Caring for Caregivers: National Case Management Week: October 13-10, 2024.

The population of individuals over the age of 60 is expected to double by 2050, resulting in nearly 2.1 billion people. Statistics show that unpaid family caregiving is on the rise and will likely go higher. A look at caregiver statistics is revealing. There are ways that institutions and case managers can support this growing population.

Advanced Hospital Healthcare at Home-How Is It Going?

The Centers for Medicare & Medicaid Services' (CMS) Acute Hospital Care at Home (AHCAH) waiver, which launched in November 2020, has prompted hundreds of hospitals across the country to initiate programs that allow certain patients to complete their acute care stays in the familiar comfort of their homes. But this waiver is about to expire in December 2024. It is a success; but can we continue it?

Anterior insula is more vulnerable than posterior insula to TDP-43 pathology in common dementias and ALS.

Based on the anatomic proximity, connectivity, and functional similarities between the anterior insula and amygdala, we tested the hypothesis that the anterior insula is an important focus in the progression of TDP-43 pathology in LATE-NC. Blinded to clinical and neuropathologic data, phospho-TDP (pTDP) inclusion pathology was assessed in paired anterior and posterior insula samples in 105 autopsied patients with Alzheimer disease, Lewy body disease, LATE-NC and hippocampal sclerosis (HS), amyotrophic lateral sclerosis (ALS), and other conditions. Insular pTDP pathology was present in 34.3% of the study cohort, most commonly as neuronal inclusions and/or short neurites in lamina II, and less commonly as subpial processes resembling those described in the amygdala region. Among positive samples, pTDP pathology was limited to the anterior insula (41.7%), or occurred in both anterior and posterior insula (58.3%); inclusion density was greater in anterior insula across all diseases (p < .001). pTDP pathology occurred in 46.7% of ALS samples, typically without a widespread TDP-43 proteinopathy. In LATE-NC, it was seen in 30.4% of samples (mostly LATE-NC stages 2 and 3), often co-occurring with basal forebrain pathology and comorbid HS, suggesting this is an important step in the evolution of this pathology beyond the medial temporal lobe.

National pilot of entrustable professional activities in pathology residency training.

Entrustable professional activities (EPAs) are observable clinical skills and/or procedures that have been introduced into medical education at the student and resident levels in most specialties to determine readiness to advance into residency or independent practice, respectively. This publication describes the process and outcomes of a pilot study looking at the feasibility of using two anatomic pathology and two clinical pathology EPAs in pathology residency in 6 pathology residency programs that volunteered for the study. Faculty development on EPAs and their assessment was provided to pilot program faculty, and EPA assessment tools were developed and used by the pilot programs. Pre- and post-study surveys were given to participating residents, faculty, and program directors to gauge baseline practices and to gather feedback on the EPA implementation experience. Results demonstrated overall good feasibility in implementing EPAs. Faculty acceptance of EPAs varied and was less than that of program directors. Residents reported a significant increase in the frequency with which faculty provided formative assessments that included specific examples of performance and specific ways to improve, as well as increased frequency with which faculty provided summative assessments that included specific ways to improve. EPAs offered the most benefit in setting clear expectations for performance of each task, for providing more specific feedback to residents, and in increasing Program director's understanding of resident strengths abilities and weaknesses.

Leveraging faculty development to support validation of entrustable professional activities assessment tools in anatomic and clinical pathology training.

Entrustable professional activities (EPAs) are observable activities that define the practice of medicine and provide a framework of evaluation that has been incorporated into US medical school curricula in both undergraduate and graduate medical education. This manuscript describes the development of an entrustment scale and formative and summative evaluations for pathology EPAs, outlines a process for faculty development that was employed in a pilot study implementing two Anatomic Pathology and two Clinical Pathology EPAs in volunteer pathology residency programs, and provides initial validation data for the proposed pathology entrustment scales. Prior to implementation, faculty development was necessary to train faculty on the entrustment scale for each given activity. A "train the trainer" model used performance dimension training and frame of reference training to train key faculty at each institution. The session utilized vignettes to practice determination of entrustment ratings and development of feedback for trainees as to strengths and weaknesses in the performance of these activities. Validity of the entrustment scale is discussed using the Messick framework, based on concepts of content, response process, and internal structure. This model of entrustment scales, formative and summative assessments, and faculty development can be utilized for any pathology EPA and provides a roadmap for programs to design and implement EPA assessments into pathology residency training.

Analysis of gliomas DNA methylation: Assessment of pre-analytical variables.

Precision oncology is driven by molecular biomarkers. For glioblastoma multiforme (GBM), the most common malignant adult primary brain tumor, O6-methylguanine-DNA methyltransferase ( MGMT ) gene DNA promoter methylation is an important prognostic and treatment clinical biomarker. Time consuming pre-analytical steps such as biospecimen storage before fixing, sampling, and processing are major sources of errors and batch effects, that are further confounded by intra-tumor heterogeneity of MGMT promoter methylation. To assess the effect of pre-analytical variables on GBM DNA methylation, tissue storage/sampling (CryoGrid), sample preparation multi-sonicator (PIXUL) and 5-methylcytosine (5mC) DNA immunoprecipitation (Matrix MeDIP-qPCR/seq) platforms were used. MGMT promoter CpG methylation was examined in 173 surgical samples from 90 individuals, 50 of these were used for intra-tumor heterogeneity studies. MGMT promoter methylation levels in paired frozen and formalin fixed paraffin embedded (FFPE) samples were very close, confirming suitability of FFPE for MGMT promoter methylation analysis in clinical settings. Matrix MeDIP-qPCR yielded similar results to methylation specific PCR (MS-PCR). Warm ex-vivo ischemia (37°C up to 4hrs) and 3 cycles of repeated sample thawing and freezing did not alter 5mC levels at MGMT promoter, exon and upstream enhancer regions, demonstrating the resistance of DNA methylation to the most common variations in sample processing conditions that might be encountered in research and clinical settings. 20-30% of specimens exhibited intratumor heterogeneity in the MGMT DNA promoter methylation. Collectively these data demonstrate that variations in sample fixation, ischemia duration and temperature, and DNA methylation assay technique do not have significant impact on assessment of MGMT promoter methylation status. However, intratumor methylation heterogeneity underscores the need for histologic verification and value of multiple biopsies at different GBM geographic tumor sites in assessment of MGMT promoter methylation. Matrix-MeDIP-seq analysis revealed that MGMT promoter methylation status clustered with other differentially methylated genomic loci (e.g. HOXA and lncRNAs), that are likewise resilient to variation in above post-resection pre-analytical conditions. These MGMT -associated global DNA methylation patterns offer new opportunities to validate more granular data-based epigenetic GBM clinical biomarkers where the CryoGrid-PIXUL-Matrix toolbox could prove to be useful.

Twenty-Five Years (Plus!) and an Impact Factor.

Professional Case Management Journal: has been published for more than 25 years. In those years, important content has helped build the foundation of case management itself. Through the years, the articles in this journal have been cited in other articles-and in other journals globally. Now this journal has been bestowed with an "impact factor."

Angiomatoid fibrous histiocytoma: primary intracranial lesion with thoracic spine metastasis and a malignant course. Illustrative case.

BACKGROUND: Angiomatoid fibrous histiocytoma (AFH) is an exceptionally rare soft tissue neoplasm. This tumor primarily presents as a benign soft tissue lesion in children with an average age of 14 years. The standard treatment regimen is wide local excision with interval follow-up. However, newer reports have demonstrated malignant potential with the possibility of intracranial metastasis. OBSERVATIONS: A 45-year-old male with no soft tissue primary tumor presented with a primary intracranial lesion and thoracic spine metastasis refractory to chemotherapy and radiation treatment. LESSONS: This report illustrates the potential for a highly malignant nature of metastatic AFH. In addition, the authors demonstrate an incidence of AFH in a middle-aged male without a primary soft tissue or skin lesion. This report highlights the importance of prompt treatment and excision for AFH, as there is still little understanding of successful options for systemic therapy.

The Loneliness Epidemic.

According to the U.S. Surgeon General's Advisory on the Healing Effects of Social Connection and Community, social disconnection is being called a critical public health issue. The epidemic of loneliness is widespread and may have profound consequences for our individual and collective health and well-being. And the "costs" of loneliness are real.

Primary visual cortex pathology in ALS patients with C9ORF72 expansion.

Poly-GA and poly-GP immunofluorescence studies show conspicuous dipeptide repeat pathology in layers IV and II of primary visual cortex in C9ALS patients.

AI and Case Management: From Artificial Intelligence to Generative Intelligence.

Conversations about artificial intelligence (AI) are impossible to escape since the inception of ChatGPT in November 2022-whether it is about the end of our jobs or the end of the world! This Editorial talks about AI and its subsets and how this may relate to health care.

A Tiny Historical Slice of Case Management.

National Case Management Week in 2023 is October 8-14. This celebration of case managers has been going on since 1999 after the Individual Case Management Association (ICMA) and the Case Management Society of America (CMSA) merged. Since the 1990s, case management has evolved significantly; this evolution impacts every case manager, on every case by case, year by year.

To All the Physicians Advisors.

Over the years, the physician advisor has become a regulatory and revenue integrity force. This Editorial discusses the evolution and roles of the physician advisor and how case managers can work more effectively with them.

Impact of population based indoor residual spraying with and without mass drug administration with dihydroartemisinin-piperaquine on malaria prevalence in a high transmission setting: a quasi-experimental controlled before-and-after trial in northeastern Uganda.

BACKGROUND: Declines in malaria burden in Uganda have slowed. Modelling predicts that indoor residual spraying (IRS) and mass drug administration (MDA), when co-timed, have synergistic impact. This study investigated additional protective impact of population-based MDA on malaria prevalence, if any, when added to IRS, as compared with IRS alone and with standard of care (SOC). METHODS: The 32-month quasi-experimental controlled before-and-after trial enrolled an open cohort of residents (46,765 individuals, 1st enumeration and 52,133, 4th enumeration) of Katakwi District in northeastern Uganda. Consented participants were assigned to three arms based on residential subcounty at study start: MDA+IRS, IRS, SOC. IRS with pirimiphos methyl and MDA with dihydroartemisinin- piperaquine were delivered in 4 co-timed campaign-style rounds 8 months apart. The primary endpoint was population prevalence of malaria, estimated by 6 cross-sectional surveys, starting at baseline and preceding each subsequent round. RESULTS: Comparing malaria prevalence in MDA+IRS and IRS only arms over all 6 surveys (intention-to-treat analysis), roughly every 6 months post-interventions, a geostatistical model found a significant additional 15.5% (95% confidence interval (CI): [13.7%, 17.5%], Z = 9.6, p = 5e-20) decrease in the adjusted odds ratio (aOR) due to MDA for all ages, a 13.3% reduction in under 5's (95% CI: [10.5%, 16.8%], Z = 4.02, p = 5e-5), and a 10.1% reduction in children 5-15 (95% CI: [8.5%, 11.8%], Z = 4.7, p = 2e-5). All ages residents of the MDA + IRS arm enjoyed an overall 80.1% reduction (95% CI: [80.0%, 83.0%], p = 0.0001) in odds of qPCR confirmed malaria compared with SOC residents. Secondary difference-in-difference analyses comparing surveys at different timepoints to baseline showed aOR (MDA + IRS vs IRS) of qPCR positivity between 0.28 and 0.66 (p < 0.001). Of three serious adverse events, one (nonfatal) was considered related to study medications. Limitations include the initial non-random assignment of study arms, the single large cluster per arm, and the lack of an MDA-only arm, considered to violate equipoise. CONCLUSIONS: Despite being assessed at long time points 5-7 months post-round, MDA plus IRS provided significant additional protection from malaria infection over IRS alone. Randomized trials of MDA in large areas undergoing IRS recommended as well as cohort studies of impact on incidence. TRIAL REGISTRATION: This trial was retrospectively registered 11/07/2018 with the Pan African Clinical Trials Registry (PACTR201807166695568).

The Inflation Reduction Act (IRA): What Case Managers Should Monitor.

Although this Editorial discusses the Inflation Reduction Act (IRA), it will focus on the health provisions only. Many issues can change between the writing of this Editorial and its publication, but here are some nuances of the law that case managers should watch.

End-of-Life Doulas.

Death doulas are people who help people at the end of life with dying, just like birth doulas help at the beginning of life. Views of traditions surrounding death, such as funerals and other ways to memorialize loved ones, are shifting. Death doula associations are seeing an increased interest from people who are seeking death doulas and those who wish to become death doulas.

The Science of Gratitude.

"Gratitude" is more than a buzzword and may be more important than we realize. The science of gratitude is worth delving into, as science is beginning to show the following: the symptoms of the grateful person versus the stressed person with headaches, sleeplessness, compassion fatigue, and digestive issues can be likened to the sympathetic nervous system (the fight or flight response) versus the parasympathetic nervous system (the part of the nervous system that allows our body to "rest and digest")-the grateful person.

Quiet Eye: Another Technique for Your Toolbox.

"Quiet Eye" is a technique that has been studied in sports, law enforcement, military, and medical settings; it refers to the amount of time one spends concentrating on a specific "next step" before initiating movement. Noted to reduce anxiety, and even have a sense of slowing things down a bit, this can be used in any situation from before walking into a difficult family's room to presenting a bid to leadership for more case managers in your department.

Workplace Violence and Bullying: You Can Survive.

One of biggest challenges facing the health care industry today is workplace violence and bullying. Sadly, this trend has increased so dramatically that The Joint Commission is tracking these trends and has instituted new requirements in 2022. This Editorial describes the trend and suggests methods to mitigate the situation.