Impact of hospital-acquired pneumonia on the Medicare program.

OBJECTIVE: Patient safety organizations and researchers describe hospital-acquired pneumonia (HAP) as a largely preventable hospital-acquired infection that affects patient safety and quality of care. We provide evidence regarding the consequences of HAP among 2019 Medicare beneficiaries. DESIGN: Retrospective case-control study. PATIENTS: Calendar year 2019 Medicare beneficiaries with HAP during an initial hospitalization, defined by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding on inpatient claims (n = 2,457). Beneficiaries with HAP were matched using diagnosis-related group (DRG) codes with beneficiaries who did not experience HAP (n = 2,457). METHODS: The 2019 calendar year Medicare 5% Standard Analytic Files (SAF), for inpatient, outpatient, physician, and all postacute hospital settings. The case group (HAP) and control group (non-HAP) were matched on disease severity, age, sex, and race and were compared for hospital length of stay, costs, and mortality during the initial hospitalization and across settings for 30, 60, and 90 days after discharge. The 2019 fiscal year MedPAR Claims data were used to determine Medicare costs. RESULTS: Medicare beneficiaries with HAP were 2.8 times more likely to die within 90 days compared with matched beneficiaries who did not develop HAP. Among those who survived, beneficiaries with HAP spent 6.6 more days in the hospital (69%) and cost the Medicare program an average of $14,487 (24%) more per episode of care across initial inpatient and postdischarge services. CONCLUSIONS: The findings of higher mortality and cost among Medicare beneficiaries who develop HAP suggest that HAP prevention should be prioritized as a patient safety and quality initiative for the Medicare program.

Cognitive status is a determinant of health resource utilization among individuals with a history of falls: a 12-month prospective cohort study.

SUMMARY: Falls are a costly public health problem worldwide. The literature is devoid of prospective data that identifies factors among fallers that significantly drive health care resource utilization. We found that cognitive function--specifically, executive functions--and cognitive status are significant determinants of health resource utilization among older fallers. INTRODUCTION: Although falls are costly, there are no prospective data examining factors among fallers that drive health care resource utilization. We identified key determinants of health resource utilization (HRU) at 6 and 12 months among older adults with a history of falls. Specifically, with the increasing recognition that cognitive impairment is associated with increased falls risk, we investigated cognition as a potential driver of health resource utilization. METHODS: This 12-month prospective cohort study at the Vancouver Falls Prevention Clinic (n = 319) included participants with a history of at least one fall in the previous 12 months. Based on their cognitive status, participants were divided into two groups: (1) no mild cognitive impairment (MCI) and (2) MCI. We constructed two linear regression models with HRU at 6 and 12 months as the dependent variables for each model, respectively. Predictors relating to mobility, global cognition, executive functions, and cognitive status (MCI versus no MCI) were examined. Age, sex, comorbidities, depression status, and activities of daily living were included regardless of statistical significance. RESULTS: Global cognition, comorbidities, working memory, and cognitive status (MCI versus no MCI ascertained using the Montreal Cognitive Assessment (MoCA)) were significant determinants of total HRU at 6 months. The number of medical comorbidities and global cognition were significant determinants of total HRU at 12 months. CONCLUSION: MCI status was a determinant of HRU at 6 months among older adults with a history of falls. As such, efforts to minimize health care resource use related to falls, it is important to tailor future interventions to be effective for people with MCI who fall. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01022866.

Vertebral Fractures: Clinical Importance and Management.

Vertebral fractures are common and can result in acute and chronic pain, decreases in quality of life, and diminished lifespan. The identification of vertebral fractures is important because they are robust predictors of future fractures. The majority of vertebral fractures do not come to clinical attention. Numerous modalities exist for visualizing suspected vertebral fracture. Although differing definitions of vertebral fracture may present challenges in comparing data between different investigations, at least 1 in 5 men and women aged >50 years have one or more vertebral fractures. There is clinical guidance to target spine imaging to individuals with a high probability of vertebral fracture. Radiology reports of vertebral fracture need to clearly state that the patient has a "fracture," with further pertinent details such as the number, recency, and severity of vertebral fracture, each of which is associated with risk of future fractures. Patients with vertebral fracture should be considered for antifracture therapy. Physical and pharmacologic modalities of pain control and exercises or physiotherapy to maintain spinal movement and strength are important components in the care of vertebral fracture patients.

School Health Services for Children With Special Health Care Needs in California.

Children with special health care needs (CSHCN) are at risk for school failure when their health needs are not met. Current studies have identified a strong connection between school success and health. This study attempted to determine (a) how schools meet the direct service health needs of children and (b) who provides those services. The study used the following two methods: (a) analysis of administrative data from the California Basic Educational Data System and (b) a cross-sectional online survey of 446 practicing California school nurses. Only 43% of California's school districts employ school nurses. Unlicensed school personnel with a variety of unregulated training provide school health services. There is a lack of identification of CSHCN, and communication barriers impair the ability to deliver care. Study results indicate that California invests minimally in school health services.

The Mismatch Between Children's Health Needs and School Resources.

There are increasing numbers of children with special health care needs (CSHCN) who require various levels of care each school day. The purpose of this study was to examine the role of public schools in supporting CSHCN through in-depth key informant interviews. For this qualitative study, the authors interviewed 17 key informants to identify key themes, provide recommendations, and generate hypotheses for further statewide survey of school nurse services. Key informants identified successful strategies and challenges that public schools face in meeting the needs of all CSHCN. Although schools are well intentioned, there is wide variation in the ability of schools to meet the needs of CSHCN. Increased funding, monitoring of school health services, integration of services, and interagency collaboration are strategies that could improve the delivery of health services to CSHCN in schools.

Basic nursing care to prevent nonventilator hospital-acquired pneumonia.

PURPOSE: Nonventilator hospital-acquired pneumonia (NV-HAP) is an underreported and unstudied disease, with potential for measurable outcomes, fiscal savings, and improvement in quality of life. The purpose of our study was to (a) identify the incidence of NV-HAP in a convenience sample of U.S. hospitals and (b) determine the effectiveness of reliably delivered basic oral nursing care in reducing NV-HAP. DESIGN: A descriptive, quasi-experimental study using retrospective comparative outcomes to determine (a) the incidence of NV-HAP and (b) the effectiveness of enhanced basic oral nursing care versus usual care to prevent NV-HAP after introduction of a basic oral nursing care initiative. METHODS: We used the International Statistical Classification of Diseases and Related Problems (ICD-9) codes for pneumonia not present on admission and verified NV-HAP diagnosis using the U.S. Centers for Disease Control and Prevention diagnostic criteria. We completed an evidence-based gap analysis and designed a site-specific oral care initiative designed to reduce NV-HAP. The intervention process was guided by the Influencer Model (see Figure) and participatory action research. FINDINGS: We found a substantial amount of unreported NV-HAP. After we initiated our oral care protocols, the rate of NV-HAP per 100 patient days decreased from 0.49 to 0.3 (38.8%). The overall number of cases of NV-HAP was reduced by 37% during the 12-month intervention period. The avoidance of NV-HAP cases resulted in an estimated 8 lives saved, $1.72 million cost avoided, and 500 extra hospital days averted. The extra cost for therapeutic oral care equipment was $117,600 during the 12-month intervention period. Cost savings resulting from avoided NV-HAP was $1.72 million. Return on investment for the organization was $1.6 million in avoided costs. CONCLUSIONS: NV-HAP should be elevated to the same level of concern, attention, and effort as prevention of ventilator-associated pneumonia in hospitals. CLINICAL RELEVANCE: Nursing needs to lead the way in the design and implementation of policies that allow for adequate time, proper oral care supplies, ease of access to supplies, clear procedures, and outcome monitoring ensuring that patients are protected from NV-HAP.

Barriers and facilitators of cervical cancer screening among women of Hmong origin.

This qualitative study explored the barriers and facilitators of cancer screening among women of Hmong origin. Using a community-based participatory research approach, we conducted focus groups (n=44) with Hmong women who represented four distinct demographic groups among the Hmong community. The participants described sociocultural barriers to screening, which included a lack of accurate knowledge about the causes of cervical cancer, language barriers, stigma, fear, lack of time, and embarrassment. Structural barriers included attitudes and practices of health care providers, lack of insurance, and negative perceptions of services at clinics for the uninsured. Health care providers may require additional training and increased time per visit to provide culturally sensitive care for refugee groups such as the Hmong. Health-related social marketing efforts aimed at improving health literacy may also help to reduce health inequities related to cancer screening among the Hmong.

The selective adhesion molecule inhibitor Natalizumab decreases multiple myeloma cell growth in the bone marrow microenvironment: therapeutic implications.

Recent advances regarding the introduction of anti-adhesion strategies as a novel therapeutic concept in oncology hold great promise. Here we evaluated the therapeutic potential of the new-in-class-molecule selective-adhesion-molecule (SAM) inhibitor Natalizumab, a recombinant humanized IgG4 monoclonal antibody, which binds integrin-α4, in multiple myeloma (MM). Natalizumab, but not a control antibody, inhibited adhesion of MM cells to non-cellular and cellular components of the microenvironment as well as disrupted the binding of already adherent MM cells. Consequently, Natalizumab blocked both the proliferative effect of MM-bone marrow (BM) stromal cell interaction on tumour cells, and vascular endothelial growth factor (VEGF)-induced angiogenesis in the BM milieu. Moreover, Natalizumab also blocked VEGF- and insulin-like growth factor 1 (IGF-1)-induced signalling sequelae triggering MM cell migration. In agreement with our in vitro results, Natalizumab inhibited tumour growth, VEGF secretion, and angiogenesis in a human severe combined immunodeficiency murine model of human MM in the human BM microenvironment. Importantly, Natalizumab not only blocked tumour cell adhesion, but also chemosensitized MM cells to bortezomib, in an in vitro therapeutically representative human MM-stroma cell co-culture system model. Our data therefore provide the rationale for the clinical evaluation of Natalizumab, preferably in combination with novel agents (e.g. bortezomib) to enhance MM cytotoxicity and improve patient outcome.

An antibody-cytotoxic conjugate, BIIB015, is a new targeted therapy for Cripto positive tumours.

BIIB015 is an immunoconjugate created for the treatment of solid tumours and is currently in Phase I of clinical evaluation. BIIB015 consists of a humanised monoclonal antibody against the Cripto protein carrying a payload, via a hindered disulphide linker, of the maytansinoid derivative, DM4. Cripto is a GPI-linked protein required for signal transduction of the TGF-beta ligand, Nodal. Cripto has been previously described as an oncogene and fits the classic pattern of an embryonic gene that is re-expressed in a transformed tumour cell. Cripto expression is highly prevalent on a number of solid tumours, including greater than 75% of breast, lung, and colorectal tumours. Our report documents for the first time that targeting the cell surface Cripto protein with an anti-Cripto antibody-cytotoxic conjugate is an effective means of inhibiting or regressing growth of Cripto positive tumours. BIIB015 which utilises a 'cleavable' linker containing a disulphide bond exhibits superior activity when compared to huB3F6 mAb conjugates with different linker systems, including one with a 'non-cleavable' linker. BIIB015 displays specificity for Cripto in both in vitro and in vivo experiments. In human xenograft models originating from lung (Calu-6), colon (CT-3), testicular (NCCIT) and breast (MDA-MB-231) tumour samples, BIIB015 shows robust activity with results ranging from >50% tumour inhibition to complete tumour regression. The efficacy seen in the MDA-MB-231 model, a triple negative (-HER2, -ER, and -PR) tumour, is particularly exciting since there is currently no approved therapy for this indication. In addition, BIIB015 can be combined with standard of care chemotherapeutics for enhanced efficacy.

Developing culturally responsive approaches with Southeast Asian American families experiencing developmental disabilities.

OBJECTIVE: Southeast Asian American families are underrepresented among recipients of special education and social services for people with developmental disabilities. Our aims were to use a community-based participatory research approach to examine Hmong and Mien families' perceptions of developmental disabilities and understand barriers to and facilitators of service provision among families experiencing developmental disabilities. We describe here a case study of a successful attempt to engage marginalized and underserved communities to understand their needs to improve access and services for persons with developmental disabilities. METHODS: We conducted 2 focus groups with 11 key informants and 1 focus group with 10 family members of persons with developmental disabilities, as well as in-depth interviews with 3 shamans. Using a thematic analysis approach, we coded notes and transcripts to assess community members' understanding of developmental disabilities, experiences negotiating educational and health care systems, and barriers to high-quality care. RESULTS: A predominant theme was the perception that reliance on governmental support services is not appropriate. Common barriers identified included lack of accurate information, language difficulties, lack of trust, and limited outreach. These perceptions and barriers, combined with limited access to services, interfere with community acceptance and use of available support services. Despite these barriers, participants indicated that with education, outreach, and culturally responsive support, families would likely accept services. CONCLUSIONS: Community-based participatory methods are effective for eliciting root causes of health inequities in marginalized communities. Outreach to community-based organizations and an inclusive research practice identified social and cultural reasons for low service uptake and provided a pathway for the community to improve services for persons with developmental disabilities.

Translation of health surveys using mixed methods.

PURPOSE: The purpose of this study was to determine the effectiveness of a process-based translation method for a health survey instrument, Searching for Hardships and Obstacles to Shots (SHOTS), using a community-based participatory approach with the Hmong community. DESIGN: The study was based on a cross-sectional survey to assess the reliability and validity of the SHOTS immunization survey, an instrument used in the Hmong community, who are refugees originally from Laos living in the United States. METHOD: Process-based universalistic health survey translation methods were used in a six-step procedure to translate the instrument. Mixed methods were used to analyze results, including cognitive interviewing, content validity indexing, Cronbach's α, t tests, and the Kolmogorov-Smirnov test. FINDINGS: Participants were able to accurately complete the SHOTS survey in either Hmong or English, depending on participant preference. CONCLUSIONS: Universalistic, process-based, mixed methods used to analyze language translation, in combination with the principles of community-based participatory research, provide effective methods to translate health surveys. Involvement of the community strengthens the quality of translation and improves reliability and validity of survey results. CLINICAL RELEVANCE: Healthcare providers require accurate and reliable information from evidence-based health surveys to plan for culturally responsive care. Cross-cultural research often relies on language translation. Translation of a health survey instrument may be improved with universalistic, process-based methodology.

Perception of barriers to immunization among parents of Hmong origin in California.

OBJECTIVES: We explored factors associated with perception of barriers to immunization among parents of Hmong origin in California, whose children experience persistent immunization inequities even with health insurance. METHODS: A partnership of academic researchers and members of the Hmong community conducted a community-based participatory research project. We collected data in naturalistic settings with a standardized instrument. We analyzed responses from 417 parents and caregivers and created a structural equation model to determine factors that contributed to perceived barriers. RESULTS: Of 3 potential contributing factors to perceived barriers-nativity, socioeconomic position, and use of traditional Hmong health care (i.e., consulting shamans and herbalists)-the latter 2 significantly predicted higher perceived barriers to immunization. Nativity, indicated by years in the United States, age of arrival in the United States, and English language fluency, did not predict perceived barriers. CONCLUSIONS: Interventions aimed at reducing immunization inequities should consider distinct sociocultural factors that affect immunization rates among different refugee and immigrant groups.

CRIPTO3, a presumed pseudogene, is expressed in cancer.

Cripto is a cell surface protein highly expressed in certain solid tumors, and overexpression of Cripto protein is oncogenic. Cripto-1 protein is encoded by CRIPTO1 gene. CRIPTO3, a presumed pseudogene, has an open reading frame with six amino acid differences from Cripto-1. We show that CRIPTO3 mRNA is the CRIPTO message expressed in many cancer samples. A CRIPTO3 SAGE tag was found in several cancer SAGE libraries, while the CRIPTO1 tag was found in ES cell libraries. In vitro experiments indicate both Cripto-1 and Cripto-3 proteins are functional in the Nodal-dependent signal pathway. Our data indicate that CRIPTO3 is an expressed gene, particularly in certain cancers, and suggest a potentially novel mechanism of oncogenesis through activation of a retrogene.

Intrapsychic dynamics, behavioral manifestations, and related interventions with youthful fire setters.

Fire setting in youth has often been overlooked and misunderstood as a coping skill for expressing rage. The act of deliberate fire setting, if uninterrupted, may continue throughout an individual's lifetime. Forensic examiners, mental health care providers, and criminal justice professionals can help guide referral and treatment through better understanding of behaviors and intrapsychic dynamics.

Is there a case for paternalism in forensic nursing?

Forensic nurses often face a competing duty to patients and society. This article explores possible solutions to the ethical conflict.

Anti-alpha4 integrin monoclonal antibody inhibits multiple myeloma growth in a murine model.

In a syngeneic murine model of multiple myeloma with many of the characteristics of the human disease, a monoclonal antibody (mAb) to the integrin very late antigen-4 (VLA-4), given after the myeloma has already homed to and begun to establish itself within the bone marrow compartment, produces statistically significant effects on multiple disease variables. These include reductions in circulating levels of IgG2b; percentage of IgG2b-positive myeloma cells circulating in blood; spleen weight; and myeloma cell burden in spleen, bone marrow, and liver. mAb therapy had no effect on nonmalignant hematopoietic cells. An acute 6-day regimen of mAb treatment, initiated very late in disease to avoid mAb elimination in the immunocompetent animals, still significantly reduced spleen and blood myeloma cell burden. The ability of the (VLA-4) mAb to affect multiple variables in this model, even as monotherapy, suggests this pathway plays a central role in disease progression.