Síndrome de Mirizzi, complicación inusual de la colelitiasis / Mirizzi Syndrome, a Rare Complication of Cholelithiasis

Introducción: El síndrome de Mirizzi es una entidad clínica rara y difícil de tratar; sin embargo, los avances tecnológicos recientes han brindado a los cirujanos nuevas opciones para un diagnóstico y tratamiento más efectivos de esta afección. Objetivo: Presentar el caso de síndrome de Mirizzi, complicación inusual de la colelitiasis. Presentación del caso: Se presenta una paciente femenina, de 56 años de edad, que acude a nuestra institución por presentar ictericia intermitente, dolor en el hipocondrio derecho, coluria y acolia. Conclusiones: El síndrome de Mirizzi, complicación de la colelitiasis, es una entidad poco frecuente, de difícil diagnóstico preoperatorio, por lo que en un gran porcentaje de los casos se diagnostica intraoperatoriamente. Su tratamiento es quirúrgico(AU)

Introduction: Mirizzi syndrome is a rare condition, difficult to treat; however, recent technological advances have provided surgeons with new options for diagnosing and treating this condition more effectively. Objective: To present a case of Mirizzi syndrome, an unusual complication of cholelithiasis. Case presentation: The case is presented of a 56-year-old female patient, who comes to our institution with intermittent jaundice, right hypochondrium pain, choluria and acholia. Conclusions: Mirizzi syndrome, a complication of cholelithiasis, is a rare entity, difficult to diagnose preoperatively; therefore, a large percentage of it's cases are diagnosed intraoperatively. Its treatment is surgical(AU)

Mitochondrial dysfunction-associated microbiota establishes a transmissible refractory response to anti-TNF therapy during ulcerative colitis.

Anti-TNF therapy can induce and maintain a remission status during intestinal bowel disease. However, up to 30% of patients do not respond to this therapy by mechanisms that are unknown. Here, we show that the absence of MCJ, a natural inhibitor of the respiratory chain Complex I, induces gut microbiota changes that are critical determinants of the lack of response in a murine model of DSS-induced inflammation. First, we found that MCJ expression is restricted to macrophages in human colonic tissue. Therefore, we demonstrate by transcriptomic analysis of colon macrophages from DSS-induced mice that MCJ-deficiency is linked to the expression of genes belonging to the FcγR signaling pathway and contains an anti-TNF refractory gene signature identified in ulcerative colitis patients. The gut microbial composition changes observed upon DSS treatment in the MCJ-deficient mice revealed the increased presence of specific colitogenic members, including Ruminococcus gnavus and Oscillospira, which could be associated with the non-response to TNF inhibitors. Further, we show that the presence of a microbiota associated resistance to treatment is dominant and transmissible to responsive individuals. Collectively, our findings underscore the critical role played by macrophage mitochondrial function in the gut ecological niche that can substantially affect not only the severity of inflammation but also the ability to successfully respond to current therapies.

Humoral and Cellular Immunology in Human Prostate Cancer: Plasma Cells and T and B Lymphocytes / Inmunología Humoral y Celular en el Cáncer de Próstata Humano: Células Plasmáticas y Linfocitos T y B

SUMMARY: In solid and malignant tumors, innate and adaptive immunity are combined in antitumor responses. This study aimed to analyze the activation of plasma cells and the correlation between the infiltration of B and T lymphocytes with the degree of malignancy or Gleason grade in human prostate biopsies diagnosed with cancer. Prostate cancer biopsies were obtained from the Clinical Hospital of Universidad de Chile (n=70), according to the bioethical norms of the institution. Histological sections of 5µm thickness were processed for immunohistochemistry with primary antibodies against BL and total TL (HRP/DAB). Recognition and quantification were performed under a Leica DM750 optical microscope. Microsoft Excel and GraphPad software were used for the statistical study. Correlation coefficient (Pearson) and mean comparison tests (Kruskal-Wallis and Dunn) and p≤ 0.05 were developed. B and T lymphocyte populations were inversely interregulated in prostate cancer (Gleason) (r= -0.46). Their relationship with Gleason grade is variable according to lymphocyte type (LB vs. Gleason r= -0.0.47 and LT vs. Gleason r= -0.21). Histological diagnosis of prostate cancer correlates with a predominance of LT. The malignancy of the pathology correlates with a predominance of LTs, according to the Gleason grade. The increased knowledge of B and T lymphocyte infiltration and plasma cell activation could be used to better target clinical trials on treatments based on immune system responses. Immunotherapy could be a new paradigm to apply better antitumor therapy strategies.

En tumores sólidos y malignos, la inmunidad innata y adaptativa se combinan en respuestas antitumorales. Este estudio tuvo como objetivo analizar la activación de células plasmáticas y la correlación entre la infiltración de linfocitos B y T con el grado de malignidad o grado de Gleason en biopsias de próstata humana diagnosticadas con cáncer. Las biopsias de cáncer de próstata se obtuvieron del Hospital Clínico de la Universidad de Chile (n=70), de acuerdo con las normas bioéticas de la institución. Secciones histológicas de 5 µm de espesor fueron procesadas para inmunohistoquímica con anticuerpos primarios contra LB y LT total (HRP/DAB). El reconocimiento y las cuantificaciones se realizaron bajo un microscopio óptico Leica DM750. Para el estudio estadístico se utilizaron los programas Microsoft Excel y GraphPad. Se desarrollaron pruebas de coeficiente de correlación (Pearson) y comparación de medias (Kruskal-Wallis y Dunn) y p≤ 0.05. Los resultados muestran que las poblaciones de linfocitos B y T están inversamente interreguladas en el cáncer de próstata (r= -0,4578). Su relación con el grado de Gleason es variable según el tipo de linfocito (LB vs Gleason r= -0,47* y LT vs Gleason r= -0,21). Se concluye que la malignidad del cáncer de próstata se correlaciona con un predominio de LT, versus el grado de Gleason. El mayor conocimiento de la infiltración de linfocitos B y T y la activación de células plasmáticas podría aprovecharse para una mejor orientación de ensayos clínicos en tratamientos basados en las respuestas del sistema inmunitario. La inmunoterapia podría ser un nuevo paradigma para aplicar mejores estrategias de terapias antitumorales.

Collaborative Learning Among Health Care Organizations to Improve Quality and Advance Racial Equity.

Background: The study examined stakeholder experiences of a statewide learning collaborative, sponsored and led by Blue Cross Blue Shield of Massachusetts (BCBSMA) and facilitated by the Institute for Healthcare Improvement (IHI) to reduce racial and ethnic disparities in quality of care. Methods: Interviews of key stakeholders (n=44) were analyzed to assess experiences of collaborative learning and interventions to reduce racial and ethnic disparities in quality of care. The interviews included BCBSMA, IHI, provider groups, and external experts. Results: Breast cancer screening, colorectal cancer screening, hypertension management, and diabetes management were focal areas for reducing disparities. Collaborative learning methods involved expert coaching, group meetings, and sharing of best practices. Interventions tested included pharmacist-led medication management, strategies to improve the collection of race, ethnicity, and language (REaL) data, transportation access improvement, and community health worker approaches. Stakeholder experiences highlighted three themes: (1) the learning collaborative enabled the testing of interventions by provider groups, (2) infrastructure and pilot funding were foundational investments, but groups needed more resources than they initially anticipated, and (3) expertise in quality improvement and health equity were critical for the testing of interventions and groups anticipated needing this expertise into the future. Conclusions: BCBSMA's learning collaborative and intervention funding supported contracted providers in enhancing REaL data collection, implementing equity-focused interventions on a small scale, and evaluating their feasibility and impact. The collaborative facilitated learning among groups on innovative approaches for reducing racial disparities in quality. Concerns about sustainability underscore the importance of expertise for implementing initiatives to reduce racial and ethnic disparities.

Cistoadenocarcinoma biliar / Biliary Cystadenocarcinoma

Introducción: El cistoadenocarcinoma biliar es un tumor quístico poco frecuente, que se origina a partir del epitelio hepatobiliar, cuyo crecimiento es lento y sus síntomas son variables e inespecíficos. Objetivo: Presentar el caso de un paciente portador de un cistoadenocarcinoma biliar. Presentación del caso: Se presenta el caso de una paciente femenina de 56 años de edad que acude a la institución por presentar dolor en el hipocondrio derecho, fiebre y pérdida de peso. Al examen físico se constata una masa palpable en dicha zona abdominal, de bordes lisos, no dolorosa, dura, de escasa movilidad y relacionada con el hígado. Conclusiones: El cistoadenocarcinoma biliar es una neoplasia quística maligna poco frecuente del hígado. La mayoría de los pacientes presentan dolor abdominal, masa palpable y pérdida de peso. El tratamiento quirúrgico es la norma y la resección con márgenes libres se considera la variante de tratamiento más empleada(AU)

Introduction: Biliary cystadenocarcinoma is a rare cystic tumor, which originates from the hepatobiliary epithelium, whose growth is slow, and whose symptoms are variable and nonspecific. Objective: To present the case of a patient with a biliary cystadenocarcinoma. Case presentation: The case is presented of a 56-year-old female patient who came to our institution with pain in the right hypochondrium, fever and weight loss. Physical examination revealed a palpable mass in such abdominal area, with smooth edges, nonpainful, hard, with low mobility and related to the liver. Conclusions: Biliary cystadenocarcinoma is a rare malignant cystic neoplasm of the liver. Most patients present with abdominal pain, a palpable mass and weight loss. Surgery is the standard treatment and margin-free resection is considered the most commonly employed treatment variant(AU)

Hospital Characteristics Associated With Clinically Integrated Network Participation.

BACKGROUND: Increased integration of physician organizations and hospitals into health systems has not necessarily improved clinical integration or patient outcomes. However, federal regulators have issued favorable opinions for clinically integrated networks (CINs) as a way to pursue coordination between hospitals and physicians. Hospital organizational affiliations, including independent practice associations (IPA), physician-hospital organizations (PHOs), and accountable care organizations (ACOs), may support CIN participation. No empirical evidence, however, exists about factors associated with CIN participation. METHODS: Data from the 2019 American Hospital Association survey (n = 4405) were analyzed to quantify hospital CIN participation. Multivariable logistic regression models were estimated to examine whether IPA, PHO, and ACO affiliations were associated with CIN participation, controlling for market factors and hospital characteristics. RESULTS: In 2019, 34.6% of hospitals participated in a CIN. Larger, not-for-profit, and metropolitan hospitals were more likely to participate in CINs. In adjusted analyses, hospitals participating in CINs were more likely to have an IPA (9.5% points, P < 0.001), a PHO (6.1% points, P < 0.001), and ACO (19.3% points, P < 0.001) compared with hospitals not participating in a CIN. CONCLUSIONS: Over one-third of hospitals participate in a CIN, despite limited evidence about their effectiveness in delivering value. Results suggest that CIN participation may be a response to integrative norms. Future work should attempt to better define CIN participation and strive to disentangle overlapping organizational participation.

Implementation of a universal screening and follow-up care system for pediatric developmental and behavioral health in federally qualified health center sites.

BACKGROUND: Despite guidelines from the American Academy of Pediatrics (AAP), many pediatric practices still do not have standardized screening processes in place to identify children with developmental delays. From April 2014 to April 2017, six federally qualified health center (FQHC) sites in Northern California implemented an intervention to increase (a) standardized developmental screening at recommended intervals and (b) follow-up care and support for early intervention services. METHOD: The intervention aimed to optimize each site's screening processes, supported by an automated electronic tablet-based system. To improve follow-up support, social workers were hired to conduct follow-up clinical assessments, provide psychosocial education and treatment, provide referrals and case management support, and collaborate with service partners. We analyze operational and implementation data to characterize site adoption, patient reach, implementation processes, and intervention effectiveness. RESULTS: During the intervention's final year, when tablet-based screening was adopted, the sites screened an estimated 6,550 children ages 0-18 at 23 intervals in three domains (developmental, autism, and psychosocial/behavioral), compared to a baseline where they screened ages 0-3 at four intervals in one domain. Screening rates increased from 65.3% to 75.5% after automation was extended from the first to the second site, then to 91.8% after automation was expanded to the remaining sites. Follow-up visit rates ranged between 74% and 88%. CONCLUSIONS: Implementation of a multicomponent developmental and behavioral health screening and follow-up care intervention enabled FQHC sites to meet AAP recommendations and provide follow-up support. Disseminating the intervention may support population-level improvement in early detection and intervention for developmental delays and behavioral health concerns. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Divertículo de Zenker / Zenker's Diverticulum

Introducción: Los divertículos de Zenker son los más frecuentes del esófago. El tratamiento quirúrgico más utilizado es la diverticulectomía con miotomía cricofaríngea abierta. Objetivo: Describir un paciente con diagnóstico de divertículo de Zenker cuya presentación fue la disfagia e infecciones respiratorias recurrentes. Presentación del caso: Describimos el caso de una paciente de 73 años con disfagia alta e infecciones respiratorias recurrentes, con el diagnóstico de divertículo de Zenker, a quien se le realiza diverticulectomía más miotomía. Conclusiones: El divertículo de Zenker o divertículo yuxtaesfinteriano faringoesofágico es una entidad de baja prevalencia que se presenta en pacientes entre los 50 y 70 años, predominantemente en los de sexo masculino. La radiografía contrastada del tracto digestivo superior y endoscopia determinan el diagnóstico en su mayoría y la diverticulectomía más cricomiotomía es la técnica más empleada(AU)

Introduction: Zenker's diverticula are the most frequent diverticula of the esophagus. The most commonly used surgical treatment is diverticulectomy with open cricopharyngeal myotomy. Objective: To describe a patient with a diagnosis of Zenker's diverticulum and whose presentation was dysphagia and recurrent respiratory infections. Case presentation: We describe the case of a 73-year-old female patient with high dysphagia and recurrent respiratory infections, with the diagnosis of Zenker's diverticulum, and who underwent diverticulectomy plus myotomy. Conclusions: Zenker's diverticulum or pharyngoesophageal juxtasphincteric diverticulum is a low-prevalence condition that occurs in patients between 50 and 70 years of age, predominantly in males. Contrast radiography of the upper digestive tract and endoscopy determine the diagnosis in the majority of cases, while diverticulectomy plus cricomyotomy is the most commonly used technique(AU)

Tratamiento quirúrgico del colangiocarcinoma extrahepático / Surgical Treatment of Extrahepatic Cholangiocarcinoma

Introducción: El colangiocarcinoma constituye la neoplasia de la vía biliar más frecuente, la cual es responsable de una alta morbimortalidad. Objetivo: Determinar la morbilidad y la mortalidad por colangiocarcinoma extrahepático en el Servicio de Cirugía del Hospital Universitario Manuel Ascunce Domenech. Métodos: Se realizó un estudio descriptivo, prospectivo y observacional de pacientes que ingresaron en el Servicio de Cirugía General con diagnóstico de colangiocarcinoma extrahepático entre septiembre de 2018 y enero del 2022. El universo estuvo conformado por 21 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: La mayor incidencia de los pacientes fueron del sexo masculino y blancos, con el 71,4 por ciento y el 85,7 por ciento respectivamente. Predominó el adenocarcinoma como variedad histológica con un 85,7 por ciento, así como el colangiocarcinoma proximal y la variante esclerosante de su clasificación. El 71,4 por ciento de los pacientes egresaron vivos y con una cirugía con finalidad curativa. Conclusiones: La mayoría de los pacientes fueron masculinos, de color blanco y de procedencia rural. Los hallazgos más frecuentes fueron la localización proximal y la variante esclerosante. A más de la mitad de los pacientes se les realizó procedimiento de Hess y Whipple con finalidad curativa. La fuga biliar, el adenocarcinoma como tipo histológico y el estado al egreso vivo prevaleció en todos los pacientes(AU)

Introduction: Cholangiocarcinoma is the most frequent biliary tract neoplasm responsible for high morbidity and mortality. Objective: To determine morbidity and mortality due to extrahepatic cholangiocarcinoma in the surgery service of Hospital Universitario Manuel Ascunce Domenech. Methods: A descriptive, prospective and observational study was carried out with patients admitted to the general surgery service with a diagnosis of extrahepatic cholangiocarcinoma between September 2018 and January 2022. The study universe consisted of 21 patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: The highest incidence of patients were male and white-skinned, accounting for 71.4 percent and 85.7 percent, respectively. Adenocarcinoma predominated as histological variety, representing 85.7 percent, together with proximal cholangiocarcinoma and the sclerosing variant of its classification. 71.4 percent of the patients were discharged alive and after curative surgery. Conclusions: Most of the patients were male, white-skinned and from rural origin. The most frequent findings were a proximal location and the sclerosing variant. Over half the patients underwent Hess and Whipple procedure with curative purpose. Biliary leakage, adenocarcinoma as histologic type, and the condition of alive at discharge prevailed in all patients(AU)

Revascularización miocárdica completa con injertos arteriales en un paciente con dextrocardia / Complete coronary artery bypass grafting in a patient with dextrocardia

Introducción: la dextrocardia es una rara anomalía cardiaca congénita. Aunque la incidencia de enfermedad coronaria es similar a la población en general, son pocos los casos documentados en la literatura. La disposición anatómica en esta anomalía constituye un desafío a la hora de planificar la técnica quirúrgica y los injertos a utilizar. Presentación del caso: paciente de 59 años con enfermedad coronaria de 2 vasos que fue sometido a una cirugía de revascularización arterial completa.

Introduction: dextrocardia is a rare congenital heart abnormality. Although the incidence of coronary heart disease is similar to that in the general population, few cases have been documented in the literature. Anatomic variants in this anomaly are a challenge when planning the surgical technique and the choice of graft configuration to be used. Case presentation: a 59 -year- old patient with 2-vessel coronary artery disease who underwent coronary artery bypass grafting

Hernia de Garengeot / Garengeot's Hernia

Introducción: La hernia de Garengeot es una de las hernias de la pared abdominal más infrecuente del mundo. Objetivo: Presentar una paciente con diagnóstico de hernia crural, con el apéndice cecal, lo cual constituye la hernia de Garengeot. Caso clínico: Paciente femenina de color de piel blanca, de 56 años de edad, con antecedentes de salud, que ingresó en el Servicio de Cirugía del Hospital Universitario "Manuel Ascunce Domenech" con el diagnóstico de hernia crural atascada. Presentó dolor en la raíz del muslo derecho, náuseas y presencia de una tumoración por debajo de la línea de malgaigne, irreductible. Conclusiones: La hernia de Garengeot es una entidad quirúrgica única, difícil de distinguir de una hernia crural irreductible. Por tanto, su diagnóstico es un hallazgo intraoperatorio y la herniorrafia es el proceder quirúrgico más empleado(AU)

Introduction: Garengeot's hernia is one of the most uncommon abdominal wall hernias worldwide. Objective: To present the case of a patient with a diagnosis of crural hernia, with cecal appendix, definitely being Garengeot's hernia. Clinical case: A female patient of white skin color, aged 56 years old, with a family history of disease, was admitted to the surgery service of Hospital Universitario "Manuel Ascunce Domenech" with the diagnosis of incarcerated crural hernia. He presented pain in the root of the right thigh, nausea and an irreducible tumor below the Malgaigne's line, irreducible. Conclusions: Garengeot's hernia is a unique surgical entity, difficult to distinguish from an irreducible crural hernia. Therefore, its diagnosis is an intraoperative finding and herniorrhaphy is the most commonly used surgical procedure(AU)

Morbilidad por lesión de la vía biliar en un servicio de cirugía / Morbility due to Bile Duct Lesion in a Surgery Service

Introducción: Las lesiones iatrogénicas de las vías biliares representan una complicación quirúrgica grave de la colecistectomía. Objetivo: Determinar la morbilidad de las lesiones de la vía biliar en el servicio de cirugía del Hospital Universitario "Manuel Ascunce Domenech". Métodos: Se realizó un estudio descriptivo, prospectivo y observacional de pacientes que ingresaron en el servicio de cirugía del Hospital Universitario "Manuel Ascunce Domenech" con diagnóstico de lesión de la vía biliar, desde septiembre del 2018 hasta enero del 2022. El universo estuvo conformado por 12 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: La mayor incidencia de los pacientes fue del sexo femenino y de piel blanca, con un 61,4 por ciento y 85,7 por ciento, respectivamente. Predom inó el tipo de cirugía convencional y diagnóstico intraoperatorio con un 66,7 por ciento y 50 por ciento, respectivamente. El tipo E1 y E2 de la clasificación de Strasberg y la hepaticoyeyunostomía fue la operación con mayor frecuencia con un 66,7 por ciento. La bilirragia fue la complicación que predominó con el 70 por ciento. Conclusiones: La mayoría de los pacientes son del sexo femenino y de piel blanca, donde la cirugía convencional y el diagnóstico intraoperatorio son los hallazgos más frecuentes. Más de la mitad de los pacientes son clasificados como tipo E1 y tipo E2 según clasificación de Strasberg. La hepaticoyeyunostomía en Y de Roux y en asa de Braum transmesocólica es el proceder realizado en casi la totalidad de los pacientes. La fuga biliar es la complicación más frecuente(AU(

Introduction: Iatrogenic bile duct lesions represent a serious surgical complication of cholecystectomy. Objective: To determine the morbility of bile duct lesions in the surgical service of Hospital Universitario "Manuel Ascunce Domenech". Methods: A descriptive, prospective and observational study was carried out with patients admitted to the surgery service of Hospital Universitario "Manuel Ascunce Domenech" with a diagnosis of bile duct lesion, from September 2018 to January 2022. The study universe consisted of twelve patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: The highest incidence of patients corresponded to the female sex and the white skin, accounting for 61.4 percent and 85.7(Percent(, respectively. Conventional surgery and intraoperative diagnosis predominated, accounting for 66.7 % and 50 %, respectively. Types E1 and E2 according to the Strasberg classification, together with hepaticojejunostomy, was the most frequent surgery type, accounting for 66.7 %. Biliary bleeding was the predominant complication, accounting for 70 %. Conclusions: Most of the patients belong to the female sex and have white skin, in which cases conventional surgery and intraoperative diagnosis are the most frequent findings. More than half of the patients are classified as types E1 or E2 according to the Strasberg classification. Transmesocolic Braun loop and Roux-en-Y hepaticojejunostomy is the procedure performed in almost all patients. Biliary leakage is the most frequent complication(AU)

X-linked hypohidrotic ectodermal dysplasia management with removable prosthesis in a pediatric patient: case report / Manejo de displasia ectodérmica hipohidrótica ligada al cromosoma X con prótesis removible en un paciente pediátrico: reporte de caso

Introduction: Ectodermal dysplasia is a rare genetic disorder that affects structures derived from ectoderm such as teeth, hair, nails, and sweat glands. Oligodontia is a common finding that affects the chewing, smiling and self- esteem of these pediatric patients. Case Report: We present a case report of a 7-years-old pediatric patient who consulted with his mother, showing the same condition. The intervention consisted of a removable prosthesis with satisfactory results. Conclusion: The X-linked hypohidrotic ectodermal dysplasia represents a challenge for a pediatric dentist who offers rehabilitation to the patient according to craniofacial development, age, socioeconomic status, and the number of missing teeth.

Introducción: La oligodoncia es un hallazgo común que afecta la masticación, la sonrisa y la autoestima de estos pacientes pediátricos. Case Report: Presentamos un reporte de caso de un paciente pediátrico de 7 años que consultó con su madre presentando la misma condición. La intervención consistió en una prótesis de remoción con resultados satisfactorios. Conclusión: La displasia ectodérmica hipohidrótica ligada al cromosoma X representa un desafío para un odontopediatra que ofrece rehabilitación al paciente de acuerdo con el desarrollo craneofacial, la edad, el nivel socioeconómico y el número de dientes faltantes.

Mammography and Decision Aid Use for Breast Cancer Screening in Older Women.

INTRODUCTION: Decision aids for breast cancer screening are increasingly being used by physicians, but the association between physician practice decision-aid use and mammography rates remains uncertain. Using national data, this study examines the association between practice-level decision-aid use and mammography use among older women. METHODS: Physician practice responses to the 2017/2018 National Survey of Healthcare Organizations and Systems (n=1,236) were linked to 2016 and 2017 Medicare fee-for-service beneficiary data from eligible beneficiaries (n=439,684) aged 65-74 years. In 2021, multivariable generalized linear models estimated the association of practice decision-aid use for breast cancer screening and advanced health information technology functions with mammography use, controlling for practice and beneficiary characteristics. RESULTS: Overall, 60.1% of eligible beneficiaries had a screening mammogram, and 37.3% of physician practices routinely used decision aids for breast cancer screening. In adjusted analyses, advanced health information technology functions (OR=1.19, p=0.04) were associated with mammography use, but practice use of decision aids was not (OR=0.95, p=0.21). Beneficiary clinical and socioeconomic characteristics, including race, comorbidities, Medicare and Medicaid eligibility, and median household income were more strongly associated with mammography use than practice-level decision-aid use or advanced health information technology functions. CONCLUSIONS: Health information technology‒enabled automation of mammography reminders and other advanced health information technology functions may support mammography, whereas breast cancer decision aids may reduce patients' propensities to be screened through the alignment of their preferences and screening decision. More resources may be needed for decision aids to be routinely implemented to improve solicitation of patient preferences and targeting of mammography services.

The Reliability of Graduate Medical Education Quality of Care Clinical Performance Measures.

Background: Graduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied. Objective: To examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care. Methods: From 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated. Results: The highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable. Conclusions: GME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.

Mitochondrial complex I dysfunction alters the balance of soluble and membrane-bound TNF during chronic experimental colitis.

Inflammatory bowel disease (IBD) is a complex, chronic, relapsing and heterogeneous disease induced by environmental, genomic, microbial and immunological factors. MCJ is a mitochondrial protein that regulates the metabolic status of macrophages and their response to translocated bacteria. Previously, an acute murine model of DSS-induced colitis showed increased disease severity due to MCJ deficiency. Unexpectedly, we now show that MCJ-deficient mice have augmented tumor necrosis factor α converting enzyme (TACE) activity in the context of chronic inflammation. This adaptative change likely affects the balance between soluble and transmembrane TNF and supports the association of the soluble form and a milder phenotype. Interestingly, the general shifts in microbial composition previously observed during acute inflammation were absent in the chronic model of inflammation in MCJ-deficient mice. However, the lack of the mitochondrial protein resulted in increased alpha diversity and the reduction in critical microbial members associated with inflammation, such as Ruminococcus gnavus, which could be associated with TACE activity. These results provide evidence of the dynamic metabolic adaptation of the colon tissue to chronic inflammatory changes mediated by the control of mitochondrial function.

Ex vivo effect of JAK inhibition on JAK-STAT1 pathway hyperactivation in patients with dominant-negative STAT3 mutations.

PURPOSE: STAT1 gain-of-function (GOF) and dominant-negative (DN) STAT3 syndromes share clinical manifestations including infectious and inflammatory manifestations. Targeted treatment with Janus-kinase (JAK) inhibitors shows promising results in treating STAT1 GOF-associated symptoms while management of DN STAT3 patients has been largely supportive. We here assessed the impact of ruxolitinib on the JAK-STAT1/3 pathway in DN STAT3 patients' cells. METHODS: Using flow cytometry, immunoblot, qPCR, and ELISA techniques, we examined the levels of basal STAT1 and phosphorylated STAT1 (pSTAT1) of cells obtained from DN STAT3, STAT1 GOF patients, and healthy donors following stimulation with type I/II interferons (IFNs) or interleukin (IL)-6. We also describe the impact of ruxolitinib on cytokine-induced STAT1 signaling in these patients. RESULTS: DN STAT3 and STAT1 GOF resulted in a similar phenotype characterized by increased STAT1 and pSTAT1 levels in response to IFNα (CD3+ cells) and IFNγ (CD14+ monocytes). STAT1-downstream gene expression and C-X-C motif chemokine 10 secretion were higher in most DN STAT3 patients upon stimulation compared to healthy controls. Ex vivo treatment with the JAK1/2-inhibitor ruxolitinib reduced cytokine responsiveness and normalized STAT1 phosphorylation in DN STAT3 and STAT1 GOF patient' cells. In addition, ex vivo treatment was effective in modulating STAT1 downstream signaling in DN STAT3 patients. CONCLUSION: In the absence of effective targeted treatment options for AD-HIES at present, modulation of the JAK/STAT1 pathway with JAK inhibitors may be further explored particularly in those AD-HIES patients with autoimmune and/or autoinflammatory manifestations.

Characterization of pain-related behaviors, changes in bone microarchitecture and sensory innervation induced by chronic cadmium exposure in adult mice.

Because of the relative lack of understanding of the neurobiological mechanisms that drive toxic effects of cadmium in bone, the purpose of this study was to characterize a preclinical model of chronic cadmium exposure. Adult male C57BL/6 J mice were exposed to cadmium 25 mg/L (as CdCl2) in drinking water for 16 weeks. During this time, pain-related behaviors including hindpaw mechanical sensitivity and vertical rears were evaluated every four weeks. We assessed changes in bone microarchitecture at the femoral neck and L5 vertebra by microcomputed tomography and quantified the density of nerve fibers expressing PGP 9.5 (a pan-neuronal marker) and CGRP (a marker of sensory nerve fibers subfamily) at the femoral neck and glabrous skin of the hindpaw using immunohistochemistry. Cadmium exposure produced mechanical hypersensitivity in both hindpaws along with decreased rearing activity (surrogate for musculoskeletal-related pain) without affecting the horizontal activity (a measure of locomotor behavior) in comparison to the control group. Intraperitoneal acute treatment with morphine and gabapentin reversed pain-related behaviors in cadmium-exposed mice. Furthermore, exposure to cadmium resulted in significant trabecular bone deterioration at the femoral neck and L5 vertebra. We also observed a significant reduction in the density of both CGRP+ and PGP 9.5+ nerve fibers in the femoral neck, but not in the hindpaw glabrous skin, suggesting tissue-dependent neurotoxicity. This model may help in developing a mechanism-based understanding of the factors that generate and maintain musculoskeletal pain and bone loss caused by chronic cadmium exposure and in translating these findings into new therapies for treating cadmium-induced bone toxicity.

Cigarettes smoked among daily and non-daily smokers following CVS Health's tobacco-free pharmacy policy.

INTRODUCTION: In September 2014, CVS Health ceased tobacco sales in all of its 7700 pharmacies nationwide. We investigate the impact of the CVS policy on the number of cigarettes smoked per day among metropolitan daily and non-daily smokers, who may respond to the availability of smoking cues in different manners. METHODS: Data are from the US Census Bureau Tobacco Use Supplement to the Current Population Survey 2014-2015 and the Blue Cross and Blue Shield Institute Community Health Management Hub. Adjusted difference-in-difference (DID) regressions assess changes in the number of cigarettes smoked per day among daily smokers (n=10 759) and non-daily smokers (n=3055), modelling core-based statistical area (CBSA) level CVS pharmacy market share continuously. To assess whether the policy had non-linear effects across the distribution of CVS market share, we also examine market share using tertiles. RESULTS: CVS's tobacco-free pharmacy policy was associated with a significant reduction in the number of cigarettes smoked by non-daily smokers in the continuous DID (rate ratio=0.985, p=0.022), with a larger reduction observed among non-daily smokers in CBSAs in the highest third of CVS market share compared with those living in CBSAs with no CVS presence (rate ratio=0.706, p=0.027). The policy, however, was not significantly associated with differential changes in the number of cigarettes by daily smokers. CONCLUSION: The removal of tobacco products from CVS pharmacies was associated with a reduction in the number of cigarettes smoked per day among non-daily smokers in metropolitan CBSAs, particularly those in which CVS had a large pharmacy market share.

Comparing health care system and physician practice influences on social risk screening.

BACKGROUND: Health care systems can support dissemination of innovations, such as social risk screening in physician practices, but to date, no studies have examined the association of health system characteristics and practice-level adoption of social risk screening. PURPOSE: The aim of the study was to examine the association of multilevel organizational capabilities and adoption of social risk screening among system-owned physician practices. METHODOLOGY: Secondary analyses of the 2018 National Survey of Healthcare Organizations and Systems were conducted. Multilevel linear regression models examined physician practice and system characteristics associated with practice adoption of screening for five social risks (food insecurity, housing instability, utility needs, interpersonal violence, and transportation needs), accounting for clustering of practices within systems using random effects. RESULTS: System-owned practices screened for an average of 1.7 of the five social risks assessed. The intraclass correlation indicated 16% of practice variation in social risk screening was attributable to differences between their health systems owners, with 84% attributable to differences between individual practices. Practices owned by systems with multiple hospitals screened for an additional 0.44 social risks (p = .046) relative to practices of systems without hospitals. Practice characteristics associated with social risk screening included health information technology capacity (ß = 0.20, p = .005), innovation culture (ß = 0.26, p < .001), and patient engagement strategies (ß = 0.57, p < .001). CONCLUSIONS: Health care system capabilities account for less variation in physician practice adoption of social risk screening compared to practice-level capabilities. PRACTICE IMPLICATIONS: Efforts to expand social risk screening among system-owned physician practices should focus on supporting practice capabilities, including enhancing health information technology, promoting an innovative organizational culture, and advancing patient engagement strategies.