Cross-setting Comparison of Risk Factors for Pressure Injuries Acquired in Post-Acute Care.

GENERAL PURPOSE: To provide information on the association between risk factors and the development of new or worsened stage 2 to 4 pressure injuries (PIs) in patients in long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Compare the unadjusted PI incidence in SNF, IRF, and LTCH populations.2. Explain the extent to which the clinical risk factors of functional limitation (bed mobility), bowel incontinence, diabetes/peripheral vascular disease/peripheral arterial disease, and low body mass index are associated with new or worsened stage 2 to 4 PIs across the SNF, IRF, and LTCH populations.3. Compare the incidence of new or worsened stage 2 to 4 PI development in SNF, IRF, and LTCH populations associated with high body mass index, urinary incontinence, dual urinary and bowel incontinence, and advanced age.

To compare the incidence of new or worsened pressure injuries (PIs) and associated risk factors for their development in inpatient post-acute care settings: long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). The authors investigated Medicare Part A SNF resident stays and LTCH patient stays that ended between October 1, 2016 and December 31, 2016 and IRF patient stays that ended between October 1, 2016 and March 31, 2017. They calculated the incidence of new or worsened PIs using the specifications of the National Quality Forum-endorsed PI quality measure #0678: Percent of Residents or Patients with Pressure Ulcers that are New or Worsened . The incidences of new or worsened stages 2 through 4 PIs varied across settings: 1.23% in SNFs, 1.56% in IRFs, and 3.07% in LTCHs. Seven risk factors were positively and consistently associated with new or worsened PIs across settings: limited bed mobility, bowel incontinence, low body mass index, diabetes/peripheral vascular disease/peripheral arterial disease, advanced age, urinary incontinence, and dual urinary and bowel incontinence. These findings provide empirical support for the alignment of risk factors for the PI quality measures across post-acute care settings.

Effects of the Anti-stigma Workplace Intervention "Working Mind" in a Canadian Health-Care Setting: A Cluster-Randomized Trial of Immediate Versus Delayed Implementation.

OBJECTIVES: The Working Mind is a program designed to reduce stigmatizing attitudes toward mental illness, improve resilience, and promote mental health in the general workplace. Previous research has revealed positive program effects in a variety of workplace settings. This study advances previous work in implementing randomization and a control group to assess the intervention's efficacy. METHODS: The program was evaluated using a cluster-randomized design, with pretest, posttest, and a 3-month follow-up in 2 implementation groups across 4 sites. RESULTS: The Working Mind program was effective at decreasing mental health stigma and increasing self-reported resilience and coping skills at the pre-post assessment in both delivery groups. The program's effects were maintained to the time of 3-month follow-up. Qualitative data provided further evidence that participants benefited from the program. CONCLUSIONS: This study represents an advancement over past research and provides further support for efficacy of the Working Mind program. Directions for future research, including replication using rigorous methodological procedures and examination of program effects over longer follow-up intervals, are discussed.

Evaluating Hospital Readmission Rates After Discharge From Inpatient Rehabilitation.

OBJECTIVE: To examine facility-level rates of all-cause, unplanned hospital readmissions for 30 days after discharge from inpatient rehabilitation facilities (IRFs). DESIGN: Observational design. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Medicare fee-for-service beneficiaries (N=567,850 patient-stays). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The outcome is all-cause, unplanned hospital readmission rates for IRFs. We adapted previous risk-adjustment and statistical approaches used for acute care hospitals to develop a hierarchical logistic regression model that estimates a risk-standardized readmission rate for each IRF. The IRF risk-adjustment model takes into account patient demographic characteristics, hospital diagnoses and procedure codes, function at IRF admission, comorbidities, and prior hospital utilization. We presented national distributions of observed and risk-standardized readmission rates and estimated confidence intervals to make statistical comparisons relative to the national mean. We also analyzed the number of days from IRF discharge until hospital readmission. RESULTS: The national observed hospital readmission rate by 30 days postdischarge from IRFs was 13.1%. The mean unadjusted readmission rate for IRFs was 12.4%±3.5%, and the mean risk-standardized readmission rate was 13.1%±0.8%. The C-statistic for our risk-adjustment model was .70. Nearly three-quarters of IRFs (73.4%) had readmission rates that were significantly different from the mean. The mean number of days to readmission was 13.0±8.6 days and varied by rehabilitation diagnosis. CONCLUSIONS: Our results demonstrate the ability to assess 30-day, all-cause hospital readmission rates postdischarge from IRFs and the ability to discriminate between IRFs with higher- and lower-than-average hospital readmission rates.

Patient experience and process measures of quality of care at home health agencies: Factors associated with high performance.

We examined the effects of provider characteristics on home health agency performance on patient experience of care (Home Health CAHPS) and process (OASIS) measures. Descriptive, multivariate, and factor analyses were used. While agencies score high on both domains, factor analyses showed that the underlying items represent separate constructs. Freestanding and Visiting Nurse Association agencies, higher number of home health aides per 100 episodes, and urban location were statistically significant predictors of lower performance. Lack of variation in composite measures potentially led to counterintuitive results for effects of organizational characteristics. This exploratory study showed the value of having separate quality domains.

Cross-setting Comparison of Risk Factors for Pressure Injuries Acquired in Post-Acute Care.

GENERAL PURPOSE: To provide information on the association between risk factors and the development of new or worsened stage 2 to 4 pressure injuries (PIs) in patients in long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Compare the unadjusted PI incidence in SNF, IRF, and LTCH populations.2. Explain the extent to which the clinical risk factors of functional limitation (bed mobility), bowel incontinence, diabetes/peripheral vascular disease/peripheral arterial disease, and low body mass index are associated with new or worsened stage 2 to 4 PIs across the SNF, IRF, and LTCH populations.3. Compare the incidence of new or worsened stage 2 to 4 PI development in SNF, IRF, and LTCH populations associated with high body mass index, urinary incontinence, dual urinary and bowel incontinence, and advanced age.

Self-efficacy in bipolar disorder: Development and validation of a self-report scale.

BACKGROUND: Successful management of bipolar disorder (BPD) typically involves individuals undertaking a complex array of self-management tasks (e.g., taking medication, monitoring symptoms, following a regular sleep routine). Many people with BPD doubt they can successfully undertake these tasks. This low sense of self-efficacy may lead to the perpetuation of BPD symptoms, poor quality of life, and low adherence to treatment. Research on self-efficacy in BPD has been hampered by the lack of a short, reliable and valid self-report scale that is practical to use in clinical and research settings. We sought to develop such a scale. METHODS: BPD patients (N = 303) completed a new battery of items measuring their self-efficacy for performing BPD self-management tasks. Modern psychometric techniques such as bifactor analyses were used to refine the scale, determine an appropriate scoring algorithm, and establish reliability and validity. RESULTS: The Bipolar Self-Efficacy Scale (BPSES) comprises 17 items. BPSES scores were reliable, sensitive to change, and correlated with theoretically related constructs such as social adjustment and positive affect. BPSES scores had substantially higher associations with depression and quality of life than an alternative instrument that measured self-efficacy in general, rather than self-efficacy specifically related to bipolar disorder self-management. LIMITATIONS: Patients were required to be medically managed while attending adjunctive psychological treatment of BPD. CONCLUSIONS: The BPSES is a brief scale that can be used to reliably and validly measure bipolar self-efficacy. It may be fruitful to use the scale in clinical practice, and studies investigating treatment outcomes, mechanisms, and moderators.

In Vivo Modeling of Chemoresistant Neuroblastoma Provides New Insights into Chemorefractory Disease and Metastasis.

Neuroblastoma is a pediatric cancer that is frequently metastatic and resistant to conventional treatment. In part, a lack of natively metastatic, chemoresistant in vivo models has limited our insight into the development of aggressive disease. The Th-MYCN genetically engineered mouse model develops rapidly progressive chemosensitive neuroblastoma and lacks clinically relevant metastases. To study tumor progression in a context more reflective of clinical therapy, we delivered multicycle treatment with cyclophosphamide to Th-MYCN mice, individualizing therapy using MRI, to generate the Th-MYCN CPM32 model. These mice developed chemoresistance and spontaneous bone marrow metastases. Tumors exhibited an altered immune microenvironment with increased stroma and tumor-associated fibroblasts. Analysis of copy number aberrations revealed genomic changes characteristic of human MYCN-amplified neuroblastoma, specifically copy number gains at mouse chromosome 11, syntenic with gains on human chromosome 17q. RNA sequencing revealed enriched expression of genes associated with 17q gain and upregulation of genes associated with high-risk neuroblastoma, such as the cell-cycle regulator cyclin B1-interacting protein 1 (Ccnb1ip1) and thymidine kinase (TK1). The antiapoptotic, prometastatic JAK-STAT3 pathway was activated in chemoresistant tumors, and treatment with the JAK1/JAK2 inhibitor CYT387 reduced progression of chemoresistant tumors and increased survival. Our results highlight that under treatment conditions that mimic chemotherapy in human patients, Th-MYCN mice develop genomic, microenvironmental, and clinical features reminiscent of human chemorefractory disease. The Th-MYCN CPM32 model therefore is a useful tool to dissect in detail mechanisms that drive metastasis and chemoresistance, and highlights dysregulation of signaling pathways such as JAK-STAT3 that could be targeted to improve treatment of aggressive disease. SIGNIFICANCE: An in vivo mouse model of high-risk treatment-resistant neuroblastoma exhibits changes in the tumor microenvironment, widespread metastases, and sensitivity to JAK1/2 inhibition.

Home health agency profit orientation and risk for hospitalization: a propensity score analysis of population weighted data.

Little recent research exists identifying home health agency (HHA) organizational characteristics that influence home health quality. This study evaluates the impact of HHA profit orientation on quality, measured as patient risk for hospitalization within 60 days of agency admission. Our sample (n = 1,304), from the National Home and Hospice Care Survey, comprised noninstitutionalized patients, 18 and older, including all payer types, discharged from free-standing HHAs. Our most deconfounded estimate, derived by propensity score adjusted, weighted polytomous logistic regression, yielded a for-profit hospitalization odds ratio of 1.31 but with a large confidence interval including unity. Results do not support our hypothesis of higher hospitalization risk for for-profit HHA patients.

Preclinical transgenic and patient-derived xenograft models recapitulate the radiological features of human adamantinomatous craniopharyngioma.

To assess the clinical relevance of transgenic and patient-derived xenograft models of adamantinomatous craniopharyngioma (ACP) using serial magnetic resonance imaging (MRI) and high resolution post-mortem microcomputed tomography (µ-CT), with correlation with histology and human ACP imaging. The growth patterns and radiological features of tumors arising in Hesx1Cre/+ ;Ctnnb1lox(ex3)/+ transgenic mice, and of patient-derived ACP xenografts implanted in the cerebral cortex, were monitored longitudinally in vivo with anatomical and functional MRI, and by ex vivo µ-CT at study end. Pathological correlates with hematoxylin and eosin stained sections were investigated. Early enlargement and heterogeneity of Hesx1Cre/+ ;Ctnnb1lox(ex3)/+ mouse pituitaries was evident at initial imaging at 8 weeks, which was followed by enlargement of a solid tumor, and development of cysts and hemorrhage. Tumors demonstrated MRI features that recapitulated those of human ACP, specifically, T1 -weighted signal enhancement in the solid tumor component following Gd-DTPA administration, and in some animals, hyperintense cysts on FLAIR and T1 -weighted images. Ex vivo µ-CT correlated with MRI findings and identified smaller cysts, which were confirmed by histology. Characteristic histological features, including wet keratin and calcification, were visible on µ-CT and verified by histological sections of patient-derived ACP xenografts. The Hesx1Cre/+ ;Ctnnb1lox(ex3)/+ transgenic mouse model and cerebral patient-derived ACP xenografts recapitulate a number of the key radiological features of the human disease and provide promising foundations for in vivo trials of novel therapeutics for the treatment of these tumors.

Lipids and lactate in human immunodeficiency virus-1 infected pregnancies with or without protease inhibitor-based therapy.

OBJECTIVE: To evaluate the effect of protease inhibitors on lipid and lactate levels and gastrointestinal symptoms in pregnancy. METHODS: Acquired Immunodeficiency Syndrome (AIDS) Clinical Trials Group (ACTG) A5084 was an observational cohort study of human immunodeficiency virus (HIV)-infected pregnant women. Women recruited between 20 and 34 weeks of gestation were required to be on a stable, highly active antiretroviral therapy (HAART) regimen, stratified by protease inhibitor compared with no protease inhibitor regimens. Interval history was assessed, and lipid and lactate levels were drawn every 8 weeks during pregnancy and 12 weeks postpartum, with levels closest to delivery and postpartum used for analysis. Statistical comparisons used Kruskal-Wallis and Fisher exact tests. RESULTS: One-hundred fifty-eight women were evaluated. Total cholesterol levels (median 230 mg/dL, interquartile range [197, 259], compared with 212 [179, 246] mg/dL, P=.042) and triglycerides (median 224 mg/dL, interquartile range [187, 288], compared with 185 [142, 230] mg/dL, P<.001] were elevated in the protease inhibitor group during pregnancy and remained higher in this group after delivery (total cholesterol 185 [163, 224] mg/dl compared with 171 [140, 190] mg/dL, P<.004; triglycerides 122 [87, 175] mg/dL compared with 89 [66, 150] mg/dL, P=.02). No difference was seen in lactate levels or rates of gastrointestinal symptoms between groups. Obstetric outcomes were similar between the two groups. A higher number of low birth weight infants were born to women in the highest twentieth percentile of triglycerides compared with the lowest across medication groups. CONCLUSION: Cholesterol and triglycerides were higher in protease inhibitor-treated women in pregnancy. Lactate and gastrointestinal symptoms were not different. A higher number of low birth weight infants were noted in women with high triglycerides, but other elevated lipid levels did not affect pregnancy outcomes. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00017797 LEVEL OF EVIDENCE: II.

p53 Loss in MYC-Driven Neuroblastoma Leads to Metabolic Adaptations Supporting Radioresistance.

Neuroblastoma is the most common childhood extracranial solid tumor. In high-risk cases, many of which are characterized by amplification of MYCN, outcome remains poor. Mutations in the p53 (TP53) tumor suppressor are rare at diagnosis, but evidence suggests that p53 function is often impaired in relapsed, treatment-resistant disease. To address the role of p53 loss of function in the development and pathogenesis of high-risk neuroblastoma, we generated a MYCN-driven genetically engineered mouse model in which the tamoxifen-inducible p53ER(TAM) fusion protein was expressed from a knock-in allele (Th-MYCN/Trp53(KI)). We observed no significant differences in tumor-free survival between Th-MYCN mice heterozygous for Trp53(KI) (n = 188) and Th-MYCN mice with wild-type p53 (n = 101). Conversely, the survival of Th-MYCN/Trp53(KI/KI) mice lacking functional p53 (n = 60) was greatly reduced. We found that Th-MYCN/Trp53(KI/KI) tumors were resistant to ionizing radiation (IR), as expected. However, restoration of functional p53ER(TAM) reinstated sensitivity to IR in only 50% of Th-MYCN/Trp53(KI/KI) tumors, indicating the acquisition of additional resistance mechanisms. Gene expression and metabolic analyses indicated that the principal acquired mechanism of resistance to IR in the absence of functional p53 was metabolic adaptation in response to chronic oxidative stress. Tumors exhibited increased antioxidant metabolites and upregulation of glutathione S-transferase pathway genes, including Gstp1 and Gstz1, which are associated with poor outcome in human neuroblastoma. Accordingly, glutathione depletion by buthionine sulfoximine together with restoration of p53 activity resensitized tumors to IR. Our findings highlight the complex pathways operating in relapsed neuroblastomas and the need for combination therapies that target the diverse resistance mechanisms at play. Cancer Res; 76(10); 3025-35. ©2016 AACR.

Racial and Ethnic Disparities in Patients' Experience With Skilled Home Health Care Services.

Racial and ethnic disparities are found in many health care settings; however, there is little prior research on such disparities among patients receiving home health care services. This study used 2012 Home Health Care CAHPS(®) data to identify any overall patient-level disparities in self-reported experience of care and to decompose these disparities according to whether they result from within-agency versus between-agency differences. Although patient experience of care ratings were high across all groups, the study identified consistently lower ratings for all minority groups on two of three Home Health Care CAHPS measures, with Asians reporting the greatest disparities. Three quarters of disparities were found to be within-agency disparities, which were primarily related to care processes and provider/patient communications rather than to specific health care services received. Despite high ratings in general, home health agencies may need to focus on cultural competency initiatives to address racial and ethnic disparities within their agencies.

Pain assessment in the paediatric Emergency Department: whose view counts?

OBJECTIVES: To compare patient, guardian and professional assessment of acute pain in children presenting to an Emergency Department, and to examine whether there was a correlation between the scores obtained using the Faces and linear scales for each group. METHODS: A prospective, observational cohort study of 73 children aged 4-14 years attending a paediatric hospital Emergency Department between March and April 2002 with pain caused by an acute injury. The child's pain on admission, as estimated by the child, their guardian and a healthcare professional (nurse/doctor/emergency nurse practitioner) was recorded using a Faces scale and a linear scale. RESULTS: Professionals consistently score pain lower [median linear scale score 3.1; interquartile range (IQR) 1.6-5.3] than do patients (6.6; 4.9-7.4) or guardians (6.0; 3.9-7.1) using both linear and Faces scales. There is a significant correlation between pain scores obtained using the two scales for professionals [Spearman R value 0.88; 95% confidence interval (CI) 0.82-0.93], guardians (0.83; 0.74-0.89) and patients (0.42; 0.21-0.59). CONCLUSION: Professionals score pain lower than do children or guardians. Similar pain scores are obtained using both a Faces and a linear scale. This study offers no support for the introduction of a uniform pain assessment tool in a paediatric Emergency Department setting.

Spectral clustering with epidemic diffusion.

Spectral clustering is widely used to partition graphs into distinct modules or communities. Existing methods for spectral clustering use the eigenvalues and eigenvectors of the graph Laplacian, an operator that is closely associated with random walks on graphs. We propose a spectral partitioning method that exploits the properties of epidemic diffusion. An epidemic is a dynamic process that, unlike the random walk, simultaneously transitions to all the neighbors of a given node. We show that the replicator, an operator describing epidemic diffusion, is equivalent to the symmetric normalized Laplacian of a reweighted graph with edges reweighted by the eigenvector centralities of their incident nodes. Thus, more weight is given to edges connecting more central nodes. We describe a method that partitions the nodes based on the componentwise ratio of the replicator's second eigenvector to the first and compare its performance to traditional spectral clustering techniques on synthetic graphs with known community structure. We demonstrate that the replicator gives preference to dense, clique-like structures, enabling it to more effectively discover communities that may be obscured by dense intercommunity linking.