient care outcomes. We aim to assess ED crowding in a median-low volume setting and evaluate associations with patient care outcomes.
METHODS: This was a prospective single-center study from November 14, 2016 until December 14, 2016. ED crowding was measured every 2 h by three different estimation tools: National Emergency Department Overcrowding Score (NEDOCS); Community Emergency Department Overcrowding Score (CEDOCS); and Severely-overcrowding Overcrowding and Not-overcrowding Estimation Tool (SONET) categorized under six different levels of crowding (not busy, busy, extremely busy, overcrowded, severely overcrowded, and dangerously overcrowded). Crowding scores were assigned to each patient upon ED arrival. We evaluated the distributions of crowding and patient ED length of stay (ED LOS) across estimation tools. Accelerated failure time models were utilized to estimate time ratios and their corresponding 95% confidence intervals comparing median LOS across levels of crowding within each estimation tool.
RESULTS: This study comprised 2,557 patients whose median ED LOS was 150 min. Approximately 2% of patients arrived during 2 h time intervals deemed overcrowded regardless of the crowding tool used. Median ED LOS increased with the increased level of ED crowding and prolonged median ED LOS (> 150 min) occurred at ED of extremely busy status. Time ratios ranged from 1.09 to 1.48 for NEDOCS, 1.25 - 1.56 for CEDOCS, and 1.26 - 1.72 for SONET.
CONCLUSION: Overcrowding rarely occurred in study ED with median-low annual volume and might not be a valuable marker for ED crowding report. Though similar patterns of prolonged ED LOS occurred with increased levels of ED crowding, it seems crowding alerts should be initiated during extremely busy status in this ED setting.

PMID: 29038668 [PubMed]

Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial.

Elizabeth Carter, MD - Wed, 01/30/2019 - 08:18
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Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial.

Am J Gastroenterol. 2016 Nov;111(11):1630-1636

Authors: Gupta S, Miller S, Koch M, Berry E, Anderson P, Pruitt SL, Borton E, Hughes AE, Carter E, Hernandez S, Pozos H, Halm EA, Gneezy A, Lieberman AJ, Sugg Skinner C, Argenbright K, Balasubramanian B

Abstract
OBJECTIVES: Offering financial incentives to promote or "nudge" participation in cancer screening programs, particularly among vulnerable populations who traditionally have lower rates of screening, has been suggested as a strategy to enhance screening uptake. However, effectiveness of such practices has not been established. Our aim was to determine whether offering small financial incentives would increase colorectal cancer (CRC) screening completion in a low-income, uninsured population.
METHODS: We conducted a randomized, comparative effectiveness trial among primary care patients, aged 50-64 years, not up-to-date with CRC screening served by a large, safety net health system in Fort Worth, Texas. Patients were randomly assigned to mailed fecal immunochemical test (FIT) outreach (n=6,565), outreach plus a $5 incentive (n=1,000), or outreach plus a $10 incentive (n=1,000). Outreach included reminder phone calls and navigation to promote diagnostic colonoscopy completion for patients with abnormal FIT. Primary outcome was FIT completion within 1 year, assessed using an intent-to-screen analysis.
RESULTS: FIT completion was 36.9% with vs. 36.2% without any financial incentive (P=0.60) and was also not statistically different for the $10 incentive (34.6%, P=0.32 vs. no incentive) or $5 incentive (39.2%, P=0.07 vs. no incentive) groups. Results did not differ substantially when stratified by age, sex, race/ethnicity, or neighborhood poverty rate. Median time to FIT return also did not differ across groups.
CONCLUSIONS: Financial incentives, in the amount of $5 or $10 offered in exchange for responding to mailed invitation to complete FIT, do not impact CRC screening completion.

PMID: 27481306 [PubMed - indexed for MEDLINE]

Prevention of Dopamine Dysregulation Syndrome in Parkinson's Disease: A Case Report.

Dustin DeMoss, DO - Wed, 01/30/2019 - 08:17
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Prevention of Dopamine Dysregulation Syndrome in Parkinson's Disease: A Case Report.

Prim Care Companion CNS Disord. 2018 Apr 26;20(2):

Authors: Luchsinger WT, Gambhir N, DeMoss D

PMID: 29701928 [PubMed - indexed for MEDLINE]

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