Effectiveness of the tobacco tactics program for psychiatric inpatient veterans: an implementation study.

BACKGROUND: The objective of this study was to evaluate the effectiveness of the inpatient, nurse-administered Tobacco Tactics program for patients admitted for psychiatric conditions in two Veterans Affairs (VA) hospitals compared to a control hospital. METHODS: This is a subgroup analysis of data from the inpatient tobacco tactics effectiveness trial, which was a longitudinal, pre- post-nonrandomized comparison design with 6-month follow-up in the three large Veterans Integrated Service Networks (VISN) 11 hospitals. RESULTS: Six-month self-reported quit rates for patients admitted for psychiatric conditions increased from 3.5% pre-intervention to 10.2% post-intervention compared to a decrease in self-reported quit rates in the control hospital (12% pre-intervention to 1.6% post-intervention). There was significant improvement in self-reported quit rates for the pre- versus post-intervention time periods in the Detroit and Ann Arbor intervention sites compared to the Indianapolis control site (P=0.01) and cotinine results were in the same direction. CONCLUSION: The implementation of the Tobacco Tactics intervention has the potential to significantly decrease smoking and smoking-related morbidity and mortality among smokers admitted to VA hospitals for psychiatric disorders.

[Pursuing the triple aim: evaluation of the integrated care system Gesundes Kinzigtal: population health, patient experience and cost-effectiveness]. / Triple Aim - Evaluation in der Integrierten Versorgung Gesundes Kinzigtal - Gesundheitszustand, Versorgungserleben und Wirtschaftlichkeit.

BACKGROUND: The integrated care system Gesundes Kinzigtal (ICSGK), one of the most comprehensive population-based ICS in Germany, started its work nearly 9 years ago. The ICSGK is pursuing the Triple Aim: improving the health of the population, improving the individual's experience of care, and at the same time reducing the per capita costs of care. OBJECTIVES: To evaluate the impact of the ICSGK on the Triple Aim. MATERIALS AND METHODS: The ICSGK is being evaluated externally and internally via a mix of diverse quantitative and qualitative methods. This paper presents selected results for each Triple Aim dimension. RESULTS AND CONCLUSIONS: Regarding population health, most of the quality indicators examined by the external scientific evaluation show positive development. For example, the prevalence of patients with fractures among all insurants with osteoporosis is presented. In 2011, this prevalence was approximately 26 % in the "Kinzigtal" population (aged ≥ 20 years old) in comparison to 33 % in the control group. As far as patient experience is concerned, to the question "Would you recommend becoming a member of Gesundes Kinzigtal to your friends or relatives?" 92.1 % of those questioned answered "Yes, for sure" or "Yes, probably." Twenty-four percent of those questioned further stated that they would now live "more healthy" than before enrolment in the ICSGK. In the subgroup of questioned insurants who had objective agreements with their doctors 45.4 % answered in this way. On the subject of cost-effectiveness, for both participating socil health insurance schemes, cost savings relative to the costs normally expected for the ICSGK population concerned are observed every year. In the seventh intervention year (2012) the total is 4.56 million Euros for the AOK Baden-Württemberg (BW), which is a contribution margin of 146 Euros per insurant for the 31.156 insurants concerned (LKK BW = 322 Euros per insurant relative to cost savings). The results presented in this paper indicate positive effects in all three Triple Aim dimensions. Further longitudinal studies are recommended to validate those first results together with a detailed analysis to obtain in-depth insights into the specific influence of subcomponents of the total intervention.

Effectiveness of the tobacco tactics program in the Department of Veterans Affairs.

PURPOSE: The purpose was to determine the effectiveness of the Tobacco Tactics program in three Veterans Affairs hospitals. METHODS: In this effectiveness trial, inpatient nurses were educated to provide the Tobacco Tactics intervention in Ann Arbor and Detroit, while Indianapolis was the control site (N = 1,070). Smokers were surveyed and given cotinine tests. The components of the intervention included nurse counseling, brochure, DVD, manual, pharmaceuticals, 1-800-QUIT-NOW card, and post-discharge telephone calls. RESULTS: There were significant improvements in 6-month quit rates in the pre- to post-intervention time periods in Ann Arbor (p = 0.004) and Detroit (p < 0.001) compared to Indianapolis. Pre- versus post-intervention quit rates were 4 % compared to 13 % in Detroit, were similar (6 %) pre- and post-intervention in Ann Arbor, and dropped from 26 % to 12 % in Indianapolis. CONCLUSION: The Tobacco Tactics program, which meets the Joint Commission standards that apply to all inpatient smokers, has the potential to significantly decrease smoking among Veterans.

Interrelationship of cranial suture fusion, basicranial development, and resynostosis following suturectomy in twist1(+/-) mice, a murine model of Saethre-Chotzen syndrome.

The interrelationships among suture fusion, basicranial development, and subsequent resynostosis in syndromic craniosynostosis have yet to be examined. The objectives of this study were to determine the potential relationship between suture fusion and cranial base development in a model of syndromic craniosynostosis and to assess the effects of the syndrome on resynostosis following suturectomy. To do this, posterior frontal and coronal suture fusion, postnatal development of sphenooccipital synchondrosis, and resynostosis in Twist1(+/+) (WT) and Twist1(+/-) litter-matched mice (a model for Saethre-Chotzen syndrome) were quantified by evaluating µCT images with advanced image-processing algorithms. The coronal suture in Twist(+/-) mice developed, fused, and mineralized at a faster rate than that in normal littermates at postnatal days 6-30. Moreover, premature fusion of the coronal suture in Twist1(+/-) mice preceded alterations in cranial base development. Analysis of synchondrosis showed faster mineralization in Twist(+/-) mice at postnatal days 25-30. In a rapid resynostosis model, there was an inability to fuse both the midline posterior frontal suture and craniotomy defects in 21-day-old Twist(+/-) mice, despite having accelerated mineralization in the posterior frontal suture and defects. This study showed that dissimilarities between Twist1(+/+) and Twist1(+/-) mice are not limited to a fused coronal suture but include differences in fusion of other sutures, the regenerative capacity of the cranial vault, and the development of the cranial base.

CD4 count is associated with postoperative infection in patients with orthopaedic trauma who are HIV positive.

BACKGROUND: Since the advent of effective antiretroviral therapy, the number of people with AIDS has increased and a certain percentage of these patients will require emergent orthopaedic surgery. Little is known regarding orthopaedic infections and the association of CD4 counts with postoperative infection in patients with HIV infection who experience orthopaedic trauma. QUESTIONS/PURPOSES: We questioned whether the postoperative infection rate is higher after orthopaedic trauma surgery for patients who are HIV positive than for patients who are HIV negative undergoing similar surgery and aimed to identify preoperative variables that may be important in predicting postoperative infection in patients who are HIV positive. METHODS: We determined the postoperative infection rate in 64 patients who were HIV positive and who underwent orthopaedic surgery requiring instrumentation or an implant from January 2001 to May 2007. We compared this rate with historical control data from 2003 to 2007 for all orthopaedic procedures at Grady Memorial Hospital. We examined numerous preoperative variables for association with postoperative infection, including CD4 count, length of inpatient stay, polytrauma, and malnutrition. RESULTS: Of the 64 patients, 15 had postoperative infections develop with an infection rate of 23%, compared with the 3.9% rate for the historical control subjects. Analysis of the 64 patients who were HIV positive revealed CD4 counts less than 300 were associated with development of postoperative infection. Hospital stay, polytrauma, and low serum albumin also were found to be associated with postoperative infection. CONCLUSIONS: It is evident that patients who are HIV positive with low CD4 counts undergoing emergent orthopaedic intervention are a patient population at risk for infection. Further study is necessary to evaluate preoperative and perioperative interventions that may decrease infections in this population. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

In-hospital smoking cessation programs: what do VA patients and staff want and need?

In preparation for delivering an inpatient smoking cessation intervention, surveys and interviews of general inpatients and staff were conducted in two Veterans Affairs (VA) hospitals to determine the motivation of veterans to quit smoking and to identify facilitators and barriers to inpatient staff delivery of inpatient cessation services. Seventy percent of inpatients were "motivated smokers" (thinking of quitting in the next 30 days), yet only 17% stated that they received cessation services during their hospitalization. Most staff said that VA should do more to assist patients to quit, yet less than half said that they personally provided cessation services due to lack of confidence/training and hesitancy to upset patients. Given the high motivation to quit among hospitalized veterans and the lack of knowledge about providing cessation services among nurses, training health professionals may facilitate and overcome barriers to the provision of these services. As frontline providers, nurses are ideally positioned to deliver inpatient smoking cessation services to hospitalized veterans.

[Hip Osteoarthritis - Epidemiology and Current Medical Care Situation - Health Care Data of 2.4 Million AOK Baden-Württemberg Insurees Aged 40 Years or Older]. / Koxarthrose ­ Epidemiologie und Versorgungsrealität ­ Versorgungsdatenanalyse von 2,4 Millionen Versicherten der AOK Baden-Württemberg ab 40 Jahren.

BACKGROUND: Due to demographic changes an increasing number of hip osteoarthritis can be expected with corresponding effects on the health care system. Hence, the objectives of our study were to obtain substantiated evidence about current medical care situation of hip osteoarthritis patients including outpatient care situation and hip replacement surgery. PATIENTS AND METHODS: Overall, the medical care data of 2.4 million insurees of the AOK Baden-Württemberg for the years 2007 to 2016 were analyzed. Lower limit of age was 40 years. The data includes outpatient and inpatient healthcare claims. RESULTS: The age standardized prevalence of hip osteoarthritis in adults aged 40 years or older is 6.18% (95% CI: ± 0.09%) among women and 6.02% (95% CI: ± 0.09%) among men. From the age of 75, sex differences become significant. The maximum number of newly diagnosed cases of hip osteoarthritis (women: 1.31%, men: 1.16%) is found in the 80 - 84-year-olds. From the age of 85, 17.4% of all women and 16.5% of all men show a hip osteoarthritis. The maximum number of hip replacement surgery among osteoarthritis patients (women: 5.2%, men: 4.3%) appears in the 75- to 79-year-olds. After the initial diagnosis of a hip osteoarthritis, every eighth (13.0%) AOK insured person receives a hip replacement surgery within the first year and one in four (24.8%) insurees within 8 years. Irrespective of the main diagnosis, numbers of hip replacement surgery did not increase between 2009 and 2016. On average, 300.9 (women) and 275.8 (men) hip replacement surgeries were performed per 100 000 insured years. From the age of 80, hip osteoarthritis drops back as the main diagnosis fur surgery. Consequently, from the age of 85 more than 70% of all hip replacement patients show a femoral fracture as main diagnosis. Only about ¾ of the hip osteoarthritis patients were in outpatient specialist care in the year before surgery, and far less than half of hip osteoarthritis patients received a referral to physiotherapy. CONCLUSION: Osteoarthritis of the hip occurs approximately equally often in women and men up to the age of 75 years. Nevertheless, women underwent surgery more frequently. Overall, the number of hip replacement surgery has not increased in the last eight years. Within the first eight years after initial diagnosis of hip osteoarthritis 24.8% of all patients receive a hip TEP. Hence, the majority of patients is treated conservatively in the first eight years. A direct comparison between incidence and prevalent hip osteoarthritis patients reveals that after many years of therapeutic care in the last 1 - 2 years prior to surgery, both the specialist care as well as the referral to physiotherapy are reduced. A reassessment of conservative treatment options over time seems to be necessary.

Role of α2ß1 integrins in mediating cell shape on microtextured titanium surfaces.

Surface microroughness plays an important role in determining osteoblast behavior on titanium. Previous studies have shown that osteoblast differentiation on microtextured titanium substrates is dependent on alpha-2 beta-1 (α2ß1) integrin signaling. This study used focused ion beam milling and scanning electron microscopy, combined with three-dimensional image reconstruction, to investigate early interactions of individual cells with their substrate and the role of integrin α2ß1 in determining cell shape. MG63 osteoblast-like cells on sand blasted/acid etched (SLA) Ti surfaces after 3 days of culturing indicated decreased cell number, increased cell differentiation, and increased expression of mRNA levels for α1, α2, αV, and ß1 integrin subunits compared to cells on smooth Ti (PT) surfaces. α2 or ß1 silenced cells exhibited increased cell number and decreased differentiation on SLA compared to wild-type cells. Wild-type cells on SLA possessed an elongated morphology with reduced cell area, increased cell thickness, and more apparent contact points. Cells on PT exhibited greater spreading and were relatively flat. Silenced cells possessed a morphology and phenotype similar to wild-type cells grown on PT. These observations indicate that surface microroughness affects cell response via α2ß1 integrin signaling, resulting in a cell shape that promotes osteoblastic differentiation.

Rapidly polymerizing injectable click hydrogel therapy to delay bone growth in a murine re-synostosis model.

Craniosynostosis is the premature fusion of cranial sutures, which can result in progressive cranial deformations, increased intracranial pressure, and restricted brain growth. Most cases of craniosynostosis require surgical reconstruction of the cranial vault with the goal of increasing the intracranial volume and correcting the craniofacial deformities. However, patients often experience rapid post-operative bone regrowth, known as re-synostosis, which necessitates additional surgical intervention. Bone morphogenetic protein (BMP) inhibitors have tremendous potential to treat re-synostosis, but the realization of a clinically viable inhibitor-based therapeutic requires the development of a delivery vehicle that can localize the release to the site of administration. Here, we present an in situ rapidly crosslinking injectable hydrogel that has the properties necessary to encapsulate co-administered proteins and demonstrate that the delivery of rmGremlin1 via our hydrogel system delays bone regrowth in a weanling mouse model of re-synostosis. Our hydrogel is composed of two mutually reactive poly(ethylene glycol) macromolecules, which when mixed crosslink via a bio-orthogonal Cu free click reaction. Hydrogels containing Gremlin caused a dose dependent inhibition of bone regrowth. In addition to craniofacial applications, our injectable click hydrogel has the potential to provide customizable protein, small molecule, and cell delivery to any site accessible via needle or catheter.

Rapid re-synostosis following suturectomy in pediatric mice is age and location dependent.

Craniosynostosis is the premature fusion of the cranial sutures early in development. If left untreated, craniosynostosis can lead to complications resulting from cranial deformities or increased intracranial pressure. The standard treatment involves calvarial reconstruction, which in many cases undergoes rapid re-synostosis. This requires additional surgical intervention that is associated with a high incidence of life threatening complications. To better understand this rapid healing, a pediatric mouse model of re-synostosis was developed and characterized. Defects (1.5mm by 2.5mm) over the posterior frontal suture were created surgically in weanling (21 days post-natal) and adolescent (50 days post-natal) C57Bl/6J mice. In addition, defects were created in the frontal bone lateral to the posterior frontal suture. The regeneration of bone in the defect was assessed using advanced image processing algorithms on micro-computed tomography scans. The genes associated with defect healing were assessed by real-time PCR of mRNA isolated from the tissue present in the defect. The results showed that the weanling mouse healed in a biphasic process with bone bridging the defect by post-operative (post-op) day 3 followed by an increase in the bone volume on day 14. In adolescent mice, there was a delay in bone bridging across the defect, and no subsequent increase in bone volume. No bridging of the defect by 14 days post-op was seen in identically sized defects placed lateral to the suture in both weanling and adolescent animals. This study demonstrates that bone regeneration in the cranium is both age and location dependent. Rapid and robust bone regeneration only occurred when the defect was created over the posterior frontal suture in immature weanling mice.

Biphasic fusion of the murine posterior frontal suture.

BACKGROUND: Craniosynostosis is the premature fusion of cranial sutures early in development. Mice are commonly used to study the mechanisms driving both normal and pathologic cranial suture development. Despite their frequency of use as a model, the time course of bone formation and mineralization during fusion of mouse posterior frontal suture is not well defined. METHODS: To address this, C57Bl/6J mice were euthanized at ages ranging from 6 to 107 days, and the posterior frontal sutures were imaged using micro-computed tomography. Scans were analyzed with an image-processing algorithm that was previously validated with serial histology to quantify both suture fusion and mineral content. The expression profile of genes associated with key developmental time points was examined using real-time polymerase chain reaction in both the bone and the dura. RESULTS: Results demonstrate that the bones of the posterior frontal suture come together during days 10 to 20 and then increase in mineral content and volume between days 21 and 45. The onset of posterior frontal suture fusion was associated with an increase in cartilage-associated genes on day 12. Later mineralization of the suture was associated with an increase in mRNAs for osteoblast differentiation markers, bone morphogenetic proteins, and bone morphogenetic protein inhibitors. CONCLUSIONS: Complete analysis fusion posterior frontal suture shows that it occurs in a discontinuous biphasic manner. The first phase is from days 10 to 20 and involves production of cartilage. A second mineralization phase from days 21 to 45 was seen with both the imaging algorithm and changes in gene expression.

Algorithm to assess cranial suture fusion with varying and discontinuous mineral density.

One of the most difficult challenges in medical imaging is the accurate segmentation of mineralized tissues. This process is complicated when studying developmental or regenerative processes due to the changes in mineral density that these tissues undergo over time. To address these limitations an algorithm was developed to enable the use of computed tomography (CT) to study tissues of varying and heterogeneous mineralization. To examine and validate this algorithm a study was performed on the development of murine cranial sutures. C57Bl/6J mice ranging in age from 6 to 25 days were imaged using micro-CT (µCT). The algorithm was developed to segment the bones of both the posterior frontal (PF) and coronal (COR) sutures. For the curved COR suture, an addition to the algorithm was developed to reconstruct images that were perpendicular to the suture about all three axes. The algorithm showed excellent linear correlation (R (2) > 0.96) with serial histomorphometry and nearly a 1:1 relationship between all measures. The algorithm was validated with serial histology. The algorithm showed that the PF suture fused between days 12 and 20 but then showed a significant increase in bone volume after day 20. The algorithm developed provides an accurate method to segment the irregular sutures of the mouse calvaria.

Use of molecular beacons to image effects of titanium surface microstructure on beta1 integrin expression in live osteoblast-like cells.

This study used molecular beacon technology to examine substrate-dependent changes in integrin subunit expression in living cells. Molecular beacons are oligonucleotide probes that can be delivered into live cells to allow for real-time imaging of mRNA. They have a stem-loop hairpin structure with a fluorophore-quencher pair, which opens when bound to the target mRNA sequence, resulting in a fluorescent signal upon excitation. A novel molecular beacon that is specific to the beta1 integrin subunit mRNA was developed and used to image osteoblast-like MG63 cells in vitro on both glass and titanium surfaces of varying roughness. Specificity was verified by comparing the molecular beacon signal intensities to real-time PCR results in both wild-type cells and cells with shRNA knockdown of beta1 integrin mRNA. The molecular beacon was able to detect changes due to both surface microtopography and silencing of the mRNA target. The results showed that effects of the substrate on beta1 mRNA noted previously in confluent cultures were evident in pre-confluent cells as well, supporting the hypothesis that beta1 integrin pairs are important in proliferation as well as differentiation of osteoblasts. This technique overcomes the limitations of traditional gene assays (PCR, immunofluorescence) by allowing for the real-time measurement and tracking of specific mRNAs in individual live cells prior to confluence.