Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity.

The objective of this study was to evaluate the impact of quality improvement (QI) and patient safety initiatives and data disaggregation on racial disparities in severe maternal morbidity from hemorrhage (SMM-H).Our hospital began monitoring and reporting on SMM-overall and SMM-H rates in 2018 using administrative data. In March 2019, we began stratifying data by race and ethnicity and noted a disparity in rates, with non-Hispanic Black women having the highest SMM rates. The data was presented as run charts at monthly department meetings. During this time, our hospital implemented several QI and patient safety initiatives around obstetric hemorrhage and used the stratified data to inform guideline development to reduce racial disparity. The initiatives included implementation of a hemorrhage patient safety bundle and in-depth case reviews of adverse patient outcomes with a health equity focus. We then retrospectively analyzed our data. Our outcome of interest was SMM-H prior to data stratification (pre-intervention: June 2018-February 2019) as compared to after data stratification (post-intervention: March 2019-June 2020).During our study time period, there were 13,659 deliveries: 37% Hispanic, 35% White, 20% Black, 7% Asian and 1% Other. Pre-intervention, there was a statistically significant difference between Black and White women for SMM-H rates (p<0.001). This disparity was no longer significant post-intervention (p=0.138). The rate of SMM-H in Black women decreased from 45.5% to 31.6% (p=0.011).Our findings suggest that QI and patient safety efforts that incorporate race and ethnicity data stratification to identify disparities and use the information to target interventions have the potential to reduce disparities in SMM.

Expect the Unexpected: A Qualitative Study of the Ripple Effects of Children's Mental Health Services Implementation Efforts.

Background: Strategies to implement evidence-based interventions (EBIs) in children's mental health services have complex direct and indirect causal impacts on multiple outcomes. Ripple effects are outcomes caused by EBI implementation efforts that are unplanned, unanticipated, and/or more salient to stakeholders other than researchers and implementers. The purpose of the current paper is to provide a compilation of possible ripple effects associated with EBI implementation strategies in children's mental health services, to be used for implementation planning, research, and quality improvement. Methods: Participants were identified via expert nomination and snowball sampling. Online surveys were completed by 81 participants, each representing one of five roles: providers of mental health services to children or youth, researchers, policy makers, caregivers, and youth. A partially directed conventional content analysis with consensus decision making was used to code ripple effects. Results: Four hundred and four unique responses were coded into 66 ripple effects and 14 categories. Categories include general knowledge, skills, attitudes, and confidence about using EBIs; general job-related ripple effects; EBI treatment adherence, fidelity, and alignment; gaming the system; equity and stigma; shifting roles, role clarity, and task shifting; economic costs and benefits; EBI treatment availability, access, participation, attendance, barriers, and facilitators; clinical process and treatment quality; client engagement, therapeutic alliance, and client satisfaction; clinical organization structure, relationships in the organization, process, and functioning; youth client and caregiver outcomes; and use of EBI strategies and insights in one's own life. Conclusions: This research advances the field by providing children's mental health implementers, researchers, funders, policy makers, and consumers with a menu of potential ripple effects. It can be a practical tool to ensure compliance with guidance from Quality Improvement/Quality Assurance, Complexity Science, and Diffusion of Innovation Theory. Future phases will match potential ripple effects with salient children's mental health implementation strategies for each participant role.

Training Needs of Peer and Non-Peer Transition Service Providers: Results of a National Survey.

Participatory action research processes guided a national online survey of service providers working with transition age youth with mental health challenges. The survey investigated transition service providers' ratings of the importance of competencies and skills, self-assessed need for training in these competencies and skills, their preferred training modalities, and obstacles to engaging in training. The 254 participants identified trauma-informed care, understanding youth culture, promoting natural supports, and using culturally responsive practices as most important training needs. Age, years in current job, years in transition work, and race/ethnicity predicted training needs regarding some competencies and skills. Peer providers expressed preferences for young adult-led training. Qualitative responses highlighted training needs for supporting specific underserved populations: youth from communities of color, LGBTQ youth, and those with co-occurring disorders. Results may guide future training initiatives for peer support and non-peer support providers and workforce development initiatives designed to improve behavioral health services for young people.

[18F]fluorothymidine PET imaging in the diagnosis of leptomeningeal involvement with diffuse large B-cell lymphoma.

The diagnosis of leptomeningeal carcinomatosis remains difficult despite improvement in central nervous system (CNS) imaging and cytologic examination of the cerebral spinal fluid. False-negative results are common, providing obstacles in assessing both prophylactic and therapeutic efforts. As a result of increased survival of patients with a variety of systemic neoplasms it is likely that central nervous involvement will need to be addressed more often. This article presents a patient with a diffuse large B-cell lymphoma with polymorphic features. Imaging using 18F-labeled fluorodeoxythymidine (FLT) proved useful in demonstrating both parenchymal and leptomeningeal CNS involvement. The potential for FLT to identify proliferative tissue may make it uniquely suitable for detection of CNS malignant disease.

Effect of radiotherapy and chemotherapy on bone marrow activity: a 18F-FLT-PET study.

BACKGROUND: Radiotherapy (RT) and chemotherapy are important treatment modalities for a variety of malignant tumor types. During therapy for malignant diseases, often the limitation for further therapy is determined by the capability of the bone marrow to withstand radiochemotherapeutic effects. Evaluation of hematologic toxicity is commonly performed with peripheral blood counts, and occasionally, sampling of marrow through a bone marrow biopsy. Neither method provides a comprehensive assessment, as bone marrow biopsy is invasive, and both are subject to sampling variability. Fluorine-18-3'-fluoro-3'-deoxy-L-thymidine-PET (18F-FLT-PET) is a noninvasive method and related to the rate of DNA synthesis and visualizes the high cycling activity of hematopoietic cells in the bone marrow compartment. To prove the clinical consistency of marrow function and imaging, we investigated populations of patients typically seen in clinical practice, after radiation and chemotherapy. In this feasibility study, patients were evaluated (i) to prove the ability of visualization and quantification of the activity of the bone marrow compartment with 18F-FLT-PET and (ii) to examine the effect of RT and chemotherapy on bone marrow activity and the correlation with clinical findings. METHODS: Bone marrow activity in the cervical region of 10 patients with laryngeal carcinoma who received a mean total dose of 68 Gy (range 30-41 fractions) was evaluated with 18F-FLT-PET, before and 1 month after RT. Whole body FLT images were assessed in nine patients with nonseminomatous testicular germ cell tumor, before and 6 months after the last chemotherapy, consisting of four courses of bleomycin, cisplatin, and etoposide. The maximum standardized uptake value (SUVmax) was used to quantify FLT uptake in bone marrow at the standard bone marrow regions. RESULTS: A significant decrease in 18F-FLT-PET uptake was observed in all the studied laryngeal carcinoma patients in the cervical region after RT of the adjacent bone marrow compartment. Tumor stage and additional field-of-view of RT were inversely related to the 18F-FLT uptake in bone marrow. The mean 18F-FLT SUVmax before RT was 3.0+/-1.34 and after RT was 1.94+/-0.60 (P=0.013). The mean 18F-FLT SUVmax of the spine (Th5-Th12) regions outside the field-of-view of RT were stable and reproducible and not significantly different (5.56+/-1.56 vs. 5.16+/-1.35, P=0.16). Chemotherapy did not result in a significant difference of whole body SUVmax value, with a mean SUVmax of 4.99+/-1.15 prechemotherapy, and a mean SUVmax of 5.28+/-1.0 postchemotherapy (P=0.21). Laboratory analysis of the hematologic parameters confirmed repopulation of the bone marrow. CONCLUSION: 18F-FLT uptake in the bone marrow decreases after RT, but not after chemotherapy. We conclude that 18F-FLT-PET is a potential noninvasive tool that can be used in the assessment of quantification of cellular division in the hematopoietic organ.

F-18-fluorothymidine-PET evaluation of bone marrow transplant in a rat model.

OBJECTIVE: The success of bone marrow transplantation in hematologic and oncologic diseases depends upon the ability to provide adequate hematologic and immunologic support in a timely manner. There is no current imaging tool for the evaluation of the bone marrow compartment in the peri-transplant period. In this study, we tested our hypothesis that whole-body positron emission tomography using fluorine-18 (F-18)-fluorothymidine has the ability to provide information about the functioning normal bone marrow and its physiologic distribution. METHODS: Wistar Furth rats were irradiated with 950 cGy followed 2 days later by syngeneic bone marrow transplantation. The animals were subjected to positron emission tomography using F-18-fluorothymidine imaging before and after ablation as well as after 4, 7, and 14 days after bone marrow transplantation. In a different set of syngeneic bone marrow transplant model, positron emission tomography using F-18-fluorodeoxyglucose was carried out for comparison. Imaging results were correlated with marrow histology upon necropsy. RESULTS: F-18-fluorothymidine images showed definitive recovery of marrow within 4 days after transplant. In contrast, F-18-fluorodeoxyglucose was unable to present a corresponding picture. Sternum and humerus marrow in the images were analyzed by drawing three-dimensional regions of interest to obtain quantitative uptake value of tracers, which corroborated the image data. CONCLUSION: We conclude that positron emission tomography using F-18-fluorothymidine offers a clinically useful noninvasive technique to evaluate bone marrow injury and recovery.