Culture Conversion at 6 Months in Patients Receiving Delamanid-containing Regimens for the Treatment of Multidrug-resistant Tuberculosis.

Delamanid should be effective against highly resistant strains of Mycobacteriumtuberculosis, but uptake has been slow globally. In the endTB (expand new drug markets for TB) Observational Study, which enrolled a large, heterogeneous cohorts of patients receiving delamanid as part of a multidrug regimen, 80% of participants experienced sputum culture conversion within 6 months. Clinical Trials Registration. NCT02754765.

Activity-based costing of health-care delivery, Haiti.

OBJECTIVE: To evaluate the implementation of a time-driven activity-based costing analysis at five community health facilities in Haiti. METHODS: Together with stakeholders, the project team decided that health-care providers should enter start and end times of the patient encounter in every fifth patient's medical dossier. We trained one data collector per facility, who manually entered the time recordings and patient characteristics in a database and submitted the data to a cloud-based data warehouse each week. We calculated the capacity cost per minute for each resource used. An automated web-based platform multiplied reported time with capacity cost rate and provided the information to health-facilities administrators. FINDINGS: Between March 2014 and June 2015, the project tracked the clinical services for 7162 outpatients. The cost of care for specific conditions varied widely across the five facilities, due to heterogeneity in staffing and resources. For example, the average cost of a first antenatal-care visit ranged from 6.87 United States dollars (US$) at a low-level facility to US$ 25.06 at a high-level facility. Within facilities, we observed similarly variation in costs, due to factors such as patient comorbidities, patient arrival time, stocking of supplies at facilities and type of visit. CONCLUSION: Time-driven activity-based costing can be implemented in low-resource settings to guide resource allocation decisions. However, the extent to which this information will drive observable changes at patient, provider and institutional levels depends on several contextual factors, including budget constraints, management, policies and the political economy in which the health system is situated.

Percutaneous aspiration of aortic valve vegetation in a patient with aortic valve endocarditis.

Key Clinical Message: Percutaneous aspiration for debulking of vegetations in right-sided infective endocarditis has been well-described, however, this technique can be employed successfully for left-sided vegetations in select high-risk patients. Abstract: We report a case of percutaneous aspiration of an aortic valve vegetation in a patient with prosthetic valve endocarditis. This novel approach was selected after patient declined surgical intervention for an enlarging vegetation despite antibiotic therapy. The procedure was successful, resulting in the complete removal of solid vegetation without complications.

Standalone epicardial left atrial appendage exclusion for thromboembolism prevention in atrial fibrillation.

OBJECTIVES: Most strokes associated with atrial fibrillation (AF) result from left atrial appendage thrombi. Oral anticoagulation can reduce stroke risk but is limited by complication risk and non-compliance. Left atrial appendage exclusion (LAAE) is a new surgical option to reduce stroke risk in AF. The study objective was to evaluate the safety and feasibility of standalone thoracoscopic LAAE in high stroke risk AF patients. METHODS: This was a retrospective, multicentre study of high stroke risk AF patients who had oral anticoagulation contraindications and were not candidates for ablation nor other cardiac surgery. Standalone thoracoscopic LAAE was performed using 3 unilateral ports access and epicardial clip. Periprocedural adverse events, long-term observational clinical outcomes and stroke rate were evaluated. RESULTS: Procedural success was 99.4% (174/175 patients). Pleural effusion occurred in 4 (2.3%) patients; other periprocedural complications were <1% each. One perioperative haemorrhagic stroke occurred (0.6%). No phrenic nerve palsy or cardiac tamponade occurred. Predicted annual ischaemic stroke rate of 4.8/100 patient-years (based on median CHA2DS2-VASc score of 4.0) was significantly higher than stroke risk observed in follow-up after LAAE. No ischaemic strokes occurred (median follow-up: 12.5 months), resulting in observed rate of 0 (95% CI 0-2.0)/100 patient-years (P < 0.001 versus predicted). Six all-cause (non-device-related) deaths occurred during follow-up. CONCLUSIONS: Study proved that a new surgical option, standalone thoracoscopic LAAE, is feasible and safe. With this method, long-term stroke rate may be reduced compared to predicted for high-risk AF population.

Aging, brain disease, and reserve: implications for delirium.

Cognitive and brain reserve are well studied in the context of age-associated cognitive impairment and dementia. However, there is a paucity of research that examines the role of cognitive or brain reserve in delirium. Indicators (or proxy measures) of cognitive or brain reserve (such as brain size, education, and activities) pose challenges in the context of the long prodromal phase of Alzheimer disease but are diminished in the context of delirium, which is of acute onset. This article provides a review of original articles on cognitive and brain reserve across many conditions affecting the central nervous system, with a focus on delirium. The authors review current definitions of reserve. The authors identify indicators for reserve used in earlier studies and discuss these indicators in the context of delirium. The authors highlight future research directions to move the field ahead. Reserve may be a potentially modifiable characteristic. Studying the role of reserve in delirium can advance prevention strategies for delirium and may advance knowledge of reserve and its role in aging and neuropsychiatric disease generally.

The validity of breath collection bags method in detecting Helicobacter pylori using the novel BreathID ® Hp Lab System: a multicenter clinical study in 257 subjects.

BACKGROUND AND AIM: The BreathID ® Hp urea breath test provides several advantages over other 13C breath analyzers for the detection of Helicobacter pylori. We evaluated the sensitivity and specificity of a new BreathID ® Hp Lab System (Exalenz Bioscience Ltd, Israel), a 13C-urea breath test system using breath sampling bags that facilitates multiple testing in a multicenter international clinical study. METHODS: A total of 257 subjects with evaluable results for urea breath test, rapid urease test, and histology were enrolled into two study groups: 189 naïve subjects were included in the pre-therapy group, and 68 subjects comprised the post-eradication therapy group. Analytical studies were conducted to evaluate the stability, reproducibility, and repeatability of the 13C-urea breath test results using a delta over baseline cut-off value of 5. RESULTS: Among the pre-therapy subjects evaluated with the composite results from the rapid urease test and histology/immunohistochemistry, 176 results matched those of the urea breath test, resulting in an overall agreement of 98.3% with a sensitivity of 100% and specificity of 97.9%. In the post-eradication therapy cohort, the overall agreement between the urea breath test and the biopsy diagnosis was 98.5%; the sensitivity of the urea breath test in this cohort was 92.3% and the specificity was 100%. There was uniformly high overall reproducibility (99.48%) of the test results over different batches of breath sample bags, when analyzed on different days and under different storage conditions, showing stability of the breath samples in the breath collection bags. CONCLUSION: The BreathID ® Hp Lab System is a highly accurate and dependable method for the diagnosis of H. pylori infection.

Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions.

In 2001, a seminal Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, put forth a comprehensive strategy for improving the quality of U.S. health care. This strategy attained considerable traction within the overall U.S. health care system and subsequent attention in the mental health community as well. A new Institute of Medicine report, Improving the Quality of Health Care for Mental and Substance Use Conditions, examines the quality chasm strategy in light of the distinctive features of mental and substance use health care, including concerns about patient decision-making abilities and coercion into care, a less developed quality measurement and improvement infrastructure, lagging use of information technology and participation in the development of the National Health Information Infrastructure, greater separations in care delivery accompanied by more restrictions on sharing clinical information, a larger number of provider types licensed to diagnose and treat, more solo practice, and a differently structured marketplace. This article summarizes the Institute of Medicine's analysis of these issues and recommendations for improving mental and substance use health care and discusses the implications for psychiatric practice and related advocacy efforts of psychiatrists, psychiatric organizations, and other leaders in mental and substance use health care.

Topical amiodarone during cardiac surgery: Does epicardial application of amiodarone prevent postoperative atrial fibrillation?

OBJECTIVES: Atrial fibrillation (AF) is a common complication after cardiac surgery. Topical amiodarone on the epicardium may help prevent postoperative AF while avoiding the side effects of its systemic administration. The purpose of this study was to evaluate the all-comer strategy of epicardial amiodarone application for the prevention of postoperative AF. METHODS: A retrospective observational study was performed that evaluated the incidence of new-onset AF in a consecutive series of cardiac surgery patients who were treated with either no amiodarone (historical control, n = 100), epicardial application of amiodarone mixed in a topical hydrogel (n = 50), or epicardial application of an amiodarone-soaked sealant patch (n = 50). Perioperative data were compared between the 3 groups, with all patients receiving continuous postoperative telemetry to monitor for new-onset AF. RESULTS: The cohort consisted of 200 cardiac surgery patients (coronary bypass 82%, valve surgery 24%) who had no history of AF (mean age 71.0 years, 28% female). Among the 3 groups, the incidence of postoperative AF did not significantly differ, with 29 of 100 (29%) patients in the historical control group having new AF, compared with 18 of 50 (36%) in the amiodarone-hydrogel group, and 18 of 50 (36%) in the amiodarone-patch group (P = .56). The results did not differ when the analysis was restricted to coronary bypass patients only (n = 142, 27% vs 38% vs 32%, no-amiodarone vs amiodarone-hydrogel vs amiodarone-patch, respectively, P = .56). In multivariate logistic regression analysis, only older age (P = .001) was significantly associated with new-onset AF, but the use of topical amiodarone was not. CONCLUSIONS: Routine epicardial application of topical amiodarone was not associated with a reduction in the incidence of new-onset postoperative AF in this observational study of older patients, leading us to question its role in contemporary cardiac surgical practice.

Transforming healthcare delivery: Why and how accountable care organizations must evolve.

Accountable care organizations (ACOs) have shown promise in reducing healthcare spending growth, but have proven to be financially unsustainable for many healthcare organizations. Even ACOs with shared savings have experienced overall losses because the shared savings bonuses have not covered the costs of delivering population health. As physicians and former ACO leaders, we believe in the concept of accountable care, but ACOs need to evolve if they are to have a viable future. We propose the novel possibility of allowing ACOs to bill fee-for-service for their population health interventions, a concept we call population health billing. Journal of Hospital Medicine 2016;11:658-661. © 2016 Society of Hospital Medicine.

Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life.

OBJECTIVES: To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. PARTICIPANTS: The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. EVIDENCE: (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. CONSENSUS PROCESS: The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. CONCLUSIONS: Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.

Can the Accountable Care Organization model facilitate integrated care in England?

Following the global economic recession, health care systems have experienced intense political pressure to contain costs without compromising quality. One response is to focus on improving the continuity and coordination of care, which is seen as beneficial for both patients and providers. However, cultural and structural barriers have proved difficult to overcome in the quest to provide integrated care for entire populations. By holding groups of providers responsible for the health outcomes of a designated population, in the United States, Accountable Care Organizations are regarded as having the potential to foster collaboration across the continuum of care. They could have a similar role in England's National Health Service. However, it is important to consider the difference in context before implementing a similar model, adapted to suit the system's strengths. Working together, general practice federations and the Academic Health Science Networks could form the basis of accountable care in England.

Developing a Pipeline for the Community-Based Primary Care Workforce and Its Leadership: The Kraft Center for Community Health Leadership's Fellowship and Practitioner Programs.

PROBLEM: Community health centers (CHCs) face challenges recruiting and retaining primary care clinicians. Providing advanced training that enhances clinical skills within a public health framework, teaches leadership, protects time for scholarly activities, and focuses on the social mission may be a successful career development strategy. APPROACH: In July 2012, the Kraft Center for Community Health Leadership developed and implemented two 2-year programs to develop physician and nursing leaders with blended academic-community career paths and identities. The fellowship program for physicians and the practitioner program for early-career physicians and advanced practice nurses include mentored practice in a CHC; monthly learning days; completion of a community-based research project; and, for fellows, matriculation in an MPH program and engagement in a bimonthly leadership seminar. OUTCOMES: The first classes of 5 fellows and 14 practitioners graduated in June 2014. All 5 fellowship graduates were offered full-time positions at the CHCs where they practiced, and 2 have accepted leadership positions at their CHCs. All 14 practitioner graduates remain in community health, 5 have accepted leadership positions, and 2 have obtained grants to support ongoing projects. NEXT STEPS: The authors are tracking graduates' career paths and the programs' impact on CHCs while modifying the programs on the basis of feedback; identifying elements of the programs that may be amenable to more cost-effective delivery; and exploring the potential for federal funding to support expansion of the practitioner program, and for the practitioner program to increase the return on investment provided by the National Health Service Corps.

Estrogen therapy and noncognitive psychiatric signs and symptoms in elderly patients with dementia.

OBJECTIVE: This study investigated the efficacy and safety of short-term estrogen therapy in decreasing noncognitive signs and symptoms of dementia in demented elderly patients. METHOD: Sixteen moderately to severely demented elderly patients with aggressive behavioral disturbances were randomly assigned to receive conjugated equine estrogens or placebo in a 4-week clinical trial. Frequency and severity of noncognitive signs and symptoms of dementia, as assessed with the Dementia Signs and Symptoms Scale, were compared between estrogen and placebo groups. Data were analyzed with intent-to-treat and regression modeling methods. RESULTS: Estrogen therapy was associated with a significantly greater improvement on the Dementia Signs and Symptoms Scale total score than placebo. All five Dementia Signs and Symptoms Scale subscale comparisons favored estrogen therapy. No adverse effects were observed. CONCLUSIONS: These preliminary data suggest that short-term estrogen therapy may safely decrease the frequency and severity of noncognitive signs and symptoms of dementia in elderly patients.

Autonomous neurobiological pathways to late-life major depressive disorder: clinical and pathophysiological implications.

The objective of our study was to elucidate distinct paths to depression in a model that incorporates age, measures of medical comorbidity, neuroanatomical compromise, and cognitive status in a sample of patients with late-life major depressive disorder (MDD) and nondepressed controls. Our study was cross-sectional in nature and utilized magnetic resonance imaging (MRI) estimates of brain and high-intensity lesion volumes together with clinical indices of cerebrovascular and nonvascular medical comorbidity. Neuroanatomic and clinical measures were incorporated into a structural covariance model in order to test pathways to MDD. Our data indicate that there are two paths to MDD; one path is represented by vascular and nonvascular medical comorbidity that contribute to high-intensity lesions that lead to depression. Smaller brain volumes represent a distinct path to the mood disorder. Age influences depression by increasing atrophy and overall medical comorbidity but has no direct impact on MDD. These findings demonstrate that there are distinct biological substrates to the neuroanatomical changes captured on MRI. These observations further suggest that neurobiological mechanisms acting in parallel may compromise brain structure/function, thereby predisposing individuals to clinical brain disorders such as depression.

Frontotemporal Dementias: A New Clinical Syndrome?

The frontal lobe dementias (FLDs) are a group of disorders that have received considerable attention recently. Diagnosis is based on the presence of behavioral and cognitive disturbances associated pathologically with focal neuronal loss and gliosis without any inclusion bodies. Reports describing FLD differ regarding its clinical features, cognitive disturbances, and neurophysiological and neuropathological characteristics. The authors review the existing literature on FLD and emphasize the similarities and differences between reports. The heterogeneity of this condition as currently described is addressed, and arguments supporting the concept of FLD as a syndrome more appropriately called frontotemporal dementia are discussed. The authors present the development of a more rigid clinical definition of this syndrome using well-defined criteria as the first step toward understanding better this group of disorders.

Clinical Research in the Managed Care Environment.

The authors present the conclusions of a workshop devoted to the challenges to clinical research in the changing environment of managed care and health care reform. They identify problems and concerns with current conditions and discuss promising opportunities for new approaches to research.

MRI High-Intensity Signals in Late-Life Depression and Alzheimer's Disease: A Comparison of Subjects Without Major Vascular Risk Factors.

The authors examined periventricular white matter, deep white matter, and subcortical magnetic resonance imaging (MRI) high-intensity signals in subjects with late-life depression, probable Alzheimer's disease (DAT), and healthy, age-matched controls. All subjects were healthy and free of major vascular risk factors, including hypertension. MRIs were performed using a 1.5-tesla GE Signa scanner. T2 and proton-density-weighted images were analyzed by a neuroradiologist blind to the clinical status of all subjects. There were no statistically significant differences on any of the MRI indices between the groups studied. These data demonstrate that late-life depression, like DAT, in the absence of major vascular risk factors, is not associated with a significant increase in MRI high-intensity signals when compared to healthy, control subjects.