Increasing Follow Up With Primary Care Providers After Emergency Department Visits in Older Adults.

PURPOSE: To increase follow up with the primary care team via telephone outreach within 3 days of emergency department (ED) discharge to schedule a follow-up visit within 14 days. Secondary aims included: identifying high utilizers of the ED (defined as more than three ED visits within 6 months), reinforcing discharge instructions from the ED via nursing education on telephone follow ups, and identifying the reasons patients used the ED. METHOD: Baseline data were gathered retrospectively by reviewing charts of patients discharged from the ED. Charts were reviewed from a biweekly automated report, and RNs initiated follow-up phone calls to patients discharged from the ED, offering appointments and providing pertinent nursing education. RESULTS: Primary care follow ups after ED discharges increased from 38% to 71% over 10 months with the new nurse-led workflow. Patients to whom the RN outreached to were more likely to attend their follow-up appointments. However, a 14-day follow-up appointment with the primary care provider (PCP) showed no significant difference in ED revisits or hospital admissions. CONCLUSION: Follow up after ED discharge led to increased coordination of care. Nurses provided education about chronic conditions and reiterated discharge instructions that might have been unclear to patients in the ED. Further studies are needed to analyze the effect of follow up with the PCP on ED utilization and hospital admissions. [Journal of Gerontological Nursing, 50(3), 33-39.].

Using Medicare Annual Wellness Visits and telehealth to enhance ambulatory geriatrics education among medical students.

The Medicare Annual Wellness visit (AWV) was mandated as a fully covered benefit for older adults to enhance preventive care and improve healthcare outcomes. Although the benefit of conducting AWV is proven, its adoption in primary care is far from universal. The COVID-19 pandemic affected medical education and clinical care in unprecedented ways. Telehealth became a prominent way of delivering healthcare. Older adults, being significantly affected by the pandemic-related mortality and morbidity, were less likely to engage in preventive care with their healthcare providers. Amidst this considerable shift, we conceptualized a clinical experience for third-year medical students during their Ambulatory Care - Geriatrics clerkship that involved a telehealth interaction with an older adult to review AWV components, followed by an in-person office visit with the geriatrician preceptor. Post-session survey data highlighted the beneficial effect on student learning about older adult health maintenance, immunizations and geriatric syndrome assessment. It also facilitated self-directed learning and increased student-patient rapport. Preceptors appreciated the additional elements of care identified by the telehealth call that would otherwise not have been addressed in a time-limited office visit. This hybrid clinical experience reduced crowding in ambulatory clinical space during the COVID-19 pandemic, yet enhanced learning for students in geriatrics preventive care.

Correction to: A rare cause of nephrocalcinosis in an infant: Answers.

Due to an unfortunate error during the processing of this article, the HTML version of this article contained a mistake.

Converting patients from warfarin to non-vitamin K antagonist oral anticoagulants.

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs) are favorable in stroke prevention for geriatric patients with nonvalvular atrial fibrillation versus warfarin. These anticoagulants do not require international normalized ratio (INR) monitoring and have lower food/drug interactions. In addition, NOACs have risk reduction in bleeding and all-cause mortality compared with warfarin. LOCAL PROBLEM: At a geriatric primary care practice, two registered nurses manage 88 patients on warfarin for INR monitoring. Nurse practitioners (NPs) provide oversight for warfarin titration after abnormal results. The goal of this quality-improvement project was to decrease the time spent monitoring patients on warfarin. METHODS: Primary care providers and cardiologists of patients on warfarin were contacted to gain approval of transition to a NOAC. The NP reviewed patients' renal function and the indication for anticoagulation and then created a list of eligible patients for transition. INTERVENTIONS: Patients eligible for transition to NOACs were contacted for their consent. The transition process included stopping warfarin, ordering apixaban, ordering INR level, educating about starting apixaban, and coordinating appropriate follow-up. RESULTS: Of 88 patients on warfarin, 21 were eligible for conversion from warfarin to apixaban. Of these 21 patients, 66% ( n = 14) consented to the conversion. Of those who were not converted to apixaban, five declined due to cost and two were lost to follow-up. CONCLUSION: There was a reduction in nurses' monthly monitoring of patients on warfarin by 22%. Transition to NOAC was not only beneficial for patient safety and efficacy but also reduced nursing clinical time for anticoagulation encounters.

Hemodialysis Catheter Breakage in an Infant.

A 3-month-old male infant was admitted to our unit due to acute decompensation of chronic kidney disease of unknown etiology. Further investigation led to the diagnosis of primary hyperoxaluria type 1. As the patient did not recover, hemodialysis was initiated with a non-tunneled femoral catheter. A tunneled Hickman catheter was placed in the internal jugular vein. The patient experienced moderate intradialytic exit-site bleeding and catheter malfunction, which initially responded to pressure and postural changes. During the third session, the patient suffered cardiopulmonary arrest. After stabilization, a chest hematoma was identified. Fluoroscopy revealed a catheter breakage. Despite initial stabilization, the patient developed septic shock due to Pseudomonas aeruginosa and died several days later. Hemodialysis is sometimes necessary in children under 24 months with chronic kidney disease. Vascular access is a major challenge in these patients due to lack of appropriate catheter sizes and high complication rates. Hemodialysis catheter fracture is an uncommon complication, and diagnosis can be difficult when the breakage involves the subcutaneous segment. Persistent intradialytic bleeding and mechanical malfunction should raise suspicion of this complication and should elicit catheter revision under fluoroscopy. Without prompt diagnosis, catheter breakage may have fatal consequences, as in our case.

Change in quantitative human chorionic gonadotropin after manual vacuum aspiration in women with pregnancy of unknown location.

OBJECTIVE: To determine whether the change in human chorionic gonadotropin after manual vacuum aspiration is predictive of an early abnormal intrauterine pregnancy in women with pregnancy of unknown location. STUDY DESIGN: This is a prospective cohort study of 23 clinically stable patients with an early abnormal pregnancy who had abnormally rising human chorionic gonadotropins and absence of sonographic evidence of an intrauterine pregnancy or ectopic pregnancy. The change in human chorionic gonadotropin within 24 hours after manual vacuum aspiration was compared with the pathologic diagnosis and the ultimate clinical diagnosis. RESULTS: Ten patients had > or = 50% decrease (mean, 74%; range, 58-80%) in human chorionic gonadotropin after manual vacuum aspiration with confirmed chorionic villi on pathology results. Two patients had a > 50% drop in human chorionic gonadotropin but absence of chorionic villi, clinically consistent with complete spontaneous abortion. The remaining 10 patients who had either rising or < 50% decrease in human chorionic gonadotropin post manual vacuum aspiration all had no chorionic villi on pathology results. The sensitivity, specificity, positive predictive value, and negative predictive value of a > or = 50% decrease in human chorionic gonadotropin after manual vacuum aspiration in predicting an abnormal intrauterine pregnancy were 92% (95% confidence interval [CI], 0.62-0.99), 100% (95% CI, 0.62-1.0), 100% (95% CI, 0.70-1.0), and 90% (95% CI, 0.54-0.99), respectively. CONCLUSION: A > or = 50% decrease in human chorionic gonadotropin within 24 hours after manual vacuum aspiration is predictive of an abnormal intrauterine pregnancy, thereby excluding an ectopic pregnancy and expediting the management of women with pregnancy of unknown location.

The F-box protein Dia2 regulates DNA replication.

Ubiquitin-mediated proteolysis plays a key role in many pathways inside the cell and is particularly important in regulating cell cycle transitions. SCF (Skp1/Cul1/F-box protein) complexes are modular ubiquitin ligases whose specificity is determined by a substrate-binding F-box protein. Dia2 is a Saccharomyces cerevisiae F-box protein previously described to play a role in invasive growth and pheromone response pathways. We find that deletion of DIA2 renders cells cold-sensitive and subject to defects in cell cycle progression, including premature S-phase entry. Consistent with a role in regulating DNA replication, the Dia2 protein binds replication origins. Furthermore, the dia2 mutant accumulates DNA damage in both S and G2/M phases of the cell cycle. These defects are likely a result of the absence of SCF(Dia2) activity, as a Dia2 DeltaF-box mutant shows similar phenotypes. Interestingly, prolonging G1-phase in dia2 cells prevents the accumulation of DNA damage in S-phase. We propose that Dia2 is an origin-binding protein that plays a role in regulating DNA replication.

Review of Transitional Care Management and Chronic Care Management Codes for Pulmonologists.

Patients with advanced respiratory illness are often hospitalized, requiring close follow-up after discharge and also requiring care coordination outside of traditional face-to-face outpatient visits. Primary care providers and specialists often provide services outside of outpatient visits that have not been captured and reimbursed with traditional billing evaluation and management codes. Within the last 5 years, the Centers for Medicare & Medicaid added new codes to the Medicare Physician Fee Schedule that reimburse for care coordination services not paid for by traditional evaluation and management codes. Transitional care management includes the 30-day period following hospitalization in which a clinician is responsible for care of the patient postdischarge from the hospital. Chronic care management provides reimbursement for coordination of care for chronic conditions that is performed by any clinician and his or her staff on a monthly basis that is > 20 min in duration.

Vitamin E hydroquinone is an endogenous regulator of ferroptosis via redox control of 15-lipoxygenase.

Ferroptosis is a form of programmed cell death associated with inflammation, neurodegeneration, and ischemia. Vitamin E (alpha-tocopherol) has been reported to prevent ferroptosis, but the mechanism by which this occurs is controversial. To elucidate the biochemical mechanism of vitamin E activity, we systematically investigated the effects of its major vitamers and metabolites on lipid oxidation and ferroptosis in a striatal cell model. We found that a specific endogenous metabolite of vitamin E, alpha-tocopherol hydroquinone, was a dramatically more potent inhibitor of ferroptosis than its parent compound, and inhibits 15-lipoxygenase via reduction of the enzyme's non-heme iron from its active Fe3+ state to an inactive Fe2+ state. Furthermore, a non-metabolizable isosteric analog of vitamin E which retains antioxidant activity neither inhibited 15-lipoxygenase nor prevented ferroptosis. These results call into question the prevailing model that vitamin E acts predominantly as a non-specific lipophilic antioxidant. We propose that, similar to the other lipophilic vitamins A, D and K, vitamin E is instead a pro-vitamin, with its quinone/hydroquinone metabolites responsible for its anti-ferroptotic cytoprotective activity.

Recombinant Enolase of Trypanosoma cruzi as a Novel Vaccine Candidate against Chagas Disease in a Mouse Model of Acute Infection.

Trypanosoma cruzi is the protozoan parasite that causes Chagas disease, which is considered by the World Health Organization to be a neglected tropical disease. Two drugs exist for the treatment of Chagas disease, nifurtimox and benznidazole; they are only effective in the acute phase, and a vaccine is currently not available. In this study, we used the recombinant enolase from T. cruzi H8 strain (MHOM/MX/1992/H8 Yucatán) (rTcENO) and its encoding DNA (pBKTcENO) to immunize mice and evaluate their protective effects in an experimental murine model of acute phase infection. Our results showed that mice vaccinated with rTcENO or its encoding DNA were able to generate typical specific antibodies (IgG1, IgG2a, and IgG2b), suggesting that a mixed Th1/Th2 immune response was induced. The parasite burden in the blood was reduced to 69.8% and 71% in mice vaccinated with rTcENO and pBKTcENO, respectively. The group vaccinated with rTcENO achieved 75% survival, in contrast to the group vaccinated with pBKTcENO that showed no survival in comparison to the control groups. Moreover, rTcENO immunization elevated the production of IFN-γ and IL-2 after the parasite challenge, suggesting that the Th1-type immune response was polarized. These results indicated that rTcENO could be used as a vaccine against Chagas disease.

Hiperpotasemia asintomática como forma de presentación de pseudohipoaldosteronismo / Asymptomatic hyperkalemia as a form of presentation of pseudohypoaldosteronism

No disponible

Three-dimensional Biomimetic Technology: Novel Biorubber Creates Defined Micro- and Macro-scale Architectures in Collagen Hydrogels.

Tissue scaffolds play a crucial role in the tissue regeneration process. The ideal scaffold must fulfill several requirements such as having proper composition, targeted modulus, and well-defined architectural features. Biomaterials that recapitulate the intrinsic architecture of in vivo tissue are vital for studying diseases as well as to facilitate the regeneration of lost and malformed soft tissue. A novel biofabrication technique was developed which combines state of the art imaging, three-dimensional (3D) printing, and selective enzymatic activity to create a new generation of biomaterials for research and clinical application. The developed material, Bovine Serum Albumin rubber, is reaction injected into a mold that upholds specific geometrical features. This sacrificial material allows the adequate transfer of architectural features to a natural scaffold material. The prototype consists of a 3D collagen scaffold with 4 and 3 mm channels that represent a branched architecture. This paper emphasizes the use of this biofabrication technique for the generation of natural constructs. This protocol utilizes a computer-aided software (CAD) to manufacture a solid mold which will be reaction injected with BSA rubber followed by the enzymatic digestion of the rubber, leaving its architectural features within the scaffold material.

Displasia fibromuscular: una causa rara de hipertensión arterial / Fibromuscular dysplasia: an uncommon cause of arterial hypertension

No disponible

Costing Dengue Fever Cases and Outbreaks: Recommendations from a Costing Dengue Working Group in the Americas.

OBJECTIVES: The overall aim of this article was to present a step-by-step guideline for determining the costs associated with dengue in dengue-endemic countries of the Latin American and the Caribbean region and to illustrate how each of these steps can be applied in dengue costing studies. METHODS: An expert panel was convened to develop standards for costing dengue so that over the next decade, decision makers will have access to improved information on the true cost of dengue in endemic countries of the Latin American and the Caribbean region. We described the outcome of the expert panel meeting, which resulted in the provision of a step-by-step dengue costing guideline that aims to provide direction to planners and program managers on how to estimate dengue economic burden studies, and provide a discussion forum of the methods used to cost dengue fever cases and outbreaks in a manner that should be accessible to persons with some familiarity with a cost study. RESULTS: The guideline includes nine sequential steps: 1) definition of the scope of the study; 2) identification of the target population; 3) description of the study perspective; 4) definition of the time horizon; 5) calculation of the sample size; 6) definition of the unit of analysis; 7) identification of the cost items; 8) measurement and valuation of the cost items; and 9) handling of uncertainty. The trade-off between accurate, patient-level cost estimates and data availability constraints is discussed. CONCLUSIONS: The current guideline is the result of constructive collaboration among a multidisciplinary research team to better ascertain the true economic burden of dengue across countries of the region.