Police Involvement in Out-of-Hospital Cardiac Arrest: A Qualitative Exploration of Law Enforcement Roles and Contributing Organizational Factors.

OBJECTIVES: Many American police organizations respond to out-of-hospital cardiac arrest (OHCA). This study sought to: 1) explore variation in the role of police in OHCA across emergency medical systems and 2) identify factors influencing this variation. METHODS: We conducted a qualitative multisite case study analysis using data collected through semi-structured key informant interviews and multidisciplinary focus groups with telecommunicators, fire, police, emergency medical services, and hospital personnel across nine Michigan emergency systems of care. Sites were sampled based on return of spontaneous circulation rates, trauma region, geography, rurality, and population density. Data were analyzed to examine police role in OHCA and the organizational factors that contribute to these roles. Transcripts and coded data were explored using iterative thematic analysis and matrices. RESULTS: Interviews included approximately 160 public safety informants of varying administrative levels (i.e., field staff, mid-level managers, and leadership). Across systems, police played four on-scene roles in OHCA response: 1) early responder, 2) resuscitation team member, 3) security, and 4) information gathering. Less consistently, police performed supplementary roles as telecommunicators and cardiac arrest educators. We found that factors including administrative structure of the police agency, resources (e.g., human and material), organizational culture, medical training, deployment and response policies, nature of response environment, and relationships with other prehospital stakeholders contributed to the degree certain roles were present. CONCLUSIONS: Police serve numerous on-scene and supplementary roles in OHCA response across jurisdictions. Their roles were influenced by multiple factors at each site. Future studies may help to better understand the value of and how to optimize police engagement in OHCA response.

A cross-stakeholder approach to improving out-of-hospital cardiac arrest survival.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) affects over 300,000 individuals per year in the United States with poor survival rates overall. A remarkable 5-fold difference in survival-to-hospital discharge rates exist across United States communities. METHODS: We conducted a study using qualitative research methods comparing the system of care across sites in Michigan communities with varying OHCA survival outcomes, as measured by return to spontaneous circulation with pulse upon emergency department arrival. RESULTS: Major themes distinguishing higher performing sites were (1) working as a team, (2) devoting resources to coordination across agencies, and (3) developing a continuous quality improvement culture. These themes spanned the chain of survival framework for OHCA. By examining the unique processes, procedures, and characteristics of higher- relative to lower-performing sites, we gleaned lessons learned that appear to distinguish higher performers. The higher performing sites reported being the most collaborative, due in part to facilitation of system integration by progressive leadership that is willing to build bridges among stakeholders. CONCLUSIONS: Based on the distinguishing features of higher performing sites, we provide recommendations for toolkit development to improve survival in prehospital systems of care for OHCA.

Loss of MXRA8 Delays Mammary Tumor Development and Impairs Metastasis.

Matrix-remodeling-associated protein 8 or MXRA8 is a transmembrane protein that can bind arthritogenic alpha viruses like the Chikungunya virus and provide viral entry into cells. MXRA8 can also interact with integrin ß3 and thus possibly regulate cell-cell interactions and binding to the extracellular matrix. While MXRA8 has been associated with reduced survival in patients with colorectal and renal clear cell cancers, the role of MXRA8 in breast cancer remains largely unexplored. Therefore, the aim of this research was to determine the role of MXRA8 in breast cancer by knocking out MXRA8 in the human triple-negative breast cancer cell line MDA-MB-231. The loss of MXRA8 reduced cell proliferation in vitro but had no effect on apoptosis or migration in cultured cells. However, the loss of MXRA8 significantly delayed tumor development and reduced metastatic dissemination to the lungs in a xenograft model. RNA sequencing identified three genes, ADMATS1, TIE1, and BMP2, whose expression were significantly reduced in MXRA8-knockout tumors compared to control tumors. MXRA8 staining of a human breast cancer tissue array revealed higher levels of MXRA8 in primary tumors and metastases of aggressive tumor subtypes (TNBC and HER2+) compared to less aggressive, ER+ breast cancers. Our findings demonstrate for the first time that MXRA8 regulates the progression of human TNBC possibly through influencing the interaction of tumor cells with their microenvironment.

How health systems facilitate patient-centered care and care coordination: a case series analysis to identify best practices.

Large- and small-scale transformation of healthcare delivery toward improved patient experience through promotion of patient-centered and coordinated care continues to be at the forefront of health system efforts in the United States. As part of a Quality Improvement (QI) project at a large, midwestern health system, a case series of high-performing organizations was explored with the goal of identifying best practices in patient-centered care and/or care coordination (PCC/CC). Identification of best practices was done through rapid realist review of peer-reviewed literature supporting three PCC/CC interventions per case. Mechanisms responsible for successful intervention outcomes and associated institutional-level facilitators were evaluated, and cross-case analysis produced high-level focus items for health system leadership, including (1) institutional values surrounding PCC/CC, (2) optimization of IT infrastructure to enhance performance and communication, (3) pay structures and employment models that enhance accountability, and (4) organizing bodies to support implementation efforts. Health systems may use this review to gain insight into how institutional-level factors may facilitate small-scale PCC/CC behaviors, or to conduct similar assessments in their own QI projects. Based on our analysis, we recommend health systems seeking to improve PCC/CC at any level or scale to evaluate how IT infrastructure affects provider-provider and provider-patient communication, and the extent to which institutional prioritization of PCC/CC is manifest and held accountable in performance feedback, incentivization, and values shared among departments and settings. Ideally, this evaluation work should be performed and/or supported by cross-department organizing bodies specifically devoted to PCC/CC implementation work.

Recreational nitrous oxide induced subacute combined degeneration of the spinal cord: A case report.

Nitrous oxide is a gas frequently used in the medical/dental field for anesthesia and analgesic purposes and in the food industry as a spray propellant or foaming agent. Overexposure can lead to subacute combined degeneration (SACD) of the spinal cord through the mechanism of vitamin B12 deficiency. Because this drug is easily accessible, relatively inexpensive, and legal to possess, it has potential to be abused for recreational purposes. The number of published cases of nitrous oxide abuse has been increasing since 2010. Large-scale and long-term use of nitrous oxide have been found to cause nerve damage from vitamin B12 deficiency, thromboembolic phenomenon from elevated homocysteine levels, and even death from hypoxia. A 44-year-old male patient with past medical history of recently diagnosed type 2 diabetes, on Metformin, presented for 1 month of worsening bilateral upper and lower extremity weakness. On initial physical examination, he demonstrated pertinent abnormal findings of 2/5 hand strength bilaterally, 4/5 strength in his left upper extremity and right lower extremity, impaired coordination, ataxic gait, rigidity, and decreased but symmetrical reflexes. He reported using 50-100 canisters of nitrous oxide per day to obtain a feeling of relaxation and euphoria. Blood work revealed vitamin B12 deficiency, and abnormalities were seen on MRI. He was treated with 1000 µg of intramuscular vitamin B12 every other day for 3 doses, followed by 500 µg oral cyanocobalamin daily. He demonstrated a great amount of improvement in his neuropathy during his stay. However, he was still dependent in basic transfers, activities of daily living, and mobility and was discharged to acute rehabilitation. Vitamin B12 deficiency can lead to subacute combined degeneration, which presents with sensory deficits, weakness, ataxia, spasticity, and gait abnormalities. Treatment for SACD should be aggressive and rapid to prevent irreversible neurological deficits. Amid an opioid epidemic, practitioners can easily overlook the use of nitrous oxide and patients may consider this drug to be relatively harmless. This case demonstrates the importance of thorough history taking, patient education, and early recognition and treatment of vitamin B12 deficiency and the deleterious effects that may result without intervention.

Evaluating the pediatric mental health care continuum at an American health system.

Objective: To describe trends in the pediatric mental health care continuum and identify potential gaps in care coordination. Methods: We used electronic medical record data from October 2016 to September 2019 to characterize the prevalence of mental health issues in the pediatric population at a large American health system. This was a single institution case study. From the electronic medical record data, primary mental health discharge and readmission diagnoses were identified using International Classification of Diseases (ICD-9-CM, ICD-10-CM) codes. The electronic medical record was queried for mental health-specific diagnoses as defined by International Classification of Diseases classification, analysis of which was facilitated by the fact that only 176 mental health codes were billed for. Additionally, prevalence of care navigation encounters was assessed through electronic medical record query, as care navigation encounters are specifically coded. These encounter data was then segmented by care delivery setting. Results: Major depressive disorder and other mood disorders comprised 49.6% and 89.4% of diagnoses in the emergency department and inpatient settings respectively compared to 9.0% of ambulatory care diagnoses and were among top reasons for readmission. Additionally, only 1% of all ambulatory care encounters had a care navigation component, whereas 86% of care navigation encounters were for mental health-associated reasons. Conclusions: Major depressive disorder and other mood disorders were more common diagnoses in the emergency department and inpatient settings, which could signal gaps in care coordination. Bridging potential gaps in care coordination could reduce emergency department and inpatient utilization through increasing ambulatory care navigation resources, improving training, and restructuring financial incentives to facilitate ambulatory care diagnosis and management of major depressive disorder and mood disorders. Furthermore, health systems can use our descriptive analytic approach to serve as a reasonable measure of the current state of pediatric mental health care in their own patient population.

Elevated Expression of miR-200c/141 in MDA-MB-231 Cells Suppresses MXRA8 Levels and Impairs Breast Cancer Growth and Metastasis In Vivo.

Breast cancer cells with mesenchymal characteristics, particularly the claudin-low subtype, express extremely low levels of miR-200s. Therefore, this study examined the functional impact of restoring miR-200 expression in a human claudin-low breast cancer cell line MDA-MB-231. MDA-MB-231 cells were stably transfected with a control vector (MDA-231EV) or the miR-200c/141 cluster (MDA-231c141). Injection of MDA-231c141 cells into the 4th mammary gland of NCG mice produced tumors that developed significantly slower than tumors produced by MDA-231EV cells. Spontaneous metastasis to the lungs was also significantly reduced in MDA-231c141 cells compared to MDA-231EV cells. RNA sequencing of MDA-231EV and MDA-231c141 tumors identified genes including MXRA8 as being downregulated in the MDA-231c141 tumors. MXRA8 was further investigated as elevated levels of MXRA8 were associated with reduced distant metastasis free survival in breast cancer patients. Quantitative RT-PCR and Western blotting confirmed that MXRA8 expression was significantly higher in mammary tumors induced by MDA-231EV cells compared to those induced by MDA-231c141 cells. In addition, MXRA8 protein was present at high levels in metastatic tumor cells found in the lungs. This is the first study to implicate MXRA8 in human breast cancer, and our data suggests that miR-200s inhibit growth and metastasis of claudin-low mammary tumor cells in vivo through downregulating MXRA8 expression.

Health Disparities among adults cared for at an urban cystic fibrosis program.

BACKGROUND: Evidence is conflicting regarding differential health outcomes in racial and ethnic minorities with cystic fibrosis (CF), a rare genetic disease affecting approximately 28,000 Americans. We performed a cross-sectional analysis of health outcomes in Black/Latinx patients compared with non-Hispanic Caucasian patients cared for in a CF center in New York City. Adult patients enrolled in the CF Foundation Patient Registry at the Columbia University Adult CF Program and seen at least once during 2019 were included. Health metrics were compared between Black/Latinx and non-Hispanic Caucasian patients. RESULTS: 262 patients were eligible. 39 patients (15%) identified as Black/Latinx or non-Hispanic Caucasian. Descriptive statistics are reported with mean (standard deviation). Current age was 35.9 (13.3) years for non-Hispanic Caucasian and 32.0 (9.3) years for Black/Latinx patients (p = 0.087). Age of diagnosis did not differ between groups; 9.56 (15.96) years versus 11.59 (15.8) years for non-Hispanic Caucasian versus Black/Latinx respectively (p = 0.464). Pulmonary function, measured as mean forced expiratory volume in one second (FEV1) was 70.6 (22.5) percent predicted in non-Hispanic Caucasian versus 59.50 (27.9) percent predicted in Black/Latinx patients (p = 0.010). Number of visits to the CF clinic were similar between groups. When controlled for age, gender, co-morbidities, median income, and insurance status, there was a continued association between minority status and lower FEV1. CONCLUSIONS: Minorities with CF have significantly lower pulmonary function, the major marker of survival, than non-Hispanic Caucasians, even when controlled for a variety of demographic and socioeconomic factors that are known to affect health status in CF. Significant health disparities based on race and ethnicity exist at a single CF center in New York City, despite apparent similarities in access to guideline based care at an accredited CF Center. This data confirms the importance of design of culturally appropriate preventative and management strategies to better understand how to direct interventions to this vulnerable population with a rare disease.

A rare case of nitrofurantoin-induced acute lung injury.

Nitrofurantoin is a common treatment for urinary tract infections. Acute lung injury resulting from nitrofurantoin is a rare, life-threatening complication with women being at greater risk. Symptoms include respiratory distress with fevers, rash, eosinophilia, and new-onset atrial fibrillation. Treatment includes discontinuing the drug and possibly glucocorticoids for persistent oxygen demand.