Exploring Hospital Transfers for Long-Stay Nursing Home Residents With End-Stage Renal Disease.

BACKGROUND: Nursing home residents with end-stage renal disease (ESRD) are an understudied, yet growing population within nursing homes. PURPOSE: To describe hospital transfers for nursing home residents diagnosed with ESRD and receiving hemodialysis. METHODS: Data were analyzed for residents with ESRD transferred to the hospital between October 2016 and September 2020 (n = 219). Descriptive statistics, bivariate analyses, logistic regression, and content analysis were used for analysis. RESULTS: Clinical factors associated with transfers included abnormal vitals, altered mental state, and pain. Other factors included lack of care planning and advance directives, provider communication, resident/family preferences, missing/refusing dialysis, and facility resources. The odds of an observation/emergency department only visit was 2.02 times larger when transferred from the dialysis clinic. CONCLUSIONS: Advance care planning and coordinated care between nursing home and dialysis clinics are needed along with proactive planning when residents miss dialysis or experience a condition change at the dialysis clinic.

Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity.

BACKGROUND: Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. METHODS: This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. RESULTS: Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. CONCLUSIONS: Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

A Comparison of Models Predicting One-Year Mortality at Time of Admission.

CONTEXT: Hospitalization provides an opportunity to address end-of-life care (EoLC) preferences if patients at risk of death can be accurately identified while in the hospital. The modified Hospital One-Year Mortality Risk (mHOMR) uses demographic and admission data in a logistic regression algorithm to identify patients at risk of death one year from admission. OBJECTIVES: This project sought to validate mHOMR and identify superior models. METHODS: The mHOMR model was validated using historical data from an academic health system. Alternative logistic regression and random forest (RF) models were developed using the same variables. Receiver operating characteristic (ROC) and precision recall curves were developed, and sensitivity, specificity, and positive and negative predictive values were compared over a range of model thresholds. RESULTS: The RF model demonstrated higher area under the ROC curve (0.950, 95% CI 0.947 - 0.954) as compared to the logistic regression models (0.818 [95% CI 0.812 - 0.825] and 0.841 [95% CI 0.836 - 0.847]). Area under the precision recall curve was higher with the random forest model compared to the logistic regression models (0.863 vs. 0.458 and 0.494, respectively). Across a range of thresholds, the RF model demonstrated superior sensitivity, equivalent specificity, and higher positive and negative predictive values. CONCLUSION: A machine learning RF model, using common demographic and utilization data available on hospital admission, identified inpatients at risk of death more effectively than logistic regression models using the same variables. Machine learning models have promise for identifying admitted patients with elevated one-year mortality risk, increasing opportunities to prompt discussion of EoLC preferences.

Global Rehabilitation Health Worker Certification: Global Agenda, Local Imperative.

Rehabilitation, seen as a disability-specific service needed only by few of the world's population, has not been prioritized in countries and is under-resourced. A rehabilitation-ready health workforce is potentially the most important resource for improving functioning and the quality of life for the 2.41 billion people worldwide needing this care. In April 2019, CGFNS International, Inc., and the Association of Schools Advancing Health Professions (ASAHP) partnered to respond to the World Health Organization's Rehab 2030, which emphasizes the need for global action by professional organizations, development agencies, and civil society to develop and maintain a sustainable workforce for rehabilitation under different healthcare models in different economies. The global certification framework presented in this article provides a mechanism to validate rehabilitation knowledge and practice competence of individual health workers. The impact of certification on upgrading rehabilitation education and upskilling the world's rehabilitation health workforce cannot be overstated.

Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic.

The COVID-19 pandemic caused by SARS-CoV-2 is unprecedented in modern history. Its effects on social behavior and health care delivery have been dramatic. The resultant burden of disease and critical illness has outpaced the diagnostic, therapeutic, and health care professional resources of many clinics and hospitals. It continues to do so globally. The allocation of hospital beds and ventilators, personal protective equipment, investigational therapeutics, and other scarce resources has required difficult decisions. Clinical and surgical practices which are standard in normal times may not be standard or safe during the COVID-19 crisis. How can we best adapt as physicians and surgeons? What foundational ethical principles and systems of principle application can help guide our decision-making? Fortunately, a large body of work in medical ethics addresses these questions. Unfortunately, many surgeons and other health care professionals are probably not as familiar with these concepts. This brief communication is intended to provide a concise explanation of ethical considerations which readers may find helpful when addressing allocation of scarce resources and alterations in surgical care brought on by the current pandemic.

Embracing the Power of Show-Me ECHO Learning Communities to Transform Clinical Practice in Missouri.

Show-Me ECHO, a state-funded project, provides access to education within a community of learners in order to optimize healthcare for the citizens of Missouri. Through videoconferencing and case-based review, ECHO shifts professional development from learning about medical problems in isolation to experiential learning as part of a multidisciplinary team. The establishment of a statewide COVID-19 ECHO is allowing a rapid response to this novel, unprecedented, and unanticipated health care crisis. There are many ongoing opportunities for clinicians from across the state to join a Show-Me ECHO learning community as a means to elevate their practice and improve ability to respond amidst a constantly evolving health care environment.

Building Regional Expertise: Perspectives from Show-Me ECHO Participants.

This article highlights four primary care providers that practice in underserved areas in Missouri. Show-Me ECHO (Extension for Community Healthcare Outcomes) provides colleagues opportunities for consultation and Continuing Medical Education (CME) around particular conditions. Through their participation, these providers have 1) enhanced their comfort and skill in diagnosis and treatment, 2) become important regional resources for patients and other providers, and 3) improved access to specialty services in their community.

Integrating the Lived Experience Conditions and Care in the ECHO Model.

Show Me ECHO has introduced a 'lived experience' role by including patients and caregivers into some of its ECHO Hub Teams. Grounded in the patient-centered care model, this role provides insights into the lived experience of patients and caregivers experiencing chronic conditions. The goals are to improve patient outcomes, strengthen authentic communication and partnership between providers, patients, and patients' support systems, and to enhance local communities' ability to support its members dealing with chronic conditions.

Occupational therapy students' perspectives of ethics in two countries: South Africa and the United States of America.

OBJECTIVES: Worldwide, health-care students, including occupational therapy students undergo ethics training. Ethics training facilitates students' critical thinking, objective analysis and clinical reasoning skills to promote impartiality and minimize bias in decision-making. The aim of the study was to explore and describe similarities and differences in occupational therapy students' perceptions and experiences of an ethical dilemma. METHODS: The study employed a descriptive qualitative approach. Eighty occupational therapy students from South Africa and the United States of America (USA) participated in the study as part of an online international ethics module. Data were collected from students' written analyses of a case study engaging them in an ethics reasoning process and were analyzed thematically. RESULTS: Three themes emerged: Personal views and biases, ethical approaches, and practical alternatives and implications. Both groups of students from South Africa and the USA approached the case in a similar manner using their knowledge of ethics, principles, and approaches. They also applied the steps of an ethics reasoning process to guide their decision-making. All occupational therapy students from both countries highlighted Ethics of Care as an integral basis for their reasoning. CONCLUSION: There is a need amongst educators to identify, share, and discuss similarities and differences in how health-care practitioners address ethical issues, using the ethics reasoning process as a guide. The international occupational therapy community needs to further the profession's meta-ethical discourse to guide clinical application within a diverse and globally connected workforce.

HIV-Specific CD8+ T Cell-Mediated Viral Suppression Correlates With the Expression of CD57.

BACKGROUND: Virus-specific CD8(+) T-cell responses are believed to play an important role in the control of HIV-1 infection; however, what constitutes an effective HIV-1 CD8(+) T-cell response remains a topic of debate. The ex vivo viral suppressive capacity was measured of CD8(+) T cells from 44 HIV-1-positive individuals. The phenotypic and cytokine profiles, and also the specificity of the CD8(+) T cells, were correlated with the suppression of HIV-1 replication. We also aimed to determine whether antiretroviral therapy (ART) had any positive effect on the HIV-1 suppressive CD8(+) T cells. METHOD: Ex vivo suppression assay was used to evaluate the ability of CD8(+) T cells to suppress HIV-1 replication in autologous CD4(+) T cells. The CD107a, interferon-γ, interleukin-2, tumor necrosis factor-α (TNF-α), and macrophage inflammatory protein-1ß (MIP-1ß) responses to HIV-1 were evaluated by intracellular staining. The phenotypic profile of CD8(+) T cells was determined by whole blood staining. RESULTS: The expression of CD57 on effector CD8(+) T cells correlated with the suppression of HIV-1 replication and to the duration of ART. CD107a and tumor necrosis factor-α expression levels were significantly higher in individuals with ex vivo suppressive activity compared with individuals without suppressive activity. CONCLUSIONS: Standard in vitro assays measuring one or several cytokines do not correlate with the functional viral suppressive capacity of CD8(+) T cells from HIV-1-positive individuals. The best correlation of viral suppression was found to be CD57 expression. CD57 expression correlated with the duration of ART, suggesting that ART restores the cytotoxic capacity of CD8(+) T lymphocytes.

Fidelity to the healing relationship: a medical student's challenge to contemporary bioethics and prescription for medical practice.

As a medical  student, I observed that different physicians had strikingly different attitudes and approaches when caring for patients. The care of one patient in particular continues to challenge my understanding of illness and moral responsibility in the practice of medicine. In this paper, I illustrate the care of this patient in order to evaluate the dominant ethics I was taught in medical school, in theory and in practice, and argue neither principlism nor the ethics of care fully captures the moral responsibility of physicians. Emphasising fidelity to the healing relationship, a core principle derived from Pellegrino's virtue theory, I conclude that this approach to clinical ethics fully explains physician responsibility. Pellegrino deconstructs the practice of medicine to clarify the moral event within the clinical encounter and offers a sufficiently useful and justified approach to patient care.

From collaboration to cause: breaking rural poverty cycles through educational partnerships.

The Missouri Health Professions Consortium (MHPC) Occupational Therapy Assistant Program is an innovative educational model that was specifically designed to address needs unique to rural communities. The model takes into account not only the distinctiveness of rural practice environments but also the educational barriers unique to rural student populations. The MHPC Occupational Therapy Assistant Program addresses the needs of these communities by providing educational opportunities to rural, place-bound students. The program has produced viable employment options, resulting in improved access to occupational therapy services as well as positive economic outcomes for graduates who reside in rural communities.

Broadening of the T-cell repertoire to HIV-1 Gag p24 by vaccination of HLA-A2/DR transgenic mice with overlapping peptides in the CAF05 adjuvant.

Induction of broad T-cell immune responses is regarded as critical for vaccines against the human immunodeficiency virus type 1 (HIV-1) which exhibit high diversity and, therefore, focus has been on inducing cytotoxic CD8 T-cell responses against the more conserved parts of the virus, such as the Gag protein. Herein, we have used the p24 protein which contains a range of conserved T-cell epitopes. We demonstrate that a vaccine of HIV-1 subtype B consensus group-specific antigen (Gag) p24 protein with the CD8-inducing liposomal cationic adjuvant formulation (CAF) 05, induces both CD4 and CD8 T-cell responses in CB6F1 mice. The adjuvanted vaccine also induced functional antigen-specific cytotoxicity in vivo. Furthermore, we found that when fragmenting the Gag p24 protein into overlapping Gag p24 peptides, a broader T-cell epitope specificity was induced in the humanized human leukocyte antigen (HLA)-A2/DR-transgenic mouse model. Thus, combining overlapping Gag p24 peptides with CAF05 appears to be a promising and simple strategy for inducing broader T-cell responses to multiple conserved epitopes which will be relevant for both prophylactic and therapeutic HIV-1 vaccines.

HIV-1-infected individuals in antiretroviral therapy react specifically with polyfunctional T-cell responses to Gag p24.

BACKGROUND: Still no effective HIV-1 prophylactic or therapeutic vaccines are available. However, as the proportion of HIV-1-infected individuals on antiretroviral treatment is increasing, knowledge about the residual immune response is important for the possible development of an HIV-1 vaccine. METHODS: In this study, the magnitude, breadth, and quality of the HIV-1-specific T-cell response in HIV-1-infected viremic individuals (n = 19) and individuals on highly active antiretroviral treatment (HAART) (n = 14) using multicolor flow cytometry were determined. RESULTS: We found that magnitude and breadth of the CD8 T-cell response were significantly higher in viremic individuals than individuals on HAART (P < 0.0001 and P < 0.0001, respectively) and that the functionality of the overall HIV-1-specific response was significantly different in individuals on HAART and viremic individuals (P = 0.0020). In individuals on HAART, the remaining responses were primarily detected upon stimulation with overlapping peptides from Gag p24, integrase, and Nef. The Gag p24 response was more polyfunctional than corresponding responses observed in viremic individuals. CONCLUSIONS: Identification of highly immunogenic regions also recognized by individuals on HAART may be important for HIV-1 vaccine development. Irrespective of HLA haplotype, specific regions within the HIV-1 genome that is targeted more frequently in individuals on HAART have been identified. However, further studies are required to establish if these particular regions could be interesting for a future vaccine that might limit the time and opportunity for escape mutations.

Adjuvanted HLA-supertype restricted subdominant peptides induce new T-cell immunity during untreated HIV-1-infection.

We investigated the potential of inducing additional T-cell immunity during chronic HIV-1 infection directed to subdominant HIV-1 epitopes from common HLA-supertypes. Ten treatment-naïve HIV-1-infected individuals were immunized with peptides in the adjuvant CAF01. One individual received placebo. T-cell immunogenicity was examined longitudinally by a flow cytometry (CD107a, IFNγ, TNFα, IL-2 and/or MIP1ß expression) as well as IFNγ ELISPOT. Safety was evaluated by clinical follow up combined with monitoring of biochemistry, hematology, CD4 T-cell counts and viral load. New CD4 and CD8 T-cell responses specific for one or more vaccine epitopes were induced in 10/10 vaccinees. The responses were dominated by CD107a and MIP1ß expression. There were no significant changes in HIV-1 viral load or CD4 T-cell counts. Our study demonstrates that the peptide/CAF01 vaccine is safe and that it is possible to generate new HIV-1 T-cell responses to defined epitopes in treatment-naïve HIV-1-infected individuals.

Changes in 1,25-dihydroxyvitamin D and 25-hydroxyvitamin D are associated with maturation of regulatory T lymphocytes in patients with chronic pancreatitis: a randomized controlled trial.

OBJECTIVES: We studied the impact of changes in 25-hydroxyvitamin D (25OHD) and 1,25-dihydroxyvitamin D (1,25(OH)(2)D) on regulatory T lymphocytes (Tregs) in patients with chronic pancreatitis (CP) and fat malabsorption in a prospective clinical trial. METHODS: The patients were randomized to 1 of 3 treatments during 10 weeks: weekly UV-B in a tanning bed (group A), 1520-IU/d vitamin D supplement (group B), or placebo (group C). A placebo tanning bed was used in groups B and C. We determined the levels of CD4 Tregs (CD3(+)CD4(+)CD25(+)CD127(low)FoxP3(+)) and CD8(+) Tregs (CD3(+)CD8(+)CD25(+)CD127(low)FoxP3(+)), together with 25OHD and 1,25(OH)2D. For baseline comparisons, we included 8 healthy individuals. Of the 30 included patients, 27 (group A, 7 patients; group B, 9 patients; and group C, 11 patients) completed the protocol. RESULTS: The baseline levels of CD4(+) Tregs relative to total CD4(+) count were higher in 22 patients with CP compared with healthy controls (2.8% vs 1.9%, P < 0.05) and were comparable for CD8+ Tregs (0.13% vs 0.05%, P = 0.3). Increases in levels of CD4(+) Tregs correlated to changes in 1,25(OH)(2)D (2% per 100 pmol/L, P = 0.002) and 25OHD (3% per 100 nmol/L, P = 0.01). CONCLUSIONS: Patients with CP have elevated relative levels of CD4(+) Tregs. Increases in 25OHD and 1,25(OH)(2)D were both related with increases in levels of Tregs.

Low level of regulatory T cells and maintenance of balance between regulatory T cells and TH17 cells in HIV-1-infected elite controllers.

BACKGROUND: A subgroup of HIV-1-infected individuals, elite controllers, have spontaneous viral control and offer an exceptional opportunity to study virological and immunolocigal factors of possible involvement in control of HIV-1 infection. METHODS: The frequencies of Tregs and TH17 cells was evaluated and correlated to markers of disease progression in peripheral blood mononuclear cells from 3 different groups of individuals infected with HIV-1: treatment-naive viremic individuals, individuals on successful highly active antiretroviral therapy, and elite controllers. In addition, a group of HIV-1-negative individuals were included. RESULTS: We demonstrate that elite controllers have lower levels of Tregs compared with HIV-1-infected viremic individuals, but that the low Treg level does not differ between individuals with HIV-1 control, whether natural or therapy induced. We also show that T-cell activation and proliferation both correlate to the level of Tregs. Finally, the TH17/Treg ratio was similar in Elite Controllers and uninfected controls, whereas in viremic and treated HIV-1-infected individuals, the TH17/Treg ratio was lower compared with uninfected controls. CONCLUSIONS: We show that one feature of spontaneous HIV-1 control is a maintained balance between regulatory T cells and TH17 cells.