Development and characterization of the first proton minibeam system for single-gantry proton facility.

BACKGROUND: Minibeam represents a preclinical spatially fractionated radiotherapy modality with great translational potential. The advantage lies in its high therapeutic index (compared to GRID and LATTICE) and ability to treat at greater depth (compared to microbeam). Proton minibeam radiotherapy (pMBRT) is a synergy of proton and minibeam. While the single-gantry proton facility has gained popularity due to its affordability and compact design, it often has limited beam time available for research purposes. Conversely, given the current requirement of pMBRT on specific minibeam hardware collimators, necessitates a reproducible and fast setup to minimize pMBRT treatment time and streamline the switching time between pMBRT and conventional treatment for clinically translation. PURPOSE: The contribution of this work is the development and characterization of the first pMBRT system tailored for single-gantry proton facility. The system allows for efficient and reproducible plug-and-play setup, achievable within minutes. METHODS: The single room pMBRT system is constructed based on IBA ProteusONE proton machine. The end of nozzle is attached with beam modifying accessories though an accessory drawer. A small snout is attached to the accessory drawer and used to hold apertures and range shifters. The minibeam aperture consists of two components: a fitting ring and an aperture body. Three minibeam apertures were manufactured. The first-generation apertures underwent qualitatively analysis with film, and the second generation aperture underwent more comprehensive quantitative measurement. The reproducibility of the setup is accessed, and the film measurements are performed to characterize the pMBRT system in cross validation with Monte Carlo (MC) simulations. RESULTS: We presented initial results of large field pMBRT aperture and the film measurements indicates the effect of source-to-isocenter distance = 930 cm in Y proton scanning direction. Consistent with TOPAS MC simulation, the dose uniformity of pMBRT field <2 cm is demonstrated to be better than 2%, rendering its suitability for pre-clinical studies. Subsequently, we developed the second generation of aperture with five slits and characterized the aperture with film dosimetry studies and compared the results to the benchmark MC. Comprehensive film measurements were also performed to evaluate the effect of divergence, air gap and gantry-angle dependency and repeatability and revealing a consistent performance within 5%. Furthermore, the 2D gamma analysis indicated a passing rate exceeding 99% using 3% dose difference and 0.2 mm distance agreement criteria. We also establish the peak valley dose ratio and the depth dose profile measurements, and the results are within 10% from MC simulation. CONCLUSIONS: We have developed the first pMBRT system tailored for a single-gantry proton facility, which has demonstrated accuracy in benchmark with MC simulations, and allows for efficient plug-and-play setup, emphasizing efficiency.

US Medical-Legal Partnerships to Address Health-Harming Legal Needs: Closing the Health Injustice Gap.

The medical-legal partnership (MLP) model is emerging across the USA as a powerful tool to address the adverse social conditions underlying health injustice. MLPs embed legal experts into healthcare teams to address health-harming legal needs with civil legal remedies. We conducted a narrative review of peer-reviewed articles published between 2007 and 2022 to characterize the structure and impacts of US MLPs on patients, providers, and healthcare systems. We found that MLPs largely serve vulnerable patient populations by integrating legal experts into community-based clinical settings or children's hospitals, although patient populations and settings varied widely. In most models, healthcare providers were trained to screen patients for legal needs and refer them to legal experts. MLPs provided a wide range of services, such as assistance accessing public benefits (e.g., Social Security, Medicaid, cash assistance) and legal representation for immigration and family law matters. Patients and their families also benefited from increased knowledge about legal rights and systems. Though the evidence base remains nascent, available studies show MLPs to be associated with greater access to care, fewer hospitalizations, and improved physical and mental health outcomes. Medical and legal providers who were engaged in MLPs reported interdisciplinary learning, and healthcare systems often experienced high returns on investment through cost savings and increased Medicaid reimbursement. Many MLPs also conducted advocacy and education to effect broader policy changes related to population health and social needs. To optimize the MLP model, more rigorous research, systematic implementation practices, evaluation metrics, and sustainable funding mechanisms are recommended. Broader integration of MLPs into healthcare systems could help address root causes of health inequity among historically marginalized populations in the USA.

Population-Based Disparities in U.S. Urban Heat Exposure from 2003 to 2018.

Previous studies have shown, in the United States (U.S.), that communities of color are exposed to significantly higher temperatures in urban environments than complementary White populations. Studies highlighting this disparity have generally been cross-sectional and are therefore "snapshots" in time. Using surface urban heat island (SUHI) intensity data, U.S. Census 2020 population counts, and a measure of residential segregation, this study performs a comparative analysis between census tracts identified as prevalent for White, Black, Hispanic and Asian populations and their thermal exposure from 2003 to 2018. The analysis concentrates on the top 200 most populous U.S. cities. SUHI intensity is shown to be increasing on average through time for the examined tracts. However, based on raw observations the increase is only statistically significant for White and Black prevalent census tracts. There is a 1.25 K to ~2.00 K higher degree of thermal exposure on average for communities of color relative to White prevalent areas. When examined on an inter-city basis, White and Black prevalent tracts had the largest disparity, as measured by SUHI intensity, in New Orleans, LA, by <6.00 K. Hispanic (>7.00 K) and Asian (<6.75 K) prevalent tracts were greatest in intensity in San Jose, CA. To further explore temporal patterns, two models were developed using a Bayesian hierarchical spatial temporal framework. One models the effect of varying the percentages of each population group relative to SUHI intensity within all examined tracts. Increases in percentages of Black, Hispanic, and Asian populations contributed to statistically significant increases in SUHI intensity. White increases in population percentage witnessed a lowering of SUHI intensity. Throughout all modeled tracts, there is a statistically significant 0.01 K per year average increase in SUHI intensity. A second model tests the effect of residential segregation on thermal inequity across all examined cities. Residential segregation, indeed, has a statistically significant positive association with SUHI intensity based on this portion of the analysis. Similarly, there is a statistically significant 0.01 K increase in average SUHI intensity per year for all cities. Results from this study can be used to guide and prioritize intervention strategies and further urgency related to social, climatic, and environmental justice concerns.

Arthroscopic Case Volumes Among Orthopaedic Surgery Residents and Orthopaedic Sports Medicine Fellows: An Analysis of ACGME Case Log Data.

Arthroscopic procedures are used to treat a multitude of disorders, but they can be technically demanding. These procedures are a fundamental aspect of orthopaedic surgery residency and surgical sports medicine fellowship. The goal of this study was to analyze the variability in arthroscopic case experience to better understand the disparities between various training programs and the opportunity for increased surgical case volume of an orthopaedic sports medicine fellowship. Resident and fellow case log reports were gathered from the Accreditation Council for Graduate Medical Education. Fellows reported 286% more arthroscopic cases in one year of fellowship than residents reported in five years of residency (554 cases vs. 193 cases, p < 0.0001). Fellows also performed 770% more arthroscopic hip procedures than residents (57 cases vs. 7 cases, p < 0.0001). There is a significant difference in arthroscopic case volume between residents and fellows. An orthopaedic sports medicine fellowship dramatically increases the arthroscopic experience of trainees. (Journal of Surgical Orthopaedic Advances 31(1):022-025, 2022).

Determining the Impact of the COVID-19 Pandemic on Hand Surgery Fellowship Education.

The purpose of this study is to report the impact of COVID-19 on hand surgery fellow learning and preparedness for practice. A multi-dimensional questionnaire was distributed to current hand fellows and fellowship directors across the United States. Survey questions included fellowship location, institutional response, impact on practice, education and job search. Thirty-two hand surgery fellows and 14 fellowship directors completed the survey. Of fellows, 59% reported a greater than 75% decrease in case volume. Mean hours worked per week per fellow decreased by 52%. All fellowship directors and 94% of fellows did not expect COVID-19 to impact their ability to graduate, and nearly all fellows felt prepared to start practice after fellowship training. However, many fellows expressed concern about job opportunities. The work hours and exposure of hand surgery fellows to elective surgical cases have been adversely impacted by COVID-19. Nevertheless, current hand fellows feel prepared to enter practice. (Journal of Surgical Orthopaedic Advances 31(1):048-052, 2022).

Spine Surgery and COVID-19: The Influence of Practice Type on Preparedness, Response, and Economic Impact.

STUDY DESIGN: Cross-sectional observational cohort study. OBJECTIVE: To investigate preparation, response, and economic impact of COVID-19 on private, public, academic, and privademic spine surgeons. METHODS: AO Spine COVID-19 and Spine Surgeon Global Impact Survey includes domains on surgeon demographics, location of practice, type of practice, COVID-19 perceptions, institutional preparedness and response, personal and practice impact, and future perceptions. The survey was distributed by AO Spine via email to members (n = 3805). Univariate and multivariate analyses were performed to identify differences between practice settings. RESULTS: A total of 902 surgeons completed the survey. In all, 45.4% of respondents worked in an academic setting, 22.9% in privademics, 16.1% in private practice, and 15.6% in public hospitals. Academic practice setting was independently associated with performing elective and emergent spine surgeries at the time of survey distribution. A majority of surgeons reported a >75% decrease in case volume. Private practice and privademic surgeons reported losing income at a higher rate compared with academic or public surgeons. Practice setting was associated with personal protective equipment availability and economic issues as a source of stress. CONCLUSIONS: The current study indicates that practice setting affected both preparedness and response to COVID-19. Surgeons in private and privademic practices reported increased worry about the economic implications of the current crisis compared with surgeons in academic and public hospitals. COVID-19 decreased overall clinical productivity, revenue, and income. Government response to the current pandemic and preparation for future pandemics needs to be adaptable to surgeons in all practice settings.

Long-Term Assessment of the Effects of COVID-19 and Isolation Care on Survivor Disability and Anxiety.

We conducted an assessment of disability, anxiety, and other life impacts of COVID-19 and isolation care in a unique cohort of individuals. These included both community admissions to a university hospital as well as some of the earliest international aeromedical evacuees. Among an initial 16 COVID-19 survivors that were interviewed 6-12 months following their admission into isolation care, perception of their isolation care experience was related to their reporting of long-term consequences. However, anxiety and disability assessed with standard scores had no relationship with each other. Both capture of the isolation care experience and caution relying on single scoring systems for assessing long-term consequences in survivors are important considerations for on-going and future COVID-19 and other pandemic survivor research.

Reducing Cardiovascular Maternal Mortality by Extending Medicaid for Postpartum Women.

Maternal mortality has been increasing in the United States over the past 3 decades, while decreasing in all other high-income countries during the same period. Cardiovascular conditions account for over one fourth of maternal deaths, with two thirds of deaths occurring in the postpartum period. There are also significant healthcare disparities that have been identified in women experiencing maternal morbidity and mortality, with Black women at 3 to 4 times the risk of death as their White counterparts and women in rural areas at heightened risk for cardiovascular morbidity and maternal morbidity. However, many maternal deaths have been shown to be preventable, and improving access to care may be a key solution to addressing maternal cardiovascular mortality. Medicaid currently finances almost half of all births in the United States and is mandated to provide coverage for women with incomes up to 138% of the federal poverty level, for up to 60 days postpartum. In states that have not expanded coverage, new mothers become uninsured after 60 days. Medicaid expansion has been shown to reduce maternal mortality, particularly benefiting racial and ethnic minorities, likely through reduced insurance churn, improved postpartum access to care, and improved interpregnancy care. However, even among states with Medicaid expansion, significant care gaps exist. An additional proposed intervention to improve access to care in these high-risk populations is extension of Medicaid coverage for 1 year after delivery, which would provide the most benefit to women in Medicaid nonexpanded states, but also improve care to women in Medicaid expanded states.

Sociodemographic differences in utilization and outcomes for temporary cardiovascular mechanical support in the setting of cardiogenic shock.

BACKGROUND: Temporary mechanical circulatory support (MCS) devices are increasingly used in cardiogenic shock, but whether sociodemographic differences by sex, race and/or ethnicity, insurance status, and neighborhood poverty exist in the utilization of these devices is unknown. METHODS: Retrospective cross-sectional study using the National Inpatient Sample for 2012-2017. Logistic regression models were used to examine predictors of use of temporary MCS devices and for in-hospital mortality, clustering by hospital-year. RESULTS: Our study population included 109,327 admissions for cardiogenic shock. Overall, 14.3% of admissions received an intra-aortic balloon pump, 4.2% a percutaneous ventricular assist device, and 1.8% extracorporeal membranous oxygenation (ECMO). After adjusting for age, comorbidities, and hospital characteristics, use of temporary MCS was lower in women compared to men (adjusted odds ratio [aOR] = 0.76, P < .001), Black patients compared to white ones (aOR = 0.73, P < .001), those insured by Medicare (aOR = 0.75, P < .001), Medicaid (aOR = 0.74, P < .001), or uninsured (aOR = 0.90, P = .015) compared to privately insured, and those in the lowest income neighborhoods (aOR = 0.94, P = .003) versus other neighborhoods. Women, admissions covered by Medicare, Medicaid, or uninsured, and those from low-income neighborhoods also had higher mortality rates even after adjustment for MCS implantation. CONCLUSIONS: There are differences in the use of temporary MCS in the setting of cardiogenic shock among specific populations within the United States. The growing use of MCS for treating cardiogenic shock highlights the need to better understand its impact on outcomes.

Results from the 2019 American Society of Cytopathology survey on rapid onsite evaluation (ROSE)-part 2: subjective views among the cytopathology community.

INTRODUCTION: This study aims to improve understanding of the cytopathology community's perspective regarding the value of rapid onsite evaluation (ROSE) in clinical practice. MATERIALS AND METHODS: The American Society of Cytopathology membership was surveyed in 2019 to obtain subjective data on the cytopathology community's perceptions regarding ROSE. Comments were categorized by major themes and attitudes and analyzed by respondent's role in laboratory, practice size, and practice setting (Fisher's exact and χ2 tests). RESULTS: A total of 541 responses were received from 255 cytopathologists/pathologists, 261 cytotechnologists, 19 trainees, and 6 others (as previously reported). Reasons for which cytopathology personnel provide this service aligned with their perceptions of why clinicians request ROSE. A minority of respondents, disproportionally from high volume centers, felt ROSE is unnecessary. Overall attitude regarding ROSE was generally positive. There were no significant differences in attitude regarding ROSE according to role in laboratory or practice size, but respondents from academic centers provided a significantly higher percentage of positive comments than those in private or community practice. Although survey respondents generally felt that ROSE is valuable to patient care, they also highlighted several challenges, including staffing, time commitment, and inadequate reimbursement. Implementation of telecytology was felt to potentially alleviate some of these challenges. CONCLUSIONS: Survey results show that the cytology community views ROSE favorably, practices vary considerably, and there is a perceived need for improved reimbursement. Data from this study may be used to identify areas that warrant additional research to clarify the clinical value of ROSE.

Assessment of Flexion Strength Following Single- Versus Double-Hamstring Tendon Harvest for Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare isometric hamstring strength deficits, knee laxity, functional outcomes, and patient-reported outcomes between patients who underwent anterior cruciate ligament (ACL) reconstruction with doubled semitendinosus and gracilis tendon autograft (ST/G) versus quadrupled semitendinosus autograft (ST), at a minimum follow-up of 1-year postoperatively. METHODS: Patients who underwent ACL reconstruction with ST/G or ST hamstring autografts were retrospectively identified. Isometric hamstring strength was tested with a hand-held dynamometer at 30, 60, and 90° of knee flexion. Anterior knee laxity was assessed using a KT-1000 arthrometer. Functional outcomes were collected using the single-leg hop test and single-leg squat test. Side-to-side differences were determined and compared between the ST/G and ST groups. Patient-reported outcomes were collected on all patients. RESULTS: Eighty-four patients who underwent ST/G (n = 34) or ST (n = 50) autograft ACL reconstruction were recruited to participate in this study. There was no difference in knee laxity between the groups. Side-to-side hamstring strength deficits increased with increased flexion angles. At 90° of flexion, the ST/G group had a significantly greater flexion strength deficit compared with the ST group (37.8 ± 15.1% vs 24.7 ± 12.5%, P < .001). Aside from a significant difference in the KOOS pain Score (P .045), no other significant differences in functional or patient reported outcomes between the groups were identified. CONCLUSIONS: Patients who underwent ACL reconstruction with ST/G compared with ST autograft have a significantly greater isometric flexion strength deficit at 90° of flexion. Future investigations are required to determine the clinical relevance of this difference and whether specialized therapy protocols can mitigate this deficit. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Risk Factors for Greater Than 24-Hour Length of Stay After Primary Total Knee Arthroplasty.

BACKGROUND: Recently, the Center for Medicare Services removed total knee arthroplasty (TKA) from the inpatient-only procedure list. The purpose of this study is to assess the role of demographics, medical comorbidities, and postsurgical complications in predicting safe discharge to home within 24 hours after TKA. METHODS: Patients undergoing primary TKA between 2011 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped into those whose length of stay (LOS) was less than 24 hours after surgery vs those greater than 24 hours. Demographics, preoperative comorbidities, operative variables, and postoperative adverse events were studied as risk factors for LOS greater than 24 hours. RESULTS: A total of 210,075 patients undergoing primary TKA met the inclusion criteria, and of those, 18,134 (8.6%) patients were discharged within 24 hours postoperatively. In a risk-adjusted multivariate analysis, patients with increasing age, obesity, preoperative comorbidities of smoking, diabetes, dyspnea, chronic obstructive pulmonary disease, hypertension, bleeding disorder, corticosteroid use preoperatively, and dependent functional status conferred a greater risk for discharge greater than 24 hours. Male gender, spinal anesthesia, and monitored anesthesia care were protective against LOS greater than 24 hours. CONCLUSION: This study suggests that dependent functional status, preoperative comorbidities, and postoperative complications are all associated with a LOS greater than 24 hours after TKA. Surgeons and patients should be aware of the clinical and demographic variables associated with risk for LOS greater than 24 hours when considering outpatient status for patients undergoing TKA.

ECHO-Chicago Geriatrics: using telementoring to "geriatricize" the primary care workforce.

BACKGROUND: The primary care workforce is under-prepared to care for the growing older adult population. Extension for Community Healthcare Outcomes (ECHO) is a continuing education intervention that connects subspecialists and community health care providers (HCPs) via videoconferencing technology for didactic and case-discussion sessions. Methods: We asked participants to complete 8 to 12 educational telementoring sessions. These sessions were conducted between February 2016 and October 2017. Pre/post surveys of self-efficacy and frequency of practice behaviors were collected from eligible participants. Results: 121 HCPs from multiple sites participated. Of these, 89 (non-trainee status) were eligible to complete surveys. Sixty-two participants (69.7%) completed pre/post surveys. Participants were queried regarding 15 geriatrics competencies. Self-efficacy significantly increased across all competencies after series participation (p < 0.05). Frequency of 8 out of 11 queried geriatrics-centered practice behaviors also increased significantly (p < 0.05). Discussion: ECHO-Chicago Geriatrics offers a novel strategy for improving community HCPs' geriatrics self-efficacy and frequency of geriatrics-centered practice behaviors.

A Simulation Suture Compared With a Clinical Suture for Training on Laparoscopic Simulators: Objective Measurements Indicate Acceptable Physical Characteristics.

OBJECTIVE: Simulation sutures are a low-cost option for training purposes, but they may not perform as well as the more expensive clinical suture. Trainees at our institution have raised concerns about their quality and integrity compared with clinical suture. The objective was to determine whether significant differences in strength of the sutures and knot holding capabilities between low and high-cost sutures existed. METHODS: Two sutures were compared: 3-0 braided silk simulation suture (Sim*Vivo LLC, Willsboro, NY) and 3-0 Perma-Hand silk braided clinical suture (Ethicon, Somerville, NJ). The diameter of the suture was assessed with light microscopy. Tensile strength of the suture and knotted suture were assessed. Both sutures were tested dry and wet. RESULTS: Tensile strength of the sutures, knotted or unknotted, were not significantly different. Knot type did not change this comparison. Soaking in saline did not change the tensile strength but did introduce a substantial difference in knot failure mode between sutures. The mean diameter of the Ethicon suture was larger than that of the Sim*Vivo suture, which could influence suture behavior. CONCLUSIONS: The applied mechanical tests identified that clinical and simulation sutures differ some in their inherent mechanical characteristics related to suture handling. However, these differences did not translate to a key measure of performance of a sutured junction, namely, the strength of the knotted suture. Based on the results of the study, any subjective impressions of simulation suture strength and knot holding should not negatively impact its use for medical education.

The Experiential Benefit of an Orthopedic Trauma Fellowship: An Analysis of ACGME Case Log Data From 2006 to 2017.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has published orthopedic case log data since the 2006/2007 academic year. Here, we use this data to analyze the variability in orthopedic trauma case experience reported by orthopedic trainees and to better understand the impact of an orthopedic trauma fellowship on orthopedic surgical training. DESIGN, SETTING, AND PARTICIPANTS: Data were gathered from ACGME case log reports for orthopedic residents (reporting the cumulative case experience of graduating residents) and orthopedic trauma fellows (reporting the case experience of their fellowship year only) for all available years. RESULTS: The average orthopedic trauma fellow reported significantly more trauma cases in multiple body regions ("Pelvis/Hip", "Femur/Knee", and "Foot/Toes") and "Open Complex" reductions (as defined by the ACGME) in their 1 year of fellowship than the average resident reported in their 5 years of residency. CONCLUSION: On average, orthopedic trauma fellowships substantially increase the trauma case volumes of orthopedic trainees, especially with respect to lower extremity trauma.

A novel conformal superficial high-dose-rate brachytherapy device for the treatment of nonmelanoma skin cancer and keloids.

PURPOSE: To develop a novel conformal superficial brachytherapy (CSBT) device as a treatment option for the patient-specific radiation therapy of conditions including superficial lesions, postsurgical positive margins, Dupuytren's contractures, keloid scars, and complex anatomic sites (eyelids, nose, ears, etc.). METHODS AND MATERIALS: A preliminary CSBT device prototype was designed, built, and tested using readily available radioactive seeds. Iodine-125 (125I) seeds were independently guided to the treatment surface to conform to the target. Treatment planning was performed via BrachyVision Planning System (BPS) and dose distributions measured with Gafchromic EBT3 film. Percent depth dose curves and profiles for Praseodymium-142 (142Pr), and Strontium-90/Yttrium-90 (90Sr-90Y) were also investigated as potential sources. Results achieved with 90Sr-90Y and electron external beam radiation therapy were compared and Monte Carlo N-Particle eXtended 2.6 simulations of 142Pr seeds were validated. RESULTS: BPS was able to predict clinical dose distributions for a multiple seeds matrix. Calculated and measured doses for the 125I seed matrix were 500 cGy and 473.5 cGy at 5 mm depth, and 171.0 cGy and 201.0 cGy at 10 mm depth, respectively. Results of 90Sr-90Y tests demonstrate a more conformal dose than electron EBRT (1.6 mm compared to 4.3 mm penumbra). Measured 142Pr doses were 500 cGy at surface and 17.4 cGy at 5 mm depth. CONCLUSIONS: The CSBT device provides a highly conformal dose to small surface areas. Commercially available BPS can be used for treatment planning, and Monte Carlo simulation can be used for plans using beta-emitting sources and complex anatomies. Various radionuclides may be used in this device to suit prescription depths and treatment areas.

Pharmacologic activation of estrogen receptor ß increases mitochondrial function, energy expenditure, and brown adipose tissue.

Most satiety-inducing obesity therapeutics, despite modest efficacy, have safety concerns that underscore the need for effective peripherally acting drugs. An attractive therapeutic approach for obesity is to optimize/maximize energy expenditure by increasing energy-utilizing thermogenic brown adipose tissue. We used in vivo and in vitro models to determine the role of estrogen receptor ß (ER-ß) and its ligands on adipose biology. RNA sequencing and metabolomics were used to determine the mechanism of action of ER-ß and its ligands. Estrogen receptor ß (ER-ß) and its selective ligand reprogrammed preadipocytes and precursor stem cells into brown adipose tissue and increased mitochondrial respiration. An ER-ß-selective ligand increased markers of tricarboxylic acid-dependent and -independent energy biogenesis and oxygen consumption in mice without a concomitant increase in physical activity or food consumption, all culminating in significantly reduced weight gain and adiposity. The antiobesity effects of ER-ß ligand were not observed in ER-ß-knockout mice. Serum metabolite profiles of adult lean and juvenile mice were comparable, while that of adult obese mice was distinct, indicating a possible impact of obesity on age-dependent metabolism. This phenotype was partially reversed by ER-ß-selective ligand. These data highlight a new role for ER-ß in adipose biology and its potential to be a safer alternative peripheral therapeutic target for obesity.-Ponnusamy, S., Tran, Q. T., Harvey, I., Smallwood, H. S., Thiyagarajan, T., Banerjee, S., Johnson, D. L., Dalton, J. T., Sullivan, R. D., Miller, D. D., Bridges, D., Narayanan, R. Pharmacologic activation of estrogen receptor ß increases mitochondrial function, energy expenditure, and brown adipose tissue.

Relative impact of a patient blood management program on utilization of all three major blood components.

BACKGROUND: Although patient blood management (PBM) programs clearly reduce transfusion overuse, the relative impact on red blood cell (RBC), plasma, and platelet (PLT) utilization is unclear. STUDY DESIGN AND METHODS: A retrospective analysis of electronic records was conducted at a medium-sized academic hospital to assess blood utilization for all inpatients admitted during 1-year periods before (n = 20,531) and after (n = 19,477) PBM efforts began in September 2014. Transfusion guideline compliance and overall utilization were assessed for RBCs, plasma, and PLTs. The primary PBM efforts included education on evidence-based transfusion guidelines, decision support in the computerized provider order entry system, and distribution of provider-specific reports showing comparison to peers for guideline compliance. Cost avoidance was determined by two methods (acquisition cost and activity-based cost), and clinical outcomes were compared during the two periods. RESULTS: For RBCs, orders outside hospital guidelines decreased (from 23.9% to 17.1%, p < 0.001), and utilization decreased by 12% (p < 0.035). For plasma and PLTs, both orders outside guidelines and utilization changed minimally. Overall cost avoidance was $181,887/year by acquisition cost (and from $582,039 to $873,058/year by activity-based cost), 93% of which was attributed to reduction in RBC utilization. Length of stay, morbidity, and mortality were unchanged. CONCLUSIONS: Our findings demonstrate a greater opportunity for reducing RBC compared to plasma and PLT utilization. A properly implemented PBM program has potential to reduce unnecessary transfusions and their associated risk and costs, without compromising clinical outcomes.

Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial.

BACKGROUND: Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal. OBJECTIVE: The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge. DESIGN: Randomized, controlled trial with concealed allocation and blinded outcome assessors SETTING: Two tertiary care academic medical centers PARTICIPANTS: Adults hospitalized with a diagnosis of ACS and/or ADHF. INTERVENTION: Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge MAIN MEASURES: The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) are reported. KEY RESULTS: A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women's Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR = 1.04, 95% CI 0.78-1.39). There was an interaction of treatment effect by site (p = 0.04 for interaction); VUH aHR = 0.77, 95% CI 0.51-1.15; BWH aHR = 1.44 (95% CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95% CI 0.17-1.00). There was no difference in treatment effect by patient cognition. CONCLUSION: A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.