Anticoagulant therapy management of venous thromboembolism recurrence occurring during anticoagulant therapy: a descriptive study.

Limited evidence exists regarding management of recurrent venous thromboembolism (VTE) that occurs during anticoagulant therapy. We aimed to describe patient characteristics, drug therapy management, and outcomes of patients with VTE recurrence during anticoagulant therapy. We identified 30 relevant episodes of VTE recurrence. Mean age was 48.9 (15.9) years, 56.7% were male, and 93.3% were White. Common VTE risk factors included cancer (46.6%), recent surgery (33.3%), and prolonged immobility (30.0%). At the time of recurrent VTE, 40.0% were receiving enoxaparin, 30.0% warfarin, and 23.3% direct oral anticoagulants. Potential causes for VTE recurrence included indwelling venous catheters (40.0%), cancer (33.3%), subtherapeutic anticoagulation (26.7%), and nonadherence (23.3%). Recurrent VTE management strategies included switching anticoagulants (26.7%), increasing anticoagulant dose (20.0%), temporarily adding enoxaparin or unfractionated heparin to oral anticoagulation therapy (13.3%), or no change in anticoagulation therapy (43.3%). Only four adverse 90-day outcomes occurred among 17 patients who received anticoagulant therapy changes in response to VTE recurrence, whereas eight adverse outcomes occurred in the 13 patients who received no change in anticoagulation therapy in response to a recurrent VTE episode (P value 0.04). Regardless of the potential etiology of recurrent VTE during anticoagulant therapy; switching anticoagulants, temporarily adding injectable anticoagulants, or increasing anticoagulant intensity appears preferable to continuing current anticoagulant therapy unchanged.

The role of symptom appraisal, concealment and social support in optimizing dyadic mental health in heart failure.

Objectives: Heart failure patients and their family care partners experience poor mental health, yet the majority of the research focuses on patients and care partners separately. Guided by the Theory of Dyadic Illness Management, the purpose of the current study was to identify distinct patterns of dyadic mental health in heart failure and identify the individual, dyadic and familial factors associated with group membership.Method: Fifty nine heart failure community-dwelling patients and their spouse care partners were recruited from an outpatient heart failure clinic. Mental health was operationalized by depressive symptoms, measured with the Patient Health Questionnaire-9 (PHQ-9) measure of depression. Distinct groups of dyadic mental health were determined by categorizing depression scores within dyads.Results: Three groups of dyadic mental health were identified: an optimal dyadic mental health group (31%), a poor dyadic mental health group (32%) and an incongruent dyadic mental health group (37%). Patient age, patient fatigue, patient concealment, incongruent dyadic appraisal of pain interference and social/familial support were significantly associated with group membership.Conclusion: Findings underscore the salience of a dyadic approach to health and the clinical relevance of identifying patterns of dyadic mental health so we may determine those most in need of intervention.

Impact of Hospitalist Team Structure on Patient-Reported Satisfaction with Physician Performance.

BACKGROUND: Patient experience is valuable because it reflects how patients perceive the care they receive within the healthcare system and is associated with clinical outcomes. Also, as part of the Hospital Value-Based Purchasing (HVBP) program, the Center for Medicare and Medicaid Services (CMS) rewards hospitals with financial incentives for patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. It is unclear how the addition of residents and advanced practice clinicians (APCs) to hospitalist-led inpatient teams affects patient satisfaction as measured by the HCAHPS and Press Ganey survey. OBJECTIVE: To compare patient satisfaction with hospitalists on resident, APC, and solo hospitalist teams measured by HCAHPS and Press Ganey physician performance domain survey results. DESIGN: Retrospective observational cohort study. PARTICIPANTS: All patients discharged from the Internal Medicine inpatient service between July 1, 2015, and July 1, 2018, who met HCAHPS survey eligibility criteria and completed a patient experience survey. MAIN MEASURES: HCAHPS and Press Ganey physician performance domain survey results. KEY RESULTS: No differences were observed in the selection of "top box" scores on the HCAHPS physician performance domain between resident, APC, and solo hospitalist teams. Adjusted Press Ganey physician performance domain survey results demonstrated significant differences between solo hospitalist and resident teams, with solo hospitalists having higher scores in three areas: time physician spent with you (4.58 vs. 4.38, p = 0.050); physician kept you informed (4.63 vs. 4.43, p = 0.047); and physician skill (4.80 vs. 4.63, p = 0.027). Solo hospitalists were perceived to have higher physician skill in comparison with hospitalist-APC teams (4.80 vs. 4.69, p = 0.042). CONCLUSION: While Press Ganey survey results suggest that patients have greater satisfaction with physicians on solo hospitalist teams, these differences were not observed on the HCAHPS physician performance survey domain, suggesting physician team structure does not impact HVBP incentive payments by CMS.

Development of Rapid Response Capabilities in a Large COVID-19 Alternate Care Site Using Failure Modes and Effect Analysis with In Situ Simulation.

Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care-intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.

Using Magnet Model Components at a COVID-19-Positive Field Hospital.

In this column, the authors who were part of a leadership team at 1000-bed field hospitals for patients with COVID-19 provide background and guidance on the development of a nurse staffing and training model.

Assessing the accuracy of ICD-10 codes for identifying acute thromboembolic events among patients receiving anticoagulation therapy.

International classification of disease (ICD) codes can improve the efficiency of epidemiological research provided the codes accurately identify outcomes of interest. The purpose of this retrospective cross-sectional study is to evaluate the accuracy of ICD-10 codes for identifying thromboembolic events occurring during anticoagulation therapy. Medical charts of patients hospitalized for any reason while receiving anticoagulant therapy between September 1, 2017 and December 31, 2017 were reviewed by two reviewers blinded to ICD-10 code status. Following identification of confirmed acute thromboembolic events, ICD-10 codes were unblinded and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) along with 95% confidence intervals (CI) were calculated for coding in any diagnosis position ("principal" or "other"). There were 661 hospitalizations identified among 487 anticoagulated patients. There were 27 thromboembolic events identified during chart review. Stroke and venous thromboembolism were the most common thromboembolic event types. Overall thromboembolic ICD-10 coding sensitivity was 100.0% (95% CI 87.2-100.0); specificity was 79.3% (75.9-82.4). PPV was 17.1% (11.6-23.9%), and NPV was 100% (99.3-100.0). ICD-10 codes can reliably be used for ruling out hospitalizations for thromboembolic events in patients receiving anticoagulation therapy but should not be used for identifying thromboembolic complications without confirmatory chart review.

Promoting Teachers' Implementation of Classroom-Based Prevention Programming Through Coaching: The Mediating Role of the Coach-Teacher Relationship.

There is growing awareness of the importance of implementation fidelity and the supports, such as coaching, to optimize it. This study examined how coaching activities (i.e., check-ins, needs assessment, modeling, and technical assistance) related directly and indirectly to implementation dosage and quality of the PAX Good Behavior Game, via a mediating pathway through working relationship. Mediation analyses of 138 teachers revealed direct effects of modeling and working relationship on implementation dosage, whereas needs assessment was associated with greater dosage indirectly, by higher ratings of the working relationship. Understanding how coaching activities promote implementation fidelity elements has implications for improving program effectiveness.

Angiotensin receptor signaling and prostate tumor growth in mice.

OBJECTIVE: The renin-angiotensin system, through its type 1 and type 2 angiotensin receptors (AT1R and AT2R, respectively) may have a role in prostate cancer. The objective of this pilot study was to explore that potential role by determining whether the AT1R blocker, losartan, would reduce the growth of LAPC-4 prostate cancer xenografts in nude mice. We also evaluated the tumor growth effects of using angiotensin II to activate both AT1R and AT2R simultaneously. Our data showed that losartan decreased tumor volumes by 56% versus control. This decrease reached statistical significance at day 54 (p = 0.0014). By day 54, Ki67 was also reduced in the losartan group, though not significantly so (p = 0.077). Losartan had no significant effect on AT1R or AT2R expression. Despite significant increases in both AT1R and AT2R at day 29 (p = 0.043 and 0.038, respectively), the administration of angiotensin II did not result in any significant differences in tumor volumes or ki67 at any time point. These data suggest that selective activation and induction of AT2R coupled with blockade of AT1R may slow prostate cancer growth. Future larger studies are needed to confirm these results.

Speaking my patient's language: bilingual nurses' perspective about provision of language concordant care to patients with limited English proficiency.

AIM: The aim of this study was to explore bilingual nurses' perspective about providing language concordant care to patients with limited English proficiency (LEP) and its impact on patients and nurses. Factors affecting the provision of language concordant care to patients LEP were also explored. BACKGROUND: With an increase in migration and mobility of people across the world, the likelihood of experiencing language barriers while providing and receiving care is high. Nurses are responsible for providing care to patients regardless of their culture, religion, ethnic background or language. Language barriers, however, are hurdles that hamper development of effective communication between nurses and patients. Eliminating language barriers is a crucial step in providing culturally competent and patient-centred care. DESIGN: Qualitative descriptive study. METHODS: During January-August 2015, 59 nurses, working in acute hospitals in the UK, participated in 26 individual in-depth interviews and three focus group discussions. The data were analysed using thematic analysis. FINDINGS: Four themes: 'when we speak the same language'; 'when I speak my patient's language'; 'what facilitates provision of language concordant care' and 'what hinders the provision of language concordant care' were identified. Factors affecting nurses' ability to provide language concordant care included individual factors (confidence; years of experience as a nurse; years of experience in the work setting; and relationship with colleagues), patients' expectation, attitudes of other patients, colleagues and nurse managers, organizational culture and organizational policies. CONCLUSION: Bilingual nurses can play a very important role in the provision of language concordant for patients with LEP. Further research is needed to explore patient perspective.

Promoting Student-Teacher Interactions: Exploring a Peer Coaching Model for Teachers in a Preschool Setting.

Peer coaching provides an attractive alternative to traditional professional development for promoting classroom quality in a sustainable, cost-effective manner by creating a collaborative teaching community. This exploratory study describes the development and evaluation of the Colleague Observation And CoacHing (COACH) program, a peer coaching program designed to increase teachers' effectiveness in enhancing classroom quality in a preschool Head Start setting. The COACH program consists of a training workshop on coaching skills and student-teacher interactions, six peer coaching sessions, and three center meetings. Pre-post observations of emotional support, classroom organization, and instructional support using the Classroom Assessment Scoring System of twelve classrooms assigned to peer coaching were compared to twelve control classrooms at baseline and following the intervention. Findings provide preliminary support that the peer coaching program is perceived as acceptable and feasible by the participating preschool teachers and that it may strengthen student-teacher interactions. Further program refinement and evaluation with larger samples is needed to enhance student-teacher interactions and, ultimately, children's adaptive development.

Understanding and Measuring Coach-Teacher Alliance: A Glimpse Inside the 'Black Box'.

Coaching models are increasingly used in schools to enhance fidelity and effectiveness of evidence-based interventions; yet, little is known about the relationship between the coach and teacher (i.e., coach-teacher alliance), which may indirectly enhance teacher and student outcomes through improved implementation quality. There is also limited research on measures of coach-teacher alliance, further hindering the field from understanding the active components for successful coaching. The current study examined the factor structure and psychometric characteristics of a measure of coach-teacher alliance as reported by both teachers and coaches and explored the extent to which teachers and coaches reliably rate their alliance. Data come from a sample of 147 teachers who received implementation support from one of four coaches; both the teacher and the coach completed an alliance questionnaire. Separate confirmatory factor analyses for each informant revealed four factors (relationship, process, investment, and perceived benefits) as well as an additional coach-rated factor (perceived teacher barriers). A series of analyses, including cross-rater correlations, intraclass correlation coefficients, and Kuder-Richardson reliability estimates suggested that teachers and coaches provide reliable, though not redundant, information about the alliance. Implications for future research and the utilization of the parallel coach-teacher alliance measures to increase the effectiveness of coaching are discussed.

Twenty years after ACEIs and ARBs: emerging treatment strategies for diabetic nephropathy.

Diabetic nephropathy (DN) is a serious complication of both type 1 and type 2 diabetes mellitus. The disease is now the most common cause of end-stage kidney disease (ESKD) in developed countries, and both the incidence and prevalence of diabetes mellitus is increasing worldwide. Current treatments are directed at controlling hyperglycemia and hypertension, as well as blockade of the renin angiotensin system with angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers. Despite these therapies, DN progresses to ESKD in many patients. As a result, much interest is focused on developing new therapies. It has been over two decades since ACEIs were shown to have beneficial effects in DN independent of their blood pressure-lowering actions. Since that time, our understanding of disease mechanisms in DN has evolved. In this review, we summarize major cell signaling pathways implicated in the pathogenesis of diabetic kidney disease, as well as emerging treatment strategies. The goal is to identify promising targets that might be translated into therapies for the treatment of patients with diabetic kidney disease.

Emotion-based preventive intervention: Effectively promoting emotion knowledge and adaptive behavior among at-risk preschoolers.

Effectiveness studies of preschool social-emotional programs are needed in low-income, diverse populations to help promote the well-being of at-risk children. Following an initial program efficacy study 2 years prior, 248 culturally diverse Head Start preschool children participated in the current effectiveness trial and received either the Emotion-Based Prevention Program (EBP) or the I Can Problem Solve (ICPS) intervention. Pre- and postdata collection included direct child assessment, teacher report, parent interview, and independent observations. Teachers implementing the EBP intervention demonstrated good and consistent fidelity to the program. Overall, children in EBP classrooms gained more emotion knowledge and displayed greater decreases in negative emotion expressions and internalizing behaviors across the implementation period as compared to children in ICPS classrooms. In addition, cumulative risk, parental depressive symptoms, and classroom climate significantly moderated treatment effects. For children experiencing more stress or less support, EBP produced more successful outcomes than did ICPS. These results provide evidence of EBP sustainability and program effectiveness, as did previous findings that demonstrated EBP improvements in emotion knowledge, regulation skills, and behavior problems replicated under unsupervised program conditions.

Theory of Mind Predicts Emotion Knowledge Development in Head Start Children.

RESEARCH FINDINGS: Emotion knowledge (EK) enables children to identify emotions in themselves and others and its development facilitates emotion recognition in complex social situations. Social-cognitive processes, such as theory of mind (ToM), may contribute to developing EK by helping children realize the inherent variability associated with emotion expression across individuals and situations. The present study explored how ToM, particularly false belief understanding, in preschool predicts children's developing EK in kindergarten. Participants were 60 3- to 5-year-old Head Start children. ToM and EK measures were obtained from standardized child tasks. ToM scores were positively related to performance on an EK task in kindergarten after controlling for preschool levels of EK and verbal ability. Exploratory analyses provided preliminary evidence that ToM serves as an indirect effect between verbal ability and EK. PRACTICE OR POLICY: Early intervention programs may benefit from including lessons on ToM to help promote socio-emotional learning, specifically EK. This consideration may be the most fruitful when the targeted population is at-risk.

Clinical Outcomes of Orthopedic Surgery Co-Management by Internal Medicine Advanced Practice Clinicians: A Cohort Study.

BACKGROUND: Comanagement of orthopedic surgery patients by internal medicine hospitalists is associated with improvements in clinical outcomes including complications, length of stay, and cost. Clinical outcomes of orthopedic comanagement performed solely by internal medicine advanced practice clinicians have not been reported. Our objecyive was to compare clinical outcomes between advanced practice clinician-based comanagement and usual orthopedic care. METHODS: This is a retrospective cohort study in patients 18 years or older, hospitalized for orthopedic joint or spine surgery between May 1, 2014 and January 1, 2022. Outcomes assessed were length of stay, intensive care unit (ICU) transfer, return to operating room, in-hospital and 30-day mortality, 30-day readmission, and total direct cost, excluding surgical implants. Generalized boosted regression and propensity score weighting was used to compare clinical outcomes and health care cost between usual care and advanced practice clinician comanagement. RESULTS: Advanced practice clinician comanagement was associated with a 5% reduction in mean length of stay (rate ratio = 0.95, P = .009), decreased odds of returning to the operating room (odds ratio [OR] 0.51, P = .002), and a significant reduction in 30-day mortality (OR 0.32, P = .037) compared with usual orthopedic care in a weighted analysis. Need for ICU transfer was higher with advanced practice clinician comanagement (OR 1.54, P = .009), without significant differences in 30-day readmission or in-hospital mortality. CONCLUSIONS: We observed reductions in length of stay, health care costs, return to the operating room, and 30-day mortality with advanced practice clinician comanagement compared with usual orthopedic care. Our findings suggest that advanced practice clinician-based comanagement may represent a safe and cost-effective model for orthopedic comanagement.

Inpatient opioid withdrawal: a qualitative study of the patient perspective.

Opioid withdrawal is common among hospitalized patients. Those with substance use disorders exhibit higher rates of patient-directed discharge. The literature lacks information regarding the patient perspective on opioid withdrawal in the hospital setting. In this study, we aimed to capture the patient-reported experience of opioid withdrawal during hospitalization and its impact on the desire to continue treatment for opioid use disorder after discharge. We performed a single-center qualitative study involving semi-structured interviews of hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal. Investigators conducted in-person interviews utilizing a combination of open-ended and dichotomous questions. Interview transcripts were then analyzed with open coding for emergent themes. Nineteen interviews were performed. All participants were linked to either buprenorphine (79%) or methadone (21%) at discharge. Eight of nineteen patients (42%) reported a patient-directed discharge during prior hospitalizations. Themes identified from the interviews included: (1) opioid withdrawal was well-managed in the hospital; (2) patients appreciated receiving medication for opioid use disorder (MOUD) for withdrawal symptoms; (3) patients valued and felt cared for by healthcare providers; and (4) most patients had plans to follow-up for opioid use disorder treatment after hospitalization. In this population with historically high rates of patient-directed discharge, patients reported having a positive experience with opioid withdrawal management during hospitalization. Amongst our hospitalized patients, we observed several different individualized MOUD induction strategies. All participants were offered MOUD at discharge and most planned to follow-up for further treatment.

How do clinicians assess, communicate about, and manage patient sleep in the hospital?

OBJECTIVE: The objective of this study was to characterize how clinicians assess, communicate about, and manage patient sleep, with the focus on identifying existing barriers and facilitators to sleep promotion in clinical practice. BACKGROUND: Sleep is a critical need for improving for hospitalized patients. METHODS: Content analysis was used to interpret descriptive data from 4 group interviews with a total of 62 clinicians. RESULTS: Clinicians reported they did not formally assess for patient sleep, which led to largely unmanaged sleep disruption during hospitalization. Major barriers to effective sleep management were limited understanding of the importance of sleep, lack of a standardized tool for assessment, and inadequate communication. Facilitators included collaborative communication with patients and the healthcare team and customized patient-centered interventions. CONCLUSIONS: It is critical to inform clinicians on the importance of sleep, to standardize sleep assessment, and to facilitate collaboration among caregivers to promote sleep for hospitalized patients.

Taking Care of Us© (TCU) study protocol: feasibility and acceptability of a dyadic intervention for couples living with heart failure.

BACKGROUND: There are more than 1 million hospital admissions and 3 million emergency visits for heart failure in the USA annually. Although spouse/partners make substantial contributions to the management of heart failure and experience poor health and high levels of care strain, they are rarely the focus of heart failure interventions. This protocol describes a pilot randomized controlled trial that tests the feasibility, acceptability, and preliminary change in outcomes of a seven-session couple-based intervention called Taking Care of Us© (TCU). The TCU© intervention is grounded in the theory of dyadic illness management and was developed to promote collaborative illness management and better physical and mental health of adults with heart failure and their partners. METHODS: A two-arm randomized controlled trial will be conducted. Eligible adults with heart failure and their co-residing spouse/partner will be recruited from a clinical site in the USA and community/social media outreach and randomized to either the TCU© intervention or to a control condition (SUPPORT©) that offers education around heart failure management. The target sample is 60 couples (30 per arm). TCU© couples will receive seven sessions over 2 months via Zoom; SUPPORT© couples will receive three sessions over 2 months via Zoom. All participants will complete self-report measures at baseline (T1), post-treatment (T2), and 3 months post-treatment (T3). Acceptability and feasibility of the intervention will be examined using both closed-ended and open-ended questions as well as enrollment, retention, completion, and satisfaction metrics. Preliminary exploration of change in outcomes of TCU© on dyadic health, dyadic appraisal, and collaborative management will also be conducted. DISCUSSION: Theoretically driven, evidence-based dyadic interventions are needed to optimize the health of both members of the couple living with heart failure. Results from this study will provide important information about recruitment and retention and benefits and drawbacks of the TCU© program to directly inform any needed refinements of the program and decision to move to a main trial. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04737759) registered on 27 January 2021.