Cost and Utilization Implications of a Health Plan's Home-Based Palliative Care Program.

Background: A California-based health plan offered home-based palliative care (HBPC) to members who needed support at home but did not yet qualify for hospice. Objectives: This study compares hospital and emergency department (ED) utilization and costs and mortality for individuals receiving HBPC to a cohort not receiving palliative care services (Usual Care). Design: This is an observational retrospective study using claims data covering a prestudy period and a study period during which time half of the study population received HBPC services. Setting/Subjects: Seriously ill individuals who received HBPC were matched with those receiving Usual Care using a propensity-based matching algorithm. Intervention: Interdisciplinary teams from home health and hospice agencies provided HBPC services. Measurements: Outcome measures included hospital and ED utilization and cost before and during the study period and mortality during the study period. Results: For both groups, hospital and ED utilization and associated costs were higher during the prestudy period than during the study period. No differences were found in outcome measures between groups during the study period. Average time in the study period was longer for the HBPC group than that in the Usual Care group, indicating that they lived longer or transitioned to hospice later. Conclusion: Although individuals in both groups were living with serious illnesses for which worsening health and increased acute care utilization are expected over time, both groups had reduced acute care utilization and costs during the study period compared with the prestudy period. Reduced utilization and costs were equivalent for both groups.

Association of dementia diagnosis with urinary tract infection in the emergency department.

OBJECTIVES: Overdiagnosis of urinary tract infections (UTI) among people living with dementia is a nationally recognized problem associated with morbidity from antibiotics as well as multidrug-resistant bacteria. However, whether this problem also exists in the emergency department (ED) is currently unknown. METHODS: To examine the association between dementia and UTI diagnosis in the ED we performed a retrospective analysis of Medicare beneficiaries older than 65 years old who presented to an ED in 2016. A diagnosis of UTI was present in 58,580 beneficiaries, and 321,479 beneficiaries without a diagnosis of UTI served as the comparison group. Our logistic regression model controlled for dementia, older age, female sex, Medicaid status, skilled nursing facility residence, history of prostate cancer, recent urinary catheter use, recurrent UTI, and multiple comorbidities. RESULTS: In our model, people living with dementia had over twice the odds (odds ratio = 2.27, 95% confidence interval = 2.21, 2.33) of being diagnosed with a UTI in the ED compared to those without dementia despite their lower prevalence of symptoms and signs localizing to the genitourinary tract (3.8% vs 8.9%, respectively). CONCLUSION: This is the first study from a national database that examines the association of dementia with UTI diagnosis among older adults who visit the ED. Our study could not establish whether the UTI diagnoses in the ED were accurate but does imply a disproportionate burden of UTI diagnoses in people living with dementia despite their lower prevalence of clinical criterion. Antimicrobial stewardship in the ED should address the complexity of UTI diagnosis in dementia.

Parental legacy, demography, and admixture influenced the evolution of the two subgenomes of the tetraploid Capsella bursa-pastoris (Brassicaceae).

Allopolyploidy is generally perceived as a major source of evolutionary novelties and as an instantaneous way to create isolation barriers. However, we do not have a clear understanding of how two subgenomes evolve and interact once they have fused in an allopolyploid species nor how isolated they are from their relatives. Here, we address these questions by analyzing genomic and transcriptomic data of allotetraploid Capsella bursa-pastoris in three differentiated populations, Asia, Europe, and the Middle East. We phased the two subgenomes, one descended from the outcrossing and highly diverse Capsella grandiflora (CbpCg) and the other one from the selfing and genetically depauperate Capsella orientalis (CbpCo). For each subgenome, we assessed its relationship with the diploid relatives, temporal changes of effective population size (Ne), signatures of positive and negative selection, and gene expression patterns. In all three regions, Ne of the two subgenomes decreased gradually over time and the CbpCo subgenome accumulated more deleterious changes than CbpCg. There were signs of widespread admixture between C. bursa-pastoris and its diploid relatives. The two subgenomes were impacted differentially depending on geographic region suggesting either strong interploidy gene flow or multiple origins of C. bursa-pastoris. Selective sweeps were more common on the CbpCg subgenome in Europe and the Middle East, and on the CbpCo subgenome in Asia. In contrast, differences in expression were limited with the CbpCg subgenome slightly more expressed than CbpCo in Europe and the Middle-East. In summary, after more than 100,000 generations of co-existence, the two subgenomes of C. bursa-pastoris still retained a strong signature of parental legacy but their evolutionary trajectory strongly varied across geographic regions.

Enterobacter cloacae infection of an expanded polytetrafluoroethylene femoral-popliteal bypass graft: a case report.

INTRODUCTION: Enterobacter cloacae infections are common among burn victims, immunocompromised patients, and patients with malignancy. Most commonly these infections are manifested as nosocomial urinary tract or pulmonary infections. Nosocomial outbreaks have also been associated with colonization of certain surgical equipment and operative cleaning solutions. Infections of an aortobifemoral prosthesis, an aortic graft, and arteriovenous fistulae are noted in the literature. To our knowledge, this is the first isolated account of an E. cloacae infection of a femoral-popliteal expanded polytetrafluoroethylene bypass graft. CASE PRESENTATION: A 68-year-old Caucasian man presented with fever and rest pain in the right lower extremity five months after the placement of a vascular expanded polytetrafluoroethylene graft for femoral-popliteal bypass. Computed tomography angiography demonstrated peri-graft fluid that was aspirated percutaneously with image guidance and cultured to reveal E. cloacae. The graft was revised and then removed. The patient completed a six-week course of ceftazidime and is currently without signs of infection. There were no other reports of E. cloacae graft infections in any patients receiving treatment in the same surgical suite within a month of this report. CONCLUSION: Isolated cases of E. cloacae infection of surgical bypass grafts are rare (unique in this setting). Clinicians should have a high index of suspicion for device contamination in such cases and should consider testing for possible microbial reservoirs. Graft removal is required due to the formation of biofilm and the recent emergence of Enterobacteriaceae producing extended-spectrum beta-lactamase in community acquired infections.