Increasing Follow Up With Primary Care Providers After Emergency Department Visits in Older Adults.

PURPOSE: To increase follow up with the primary care team via telephone outreach within 3 days of emergency department (ED) discharge to schedule a follow-up visit within 14 days. Secondary aims included: identifying high utilizers of the ED (defined as more than three ED visits within 6 months), reinforcing discharge instructions from the ED via nursing education on telephone follow ups, and identifying the reasons patients used the ED. METHOD: Baseline data were gathered retrospectively by reviewing charts of patients discharged from the ED. Charts were reviewed from a biweekly automated report, and RNs initiated follow-up phone calls to patients discharged from the ED, offering appointments and providing pertinent nursing education. RESULTS: Primary care follow ups after ED discharges increased from 38% to 71% over 10 months with the new nurse-led workflow. Patients to whom the RN outreached to were more likely to attend their follow-up appointments. However, a 14-day follow-up appointment with the primary care provider (PCP) showed no significant difference in ED revisits or hospital admissions. CONCLUSION: Follow up after ED discharge led to increased coordination of care. Nurses provided education about chronic conditions and reiterated discharge instructions that might have been unclear to patients in the ED. Further studies are needed to analyze the effect of follow up with the PCP on ED utilization and hospital admissions. [Journal of Gerontological Nursing, 50(3), 33-39.].

Converting patients from warfarin to non-vitamin K antagonist oral anticoagulants.

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs) are favorable in stroke prevention for geriatric patients with nonvalvular atrial fibrillation versus warfarin. These anticoagulants do not require international normalized ratio (INR) monitoring and have lower food/drug interactions. In addition, NOACs have risk reduction in bleeding and all-cause mortality compared with warfarin. LOCAL PROBLEM: At a geriatric primary care practice, two registered nurses manage 88 patients on warfarin for INR monitoring. Nurse practitioners (NPs) provide oversight for warfarin titration after abnormal results. The goal of this quality-improvement project was to decrease the time spent monitoring patients on warfarin. METHODS: Primary care providers and cardiologists of patients on warfarin were contacted to gain approval of transition to a NOAC. The NP reviewed patients' renal function and the indication for anticoagulation and then created a list of eligible patients for transition. INTERVENTIONS: Patients eligible for transition to NOACs were contacted for their consent. The transition process included stopping warfarin, ordering apixaban, ordering INR level, educating about starting apixaban, and coordinating appropriate follow-up. RESULTS: Of 88 patients on warfarin, 21 were eligible for conversion from warfarin to apixaban. Of these 21 patients, 66% ( n = 14) consented to the conversion. Of those who were not converted to apixaban, five declined due to cost and two were lost to follow-up. CONCLUSION: There was a reduction in nurses' monthly monitoring of patients on warfarin by 22%. Transition to NOAC was not only beneficial for patient safety and efficacy but also reduced nursing clinical time for anticoagulation encounters.

Hemodialysis Catheter Breakage in an Infant.

A 3-month-old male infant was admitted to our unit due to acute decompensation of chronic kidney disease of unknown etiology. Further investigation led to the diagnosis of primary hyperoxaluria type 1. As the patient did not recover, hemodialysis was initiated with a non-tunneled femoral catheter. A tunneled Hickman catheter was placed in the internal jugular vein. The patient experienced moderate intradialytic exit-site bleeding and catheter malfunction, which initially responded to pressure and postural changes. During the third session, the patient suffered cardiopulmonary arrest. After stabilization, a chest hematoma was identified. Fluoroscopy revealed a catheter breakage. Despite initial stabilization, the patient developed septic shock due to Pseudomonas aeruginosa and died several days later. Hemodialysis is sometimes necessary in children under 24 months with chronic kidney disease. Vascular access is a major challenge in these patients due to lack of appropriate catheter sizes and high complication rates. Hemodialysis catheter fracture is an uncommon complication, and diagnosis can be difficult when the breakage involves the subcutaneous segment. Persistent intradialytic bleeding and mechanical malfunction should raise suspicion of this complication and should elicit catheter revision under fluoroscopy. Without prompt diagnosis, catheter breakage may have fatal consequences, as in our case.

Using Medicare Annual Wellness Visits and telehealth to enhance ambulatory geriatrics education among medical students.

The Medicare Annual Wellness visit (AWV) was mandated as a fully covered benefit for older adults to enhance preventive care and improve healthcare outcomes. Although the benefit of conducting AWV is proven, its adoption in primary care is far from universal. The COVID-19 pandemic affected medical education and clinical care in unprecedented ways. Telehealth became a prominent way of delivering healthcare. Older adults, being significantly affected by the pandemic-related mortality and morbidity, were less likely to engage in preventive care with their healthcare providers. Amidst this considerable shift, we conceptualized a clinical experience for third-year medical students during their Ambulatory Care - Geriatrics clerkship that involved a telehealth interaction with an older adult to review AWV components, followed by an in-person office visit with the geriatrician preceptor. Post-session survey data highlighted the beneficial effect on student learning about older adult health maintenance, immunizations and geriatric syndrome assessment. It also facilitated self-directed learning and increased student-patient rapport. Preceptors appreciated the additional elements of care identified by the telehealth call that would otherwise not have been addressed in a time-limited office visit. This hybrid clinical experience reduced crowding in ambulatory clinical space during the COVID-19 pandemic, yet enhanced learning for students in geriatrics preventive care.

Correction to: A rare cause of nephrocalcinosis in an infant: Answers.

Due to an unfortunate error during the processing of this article, the HTML version of this article contained a mistake.

Efectos de un programa de actividad física integral sobre la motricidad gruesa de niños y niñas con diversidad funcional / Effects of a program of integral physical activity on the gross motor control in children with functional diversity / Efeitos de um programa da atividade física integral nas habilidades motoras de grande porte em crianças com diversidade funcional

Resumen Introducción. Recientemente, en el Ecuador se está sensibilizado sobre la inclusión escolar de niños/as con diversidad funcional. Sin embargo, la ausencia de espacios adecuados y profesionales preparados hace que estos sean remitidos a hospitales o centros de rehabilitación. Además, los beneficios de la terapia física no se limitan al ámbito de la motricidad, ofreciendo igualmente avances en la función cognitiva y el aprendizaje. Así pues, este trabajo muestra una investigación realizada en el área de Medicina Física y Rehabilitación del Hospital Teófilo Dávila (Ecuador). Objetivo. El propósito del estudio es determinar el impacto de un programa de actividad física integral, respecto de la motricidad gruesa de niños/as con diversidad funcional. Materiales y métodos. La investigación acomete un diseño cuasi-experimental con un grupo experimental, tomando medidas pretest y postest. La metodología utilizada es cuantitativa descriptiva, implementando el test Gross Motor Function Measure (GMFM 88) y dos encuestas de valoración personal. Resultados. El análisis de datos revela mejoras estadísticamente significativas (p<0,001) en la motricidad gruesa de los niños/as, tanto a nivel global como en cada una de las categorías del test. Igualmente, las encuestas proporcionaron información relevante respecto de la opinión de maestros y padres/tutores. Conclusiones. Los resultados de las pruebas estadísticas no dejan lugar a dudas respecto a la mejora en la motricidad gruesa de los niños/as. Asimismo, las encuestas reflejan un grado de satisfacción muy elevado, además de resaltar beneficios en la función cognitiva y el aprendizaje.

Abstract Introduction. Recently, in Ecuador, we are aware of school inclusion of children with functional diversity. However, the absence of adequate spaces and trained professionals make them to be referred to hospitals or rehabilitation centers. In addition, the benefits of physical therapy are not limited to the field of motor skills, offering advances in cognitive function and learning as well. Thus, this work shows an investigation carried out in the area of Physical Medicine and Rehabilitation at Teófilo Dávila Hospital (Ecuador). Objective. The purpose of the study is to determine the impact of a Physical Therapy program on the gross motor skills of children with functional diversity. Materials and methods. The research is approached through a quasi-experimental design with an Experimental Group, taking Pretest and Posttest measurements. The methodology used is descriptive quantitative, implementing the Gross Motor Function Measure Test (GMFM 88) and two opinion surveys. Results. The data analysis reveals statistically significant improvements (p<0.001) in the gross motor skills of the children, both globally and in each of the test categories. Likewise, the surveys provided relevant information regarding the opinion of the children's teachers and parents/ guardians. Conclusions. The results of the statistical tests leave no doubt about the improvement in the children's gross motor skills. Likewise, the surveys revealed a very high level of satisfaction, highlighting benefits in cognitive function and learning as well.

Resumo Introdução. Recentemente, no Equador está sendo promovida a inclusão escolar de crianças com diversidade funcional. No entanto, a ausência de espaços adequados e professionais capacitados faz com que estes sejam encaminhados à hospitais ou centros de reabilitação. Além disso, os benefícios da fisioterapia física não se limitam ao âmbito da motricidade, oferecendo de igual maneira avanços na função cognitiva e na aprendizagem. Assim, este trabalho amostra uma pesquisa realizada na área de Medicina Física e Reabilitação do Hospital Teofilo Davila (Equador). Objetivo. O propósito do estudo é determinar o impacto de um programa de atividade física integral, respeito da motricidade de grande porte de crianças com diversidade funcional. Materiais e métodos. A pesquisa é abordada por meio de um delineamento quase-experimental com uma turma experimental, utilizando medidas pré-teste e pós-teste. A metodologia utilizada é quantitativa descritiva, implementando o Teste Gross Motor Function Measure (GMFM 88) e duas entrevista de avaliação pessoal. Resultados. A análise de dados revela melhorias estatisticamente significativas (p<0,001) na motricidade de grande porte nas crianças, tanto globalmente quanto em cada uma das categorias do teste. Igualmente, as entrevistas forneceram informação relevante respeito da opinião dos docentes e pais/representantes. Conclusões. Os resultados dos testes estatísticos não deixam margem para dúvidas respeito a melhoria da motricidade de grande porte nas crianças. Da mesma forma, as entrevistas refletem um grau elevado de satisfação, além de destacar os benefícios na função cognitiva e na aprendizagem.

Vitamin E hydroquinone is an endogenous regulator of ferroptosis via redox control of 15-lipoxygenase.

Ferroptosis is a form of programmed cell death associated with inflammation, neurodegeneration, and ischemia. Vitamin E (alpha-tocopherol) has been reported to prevent ferroptosis, but the mechanism by which this occurs is controversial. To elucidate the biochemical mechanism of vitamin E activity, we systematically investigated the effects of its major vitamers and metabolites on lipid oxidation and ferroptosis in a striatal cell model. We found that a specific endogenous metabolite of vitamin E, alpha-tocopherol hydroquinone, was a dramatically more potent inhibitor of ferroptosis than its parent compound, and inhibits 15-lipoxygenase via reduction of the enzyme's non-heme iron from its active Fe3+ state to an inactive Fe2+ state. Furthermore, a non-metabolizable isosteric analog of vitamin E which retains antioxidant activity neither inhibited 15-lipoxygenase nor prevented ferroptosis. These results call into question the prevailing model that vitamin E acts predominantly as a non-specific lipophilic antioxidant. We propose that, similar to the other lipophilic vitamins A, D and K, vitamin E is instead a pro-vitamin, with its quinone/hydroquinone metabolites responsible for its anti-ferroptotic cytoprotective activity.

Recombinant Enolase of Trypanosoma cruzi as a Novel Vaccine Candidate against Chagas Disease in a Mouse Model of Acute Infection.

Trypanosoma cruzi is the protozoan parasite that causes Chagas disease, which is considered by the World Health Organization to be a neglected tropical disease. Two drugs exist for the treatment of Chagas disease, nifurtimox and benznidazole; they are only effective in the acute phase, and a vaccine is currently not available. In this study, we used the recombinant enolase from T. cruzi H8 strain (MHOM/MX/1992/H8 Yucatán) (rTcENO) and its encoding DNA (pBKTcENO) to immunize mice and evaluate their protective effects in an experimental murine model of acute phase infection. Our results showed that mice vaccinated with rTcENO or its encoding DNA were able to generate typical specific antibodies (IgG1, IgG2a, and IgG2b), suggesting that a mixed Th1/Th2 immune response was induced. The parasite burden in the blood was reduced to 69.8% and 71% in mice vaccinated with rTcENO and pBKTcENO, respectively. The group vaccinated with rTcENO achieved 75% survival, in contrast to the group vaccinated with pBKTcENO that showed no survival in comparison to the control groups. Moreover, rTcENO immunization elevated the production of IFN-γ and IL-2 after the parasite challenge, suggesting that the Th1-type immune response was polarized. These results indicated that rTcENO could be used as a vaccine against Chagas disease.

Review of Transitional Care Management and Chronic Care Management Codes for Pulmonologists.

Patients with advanced respiratory illness are often hospitalized, requiring close follow-up after discharge and also requiring care coordination outside of traditional face-to-face outpatient visits. Primary care providers and specialists often provide services outside of outpatient visits that have not been captured and reimbursed with traditional billing evaluation and management codes. Within the last 5 years, the Centers for Medicare & Medicaid added new codes to the Medicare Physician Fee Schedule that reimburse for care coordination services not paid for by traditional evaluation and management codes. Transitional care management includes the 30-day period following hospitalization in which a clinician is responsible for care of the patient postdischarge from the hospital. Chronic care management provides reimbursement for coordination of care for chronic conditions that is performed by any clinician and his or her staff on a monthly basis that is > 20 min in duration.

Three-dimensional Biomimetic Technology: Novel Biorubber Creates Defined Micro- and Macro-scale Architectures in Collagen Hydrogels.

Tissue scaffolds play a crucial role in the tissue regeneration process. The ideal scaffold must fulfill several requirements such as having proper composition, targeted modulus, and well-defined architectural features. Biomaterials that recapitulate the intrinsic architecture of in vivo tissue are vital for studying diseases as well as to facilitate the regeneration of lost and malformed soft tissue. A novel biofabrication technique was developed which combines state of the art imaging, three-dimensional (3D) printing, and selective enzymatic activity to create a new generation of biomaterials for research and clinical application. The developed material, Bovine Serum Albumin rubber, is reaction injected into a mold that upholds specific geometrical features. This sacrificial material allows the adequate transfer of architectural features to a natural scaffold material. The prototype consists of a 3D collagen scaffold with 4 and 3 mm channels that represent a branched architecture. This paper emphasizes the use of this biofabrication technique for the generation of natural constructs. This protocol utilizes a computer-aided software (CAD) to manufacture a solid mold which will be reaction injected with BSA rubber followed by the enzymatic digestion of the rubber, leaving its architectural features within the scaffold material.

Costing Dengue Fever Cases and Outbreaks: Recommendations from a Costing Dengue Working Group in the Americas.

OBJECTIVES: The overall aim of this article was to present a step-by-step guideline for determining the costs associated with dengue in dengue-endemic countries of the Latin American and the Caribbean region and to illustrate how each of these steps can be applied in dengue costing studies. METHODS: An expert panel was convened to develop standards for costing dengue so that over the next decade, decision makers will have access to improved information on the true cost of dengue in endemic countries of the Latin American and the Caribbean region. We described the outcome of the expert panel meeting, which resulted in the provision of a step-by-step dengue costing guideline that aims to provide direction to planners and program managers on how to estimate dengue economic burden studies, and provide a discussion forum of the methods used to cost dengue fever cases and outbreaks in a manner that should be accessible to persons with some familiarity with a cost study. RESULTS: The guideline includes nine sequential steps: 1) definition of the scope of the study; 2) identification of the target population; 3) description of the study perspective; 4) definition of the time horizon; 5) calculation of the sample size; 6) definition of the unit of analysis; 7) identification of the cost items; 8) measurement and valuation of the cost items; and 9) handling of uncertainty. The trade-off between accurate, patient-level cost estimates and data availability constraints is discussed. CONCLUSIONS: The current guideline is the result of constructive collaboration among a multidisciplinary research team to better ascertain the true economic burden of dengue across countries of the region.

Teaching geriatric fellows how to teach: a needs assessment targeting geriatrics fellowship program directors.

The entire healthcare workforce needs to be educated to better care for older adults. The purpose of this study was to determine whether fellows are being trained to teach, to assess the attitudes of fellowship directors toward training fellows to be teachers, and to understand how to facilitate this type of training for fellows. A nine-question survey adapted from a 2001 survey issued to residency program directors inquiring about residents-as-teachers curricula was developed and administered. The survey was issued electronically and sent out three times over a 6-week period. Of 144 ACGME-accredited geriatric fellowship directors from geriatric, internal medicine, and family medicine departments who were e-mailed the survey, 101 (70%) responded; 75% had an academic affiliation, 15% had a community affiliation, and 10% did not report. Academic and community programs required their fellows to teach, but just 55% of academic and 29% of community programs offered teaching skills instruction as part of their fellowship curriculum; 67% of academic programs and 79% of community programs felt that their fellows would benefit from more teaching skill instruction. Program directors listed fellow (39%) and faculty (46%) time constraints as obstacles to creation and implementation of a teaching curriculum. The majority of fellowship directors believe that it is important for geriatric fellows to become competent educators, but only approximately half of programs currently provide formal instruction in teaching skills. A reproducible, accessible curriculum on teaching to teach that includes a rigorous evaluation component should be created for geriatrics fellowship programs.