Improving Patient Outcomes Using Measures to Increase Discharge Rates to Home.

Background Post-acute care (PAC) centers are facilities used for recuperation, rehabilitation, and symptom management in an effort to improve the long-term outcomes of patients. PAC centers include skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals. In the 1990s, Medicare payment reforms significantly increased the discharge rates to PAC centers and subsequently increased the length of stay (LOS) among these patient populations. Over the last several years, there have been national initiatives and multidisciplinary approaches to improve safe discharge rates to home. Multiple studies have shown that patients who are discharged to home have decreased rates of 30-day readmissions, reduced short-term mortality, and an improvement in their activities of daily living.  Objectives This study aimed to investigate how multidisciplinary approaches could improve a single institution's discharge rates to home. In doing so, we aim to lower hospital readmission rates, hospital length of stay, morbidity and mortality rates, and healthcare-associated costs. Methods A retrospective single-institution cohort study was implemented at Jersey Shore University Medical Center (JSUMC). Data from January 2015 to December 2019 served as the control period, compared to the intervention period from January 2020 to January 2024. Patients were either admitted to JSUMC teaching faculty, hospitalists, or "others," which is composed of various medical and surgical subspecialists. Interventions performed to improve home discharge rates can be categorized into the following: physician education, patient education, electronic medical record (EMR) initiatives, accountability, and daily mobility initiatives. All interventions were performed equally across the three patient populations. The primary endpoint was the proportion of patients discharged to home. Results There were 190,699 patients, divided into a pre-intervention group comprising 98,885 individuals and a post-intervention group comprising 91,814 patients. Within the pre-intervention group, the faculty attended to 8,495 patients, hospitalists cared for 39,145 patients, and others managed 51,245 patients. In the post-intervention period, the faculty oversaw 8,014 patients, hospitalists attended to 35,094 patients, and others were responsible for 48,706 patients. After implementing a series of multidisciplinary interventions, there was a significant increase in the proportion of patients discharged home, rising from 74.9% to 80.2% across the entire patient population. Specifically, patients under the care of the faculty experienced a more substantial improvement, with a discharge rate increasing from 73.6% to 84.4%. Similarly, the hospitalists exhibited a rise from 69.4% to 74.3%, and the others demonstrated an increase from 79.3% to 83.7%. All observed changes yielded a p-value < 0.001. Conclusions By deploying a multifaceted strategy that emphasized physician education, patient education, EMR initiatives, accountability measures, and daily mobility, there was a statistically significant increase in the rate of patient discharges to home. These initiatives proved to be cost-effective and led to a tangible reduction in healthcare-associated costs and patient length of stay. Further studies are required to look into the effect on hospital readmission rates and morbidity and mortality rates. The comprehensive approach showcased its potential to optimize patient outcomes.

Whole Snake Genomes from Eighteen Families of Snakes (Serpentes: Caenophidia) and Their Applications to Systematics.

We present genome assemblies for 18 snake species representing 18 families (Serpentes: Caenophidia): Acrochordus granulatus, Aparallactus werneri, Boaedon fuliginosus, Calamaria suluensis, Cerberus rynchops, Grayia smithii, Imantodes cenchoa, Mimophis mahfalensis, Oxyrhabdium leporinum, Pareas carinatus, Psammodynastes pulverulentus, Pseudoxenodon macrops, Pseudoxyrhopus heterurus, Sibynophis collaris, Stegonotus admiraltiensis, Toxicocalamus goodenoughensis, Trimeresurus albolabris, and Tropidonophis doriae. From these new genome assemblies, we extracted thousands of loci commonly used in systematic and phylogenomic studies on snakes, including target-capture datasets composed of UCEs and AHEs, as well as traditional Sanger loci. Phylogenies inferred from the two target-capture loci datasets were identical with each other, and strongly congruent with previously published snake phylogenies. To show additional utility of these non-model genomes for investigative evolutionary research, we mined the genome assemblies of two New Guinea island endemics in our dataset (Stegonotus admiraltiensis and Tropidonophis doriae) for the ATP1a3 gene, a thoroughly researched indicator of resistance to toad toxin ingestion by squamates. We find that both these snakes possess the genotype for toad toxin resistance despite their endemism to New Guinea, a region absent of any toads until the human-mediated introduction of Cane Toads in the 1930s. These species possess identical substitutions that suggest the same bufotoxin resistance as their Australian congenerics (Stegonotus cucullatus and Tropidonophis mairii) which forage on invasive Cane Toads. Herein, we show the utility of short-read high coverage genomes, as well as improving the deficit of available squamate genomes with associated voucher specimens.

Establishing a Validation Infrastructure for Imaging-Based AI Algorithms Prior to Clinical Implementation.

With promising Artificial Intelligence (AI) algorithms receiving FDA (Food and Drug Administration) clearance, the potential impact of these models on clinical outcomes must be evaluated locally before their integration into routine workflows. Robust validation infrastructures are pivotal to inspecting the accuracy and generalizability of these deep learning algorithms to ensure both patient safety and health equity. Protected Health Information (PHI) concerns, intellectual property rights, and diverse requirements of models impede the development of rigorous external validation infrastructures. Our work proposes various suggestions for addressing the challenges associated with the development of efficient, customizable, and cost-effective infrastructures for the external validation of AI models at large medical centers and institutions. We present comprehensive steps to establish an AI inferencing infrastructure outside clinical systems to examine the local performance of AI algorithms before health practice- or system-wide implementation and promote an evidence-based approach for adopting AI models that can enhance radiology workflows and improve patient outcomes.

Repair of a fistula between the aorta and right ventricular outflow tract secondary to infective endocarditis of a unicuspid aortic valve and previously repaired ventricular septal defect.

BACKGROUND: Infective endocarditis of the aortic valve can result in a wide range of destructive pathology beyond the valve leaflets and annulus which require careful surgical planning to provide appropriate debridement and reconstruction. Failure to do so can result in a failure of surgical treatment, recurrent infection and cardiac failure with concomitant high morbidity and mortality. CASE REPORT: We describe the case of a 45-year-old male with previous patch repair of a ventricular septal defect, who was diagnosed with sub-acute bacterial endocarditis of the native aortic valve and developed a new fistula from the aorta to the right ventricular outflow tract which. This was managed surgically. CONCLUSION: This unique case highlights another spectrum of infective endocarditis with a unique approach to repair and management.

Specimen collection is essential for modern science.

Natural history museums are vital repositories of specimens, samples and data that inform about the natural world; this Formal Comment revisits a Perspective that advocated for the adoption of compassionate collection practices, querying whether it will ever be possible to completely do away with whole animal specimen collection.

Metachronous Squamous Cell Carcinoma of the Esophagus After Resolution of Previous Adenocarcinoma.

Esophageal cancer is the sixth leading cause of cancer-related death worldwide. Metachronous malignancies refer to multiple independent primary cancers diagnosed at least 6 months apart. The incidence of metachronous esophageal cancers with different histologic subtypes is extremely rare. This case presents an unprecedented occurrence of esophageal adenocarcinoma, followed by metachronous squamous cell carcinoma.

A framework for assessing clinical trial site readiness.

Clinical trial processes are unnecessarily inefficient and costly, slowing the translation of medical discoveries into treatments for people living with disease. To reduce redundancies and inefficiencies, a group of clinical trial experts developed a framework for clinical trial site readiness based on existing trial site qualifications from sponsors. The site readiness practices are encompassed within six domains: research team, infrastructure, study management, data collection and management, quality oversight, and ethics and safety. Implementation of this framework for clinical trial sites would reduce inefficiencies in trial conduct and help prepare new sites to enter the clinical trials enterprise, with the potential to improve the reach of clinical trials to underserved communities. Moreover, the framework holds benefits for trial sponsors, contract research organizations, trade associations, trial participants, and the public. For novice sites considering future trials, we provide a framework for site preparation and the engagement of stakeholders. For experienced sites, the framework can be used to assess current practices and inform and engage sponsors, staff, and participants. Details in the supplementary materials provide easy access to key regulatory documents and resources. Invited perspective articles provide greater depth from a systems, DEIA (diversity, equity, inclusion, and accessibility) and decentralized trials perspective.

Multi-vendor evaluation of artificial intelligence as an independent reader for double reading in breast cancer screening on 275,900 mammograms.

BACKGROUND: Double reading (DR) in screening mammography increases cancer detection and lowers recall rates, but has sustainability challenges due to workforce shortages. Artificial intelligence (AI) as an independent reader (IR) in DR may provide a cost-effective solution with the potential to improve screening performance. Evidence for AI to generalise across different patient populations, screening programmes and equipment vendors, however, is still lacking. METHODS: This retrospective study simulated DR with AI as an IR, using data representative of real-world deployments (275,900 cases, 177,882 participants) from four mammography equipment vendors, seven screening sites, and two countries. Non-inferiority and superiority were assessed for relevant screening metrics. RESULTS: DR with AI, compared with human DR, showed at least non-inferior recall rate, cancer detection rate, sensitivity, specificity and positive predictive value (PPV) for each mammography vendor and site, and superior recall rate, specificity, and PPV for some. The simulation indicates that using AI would have increased arbitration rate (3.3% to 12.3%), but could have reduced human workload by 30.0% to 44.8%. CONCLUSIONS: AI has potential as an IR in the DR workflow across different screening programmes, mammography equipment and geographies, substantially reducing human reader workload while maintaining or improving standard of care. TRIAL REGISTRATION: ISRCTN18056078 (20/03/2019; retrospectively registered).

Role of Plasmapheresis in Hemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) Syndrome.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a rare abnormality comprising a series of symptoms that make up a syndrome. It usually happens during pregnancy or right after delivery. We describe a case of a 31-year-old female G4P2A2 (Gravida 4 Para 2 Abortions 2) who presented to the hospital for normal vaginal delivery but immediately postpartum developed HELLP syndrome. Acute fatty liver of pregnancy was a differential that the patient also met the criteria for. Her condition improved after starting her on plasmapheresis without considering hepatic transplantation. We emphasize distinguishing the overlap of symptoms between HELLP syndrome vs. acute fatty liver of pregnancy and the outcomes of plasmapheresis in managing HELLP syndrome without needing hepatic transplantation.

Advancing translational science education.

In this communication, the authors offer considerations for how the scientific community can capitalize on decades of translational science advances and experiential knowledge to develop new education opportunities for a diverse and highly skilled translational science workforce. Continued advancement of the field of translational science will require new education approaches that distill key concepts in translational science from past and ongoing research initiatives and teach this foundational knowledge to current and future translational scientists. These key concepts include generalizable scientific and operational principles to guide translational science, as well as evidence-informed practices. Inspired by this approach, the National Center for Advancing Translational Sciences (NCATS) has developed an initial set of guiding principles for translational science generated via case studies of multiple highly successful translational science initiatives, and is now teaching them via new education activities that aim to reach a broad scientific audience interested in translational science. Our goal with this review is to prompt continued conversation with the translational science community regarding capitalizing on our collective translational science knowledge to advance core content for translational science education and disseminating this content to a broad range of scientific audiences.

Iodinated Contrast-Induced Thyroid Storm With Concomitant Cardiac Tamponade: A Case Report.

A thyroid storm is a rare but life-threatening condition caused by the exaggeration of the clinical manifestations of thyrotoxicosis. The symptoms of thyroid storms are non-specific in nature, making the Burch Wartofsky Point Scale (BWPS) a valuable resource in the diagnosis of thyroid storms. Though not part of the BWPS scoring criteria, literature reviews have shown an increasing number of reports of pericardial effusion secondary to thyrotoxicosis. Pericardial effusion is a well-known sequela of hypothyroidism that, in severe cases, can cause cardiac tamponade. With increasing reports, clinicians should be aware that pericardial effusions can develop secondary to both underactive and overactive thyroid states. We present a case of iodine contrast-induced Jod-Basedow in a 29-year-old with a prior history of Graves disease with concomitant pericardial effusion requiring thyroidectomy.

Supraventricular Tachycardia: An Atypical Presentation of Thyroid Storm.

Thyroid storm (or thyrotoxic crisis) is commonly defined as a life-threatening condition caused by the exaggeration of the clinical manifestations of thyrotoxicosis. Supraventricular tachycardia (SVT) is an atypical precipitating symptom of thyrotoxicosis that clinicians should be aware of. An empirically derived scoring system known as the Burch-Wartofsky Point Scale (BWPS) has been used by clinicians since the early 1990s. The BWPS considers an array of precipitating factors and the severity of symptoms of multiple organ decompensation. In recent years, there has been an increasing correlation between SARS-CoV-2 and thyroid pathologies. We present a case of an unresponsive elderly male with a recent coronavirus disease 2019 (COVID-19) infection presenting with SVT and a BWPS score of 45, highly indicative of a thyroid storm.

Lemierre's Syndrome: A Comeback Story.

Lemierre's syndrome is a very rare and life-threatening complication of bacterial pharyngitis and tonsillitis. Often referred to as a 'forgotten disease', Lemierre's syndrome has seen a rise in cases over the years secondary to increased antibiotic resistance. With the potential for multiple organ failure secondary to widespread septic emboli, Lemierre's syndrome can no longer be forgotten. Prompt initiation of treatment is needed for better patient outcomes. We describe an unusual case of a young female without any significant past medical history who presented with left-sided pleuritic chest pain several days after experiencing a sore throat.

Teaching principles of translational science to a broad scientific audience using a case study approach: A pilot course from the National Center for Advancing Translational Sciences.

There are numerous examples of translational science innovations addressing challenges in the translational process, accelerating progress along the translational spectrum, and generating solutions relevant to a wide range of human health needs. Examining these successes through an education lens can identify core principles and effective practices that lead to successful translational outcomes. The National Center for Advancing Translational Sciences (NCATS) is identifying and teaching these core principles and practices to a broad audience via online courses in translational science which teach from case studies of NCATS-led or supported research initiatives. In this paper, we share our approach to the design of these courses and offer a detailed description of our initial course, which focused on a preclinical drug discovery and development project spanning academic and government settings. Course participants were from a variety of career stages and institutions. Participants rated the course high in overall value to them and in providing a unique window into the translational science process. We share our model for course development as well as initial findings from the course evaluation with the goal of continuing to stimulate development of novel education activities teaching foundational principles in translational science to a broad audience.

Evolution of the albumin protein family in reptiles.

The albumin family of proteins consists of vitamin-D binding protein/group-specific component (GC), serum albumin (ALB), alpha-fetoprotein (AFP), and afamin (AFM), which are responsible for transporting many ligands throughout the body. The albumin family proteins are physiologically and medically important, but our understanding of their functions and applications is hindered by the dearth of information regarding these proteins' evolutionary relationships and functions in non-mammalian lineages. In this study we investigate the evolution of the albumin family proteins in reptiles, using bioinformatic methods to survey available reptile genomes and transcriptomes for albumin family proteins and phylogenetically characterize their relationships. We reinforce the established evolutionary relationships among the albumin protein family in reptiles, however, they are variable in their number of domains, overall genetic sequence, and synteny. We find a novel absence of the physiologically important ALB in squamates and identify two distinct lineages of AFP, one in mammals and another in reptiles. Our study provides a comparative genomic framework for further studies identifying lineage-specific gene expansions that may compensate for the lack of serum albumin in squamates.

Defining clinical outcome pathways.

Here, we propose a broad concept of 'Clinical Outcome Pathways' (COPs), which are defined as a series of key molecular and cellular events that underlie therapeutic effects of drug molecules. We formalize COPs as a chain of the following events: molecular initiating event (MIE) â†’ intermediate event(s) â†’ clinical outcome. We illustrate the concept with COP examples both for primary and alternative (i.e., drug repurposing) therapeutic applications. We also describe the elucidation of COPs for several drugs of interest using the publicly accessible Reasoning Over Biomedical Objects linked in Knowledge-Oriented Pathways (ROBOKOP) biomedical knowledge graph-mining tool. We propose that broader use of COP uncovered with the help of biomedical knowledge graph mining will likely accelerate drug discovery and repurposing efforts.

Assessment of the Educational Value of Distal Hypospadias Repair Videos on YouTube.

OBJECTIVE: To evaluate the quality of YouTube videos depicting distal hypospadias repair. METHODS: The search terms "distal hypospadias repair" were used to identify surgical videos on YouTube. Videos were sorted by view count and the top 34 videos were reviewed for baseline video characteristics, key surgical steps covered, and conformity to a modified LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) checklist. All videos were reviewed and discussed for conformity by 2 attending pediatric urologists and a urology resident. RESULTS: Of the 34 videos reviewed, 16 videos were excluded due to content. The median length of videos was 9.94 minutes (range, 2.57-99.12 minutes). Video quality was deemed of high quality in only 39% of videos. The most common type of hypospadias procedures described were tubularized incised plate urethroplasty (n = 13) and meatal advancement and glanuloplasty incorporated (n = 2). The median view count was 7828.5 (range, 1,133-58,619 views). Only 1 video met all modified LAP-VEGaS criteria (range of 33%-100%), and only 2 videos showed every surgical step of distal hypospadias repair (range 33%-100%). Modified LAP-VEGaS score, surgical step score, or quality of the video was not associated with a higher view count. CONCLUSION: Despite being a common procedure, there is a paucity of high-quality videos on YouTube describing distal hypospadias repair techniques. It is unclear how learners select videos for study purposes and the most utilized videos on YouTube are not the most educational videos.