A Hospitalist-Led Team to Manage Patient Boarding in the Emergency Department: Impact on Hospital Length of Stay and Cost.

OBJECTIVES: Admitted patients boarding in the emergency department (ED) while awaiting inpatient beds represent a bottleneck in patient flow. We sought to examine the impact on patient flow and potential for cost savings by an active management of boarded ED medical admissions by a hospitalist-led team, which included a hospitalist, an advanced practitioner, and a case manager. METHODS: This was a retrospectively conducted analysis of a quality improvement pilot intervention implemented at a large tertiary center. We analyzed patients admitted under observation status between April 1, 2016 and June 30, 2016. We calculated the difference for length of stay (in hours) and direct cost between patients in the intervention group and a usual care group from a similar time period in the prior year matched on the all patients refined-diagnosis related groups (APR-DRG) and severity of illness (SOI) level. RESULTS: One hundred seventy-five observation patients were managed by the hospitalist team during the 3-month pilot period. This group had an average hospital stay of 26.0 hours compared with 29.7 hours in the usual care group. Direct costs resulted in the following results: average cost for the intervention patient group $1452 (±$775) versus $2524 (±$894) group, for an average savings of $1072 (P < 0.001), with a total estimated direct cost savings of $187,660. CONCLUSIONS: Active management of ED boarding patients by a hospitalist-led team is feasible and can lead to hospital cost savings and decrease in hospital stay. The findings from this pilot resulted in a decision to make the ED hospitalist-led team permanent in our institution. The evaluation of the program may help other hospitals to decide whether this intervention is worth pursuing in their own organization.

Evidence-Based Reporting: A Method to Optimize Prostate MRI Communications With Referring Physicians.

OBJECTIVE: The purpose of this study was to develop an evidence-based method to optimize prostate MRI reports that would improve communication between urologists and radiologists. MATERIALS AND METHODS: This quality improvement initiative was approved by the institutional Quality Improvement Review Committee. A structured report was developed containing essential components defined by local practice norms and Prostate Imaging Reporting and Data System (PI-RADS) lexicon version 2. Two hundred preintervention and 100 postintervention reports were retrospectively reviewed for essential components. Additionally, a sample of 40 reports generated before the intervention and 40 reports generated after the intervention that made use of the structured report were evaluated by a urologist and were scored on a 5-point scale for consistency, completeness, conciseness, clarity, likelihood to contact radiologist, and clinical impact. Variables were compared with ANOVA, chi-square, or Fisher exact test. RESULTS: Essential components of the report were utilization of the PI-RADSv2 lexicon, findings listed by lesion, reporting of pertinent positive and negative findings (extraprostatic extension, seminal vesicle, and neurovascular bundle invasion), and low word count. In postintervention reports, all essential measures were statistically improved except for mean report word count. The urologist indicated statistically improved consistency (before intervention, 2.7; after intervention, 3.5; χ2 < 0.001), completeness (before intervention, 2.8; after intervention, 3.3; χ2 < 0.001), clarity (before intervention, 2.9; after intervention, 3.3; χ2 < 0.05), and clinical impact (before intervention, 2.8; after intervention, 3.8; χ2 < 0.001) of the report with reduced perceived need to contact (before intervention, 3.2; after intervention, 2.1; χ2 < 0.001) the interpreting radiologist for explanation. CONCLUSION: The structured prostate MRI report resulted in improved communication with referring urologists as indicated by the increased perceived clinical impact of the report.

Exploring the complexity of quantum control optimization trajectories.

The control of quantum system dynamics is generally performed by seeking a suitable applied field. The physical objective as a functional of the field forms the quantum control landscape, whose topology, under certain conditions, has been shown to contain no critical point suboptimal traps, thereby enabling effective searches for fields that give the global maximum of the objective. This paper addresses the structure of the landscape as a complement to topological critical point features. Recent work showed that landscape structure is highly favorable for optimization of state-to-state transition probabilities, in that gradient-based control trajectories to the global maximum value are nearly straight paths. The landscape structure is codified in the metric R ≥ 1.0, defined as the ratio of the length of the control trajectory to the Euclidean distance between the initial and optimal controls. A value of R = 1 would indicate an exactly straight trajectory to the optimal observable value. This paper extends the state-to-state transition probability results to the quantum ensemble and unitary transformation control landscapes. Again, nearly straight trajectories predominate, and we demonstrate that R can take values approaching 1.0 with high precision. However, the interplay of optimization trajectories with critical saddle submanifolds is found to influence landscape structure. A fundamental relationship necessary for perfectly straight gradient-based control trajectories is derived, wherein the gradient on the quantum control landscape must be an eigenfunction of the Hessian. This relation is an indicator of landscape structure and may provide a means to identify physical conditions when control trajectories can achieve perfect linearity. The collective favorable landscape topology and structure provide a foundation to understand why optimal quantum control can be readily achieved.

Exploring the Hamiltonian inversion landscape.

The identification of quantum system Hamiltonians through the use of experimental data remains an important research goal. Seeking a Hamiltonian that is consistent with experimental measurements constitutes an excursion over a Hamiltonian inversion landscape, which is the quality of reproducing the data as a function of the Hamiltonian parameters. Recent theoretical work showed that with sufficient experimental data there should be local convexity about the true Hamiltonian on the landscape. The present paper builds on this result and performs simulations to test whether such convexity is observed. A gradient-based Hamiltonian search algorithm is incorporated into an inversion routine as a means to explore the local inversion landscape. The simulations consider idealized noise-free as well as noise-ridden experimental data. The results suggest that a sizable convex domain exists about the true Hamiltonian, even with a modest amount of experimental data and in the presence of a reasonable level of noise.

Automated Neuropsychological Assessment Metrics: Normative Reference Values for U. S. Army National Guard Soldiers.

OBJECTIVE: The Automated Neuropsychological Assessment Metrics (ANAM) is a computerized cognitive test system used extensively with military service members. The aim of this study was to develop a nationally representative normative dataset of Army National Guard (ARNG) personnel and to explore potential relationships between ANAM performances and select military service, demographic, and health factors. METHODS: ANAM performance data were collected using standardized procedures from a representative sample of ARNG service members in six U.S. states. Normative performance values, stratified by age, sex, and military occupational category, were calculated for each ANAM subtest and descriptive measures were computed, along with base rates of below-average performance. The effect of demographic (e.g., age, sex, education, race) and military service and health factors (e.g., deployment, job category, history of head injury) was examined. RESULTS: Data from 1,436 ARNG service members (14.3% female) were analyzed, and normative values calculated. Overall, differences in ANAM performance based on demographic, military service, and health factors were small. A total of 8.9% of the sample had scores on two or more subtests that were ≥ 1.3 SD below the mean; this dropped to 1.9% using a more stringent cut point (≥2 SD below the mean). CONCLUSION: The ANAM normative data reported herein ensure that healthcare providers and researchers have access to reference data that more accurately reflect the larger population of ARNG service members. These data support the assessment and management of ARNG service members' health, as well as future ANAM research involving ARNG service members.

Evaluation of clinical and imaging biomarkers for the prediction of new onset diabetes following pancreatic resection.

PURPOSE: To identify clinical and imaging biomarkers that can predict the new onset of diabetes mellitus (NODM) within 1 year of pancreatic resection. METHODS: A retrospective chart review was conducted of 426 non-diabetic patients who underwent a pancreaticoduodenectomy or distal pancreatectomy at the University of Pittsburgh Medical Center between 2006 and 2016. Clinical characteristics and the patient's diabetic status at 1-year post resection were collected from the EMR. Imaging biomarkers included hepatic and pancreatic fat replacement, pancreatic calcifications, pancreatic duct diameter, pancreatic volume and body composition. Univariate and multivariable analyses were performed to demonstrate any predictive biomarkers of diabetes occurrence within 1 year of pancreatic resection. RESULTS: 135/426 (31.7%) patients developed NODM. The only significant clinical predictor was older age (OR 1.02, 95% CI 1.002-1.039, p = 0.032). Imaging characteristics found to be significant included hepatic steatosis (OR 1.777, 95% CI 1.094-2.886, p = 0.02), larger reduction in pancreas volume (OR 0.989, 95% CI 0.979-0.999, p = 0.027), and greater preoperative visceral fat (OR 1.004, 95% CI 1.001-1.006, p = 0.001). CONCLUSION: Age, presence of hepatic steatosis, change in pancreatic volume, and preoperative visceral fat are independent predictive biomarkers for NODM following pancreatic resection.

Radiology Online Patient Education Materials Provided by Major University Hospitals: Do They Conform to NIH and AMA Guidelines?

AIMS: The internet creates opportunities for Americans to access medical information about imaging tests and modalities to guide them in their medical decision-making. Owing to health literacy variations in the general population, the American Medical Association and National Institutes of Health recommend patient education resources to be written between the third and seventh grade levels. Our purpose is to quantitatively assess the readability levels of online radiology educational materials, written for the public, in 20 major university hospitals. MATERIALS AND METHODS: In September and October 2016, we identified 20 major university hospitals with radiology residency-affiliated hospital systems. On each hospital׳s website, we downloaded all radiology-related articles written for patient use. A total of 375 articles were analyzed for readability level using 9 quantitative readability scales that are well validated in the medical literature. RESULTS: The 375 articles from 20 hospital systems were collectively written at an 11.4 ± 3.0 grade level (range: 8.4-17.1). Only 11 (2.9%) articles were written at the recommended third to seventh grade levels. Overall, 126 (33.6%) were written above a full high-school reading level. University of Washington Medical Center׳s articles were the most readable with a reading level corresponding to 7.9 ± 0.9. CONCLUSIONS: The vast majority of websites at major academic hospitals with radiology residencies designed to provide patients with information about imaging were written above the nationally recommended health literacy guidelines to meet the needs of the average American. This may limit the benefit that patients can derive from these educational materials.

Structure-activity study of brassinin derivatives as indoleamine 2,3-dioxygenase inhibitors.

A screen of indole-based structures revealed the natural product brassinin to be a moderate inhibitor of indoleamine 2,3-dioxygenase (IDO), a new cancer immunosuppression target. A structure-activity study was undertaken to determine which elements of the brassinin structure could be modified to enhance potency. Three important discoveries have been made, which will impact future IDO inhibitor development: (i) The dithiocarbamate portion of the brassinin lead is a crucial moiety, which may be binding to the heme iron of IDO; (ii) an indole ring is not necessary for IDO inhibition; and (iii) substitution of the S-methyl group of brassinin with large aromatic groups provides inhibitors that are three times more potent in vitro than the most commonly used IDO inhibitor, 1-methyl-tryptophan.