Sepsis in Home Health Care: Screening, Education, and Rapid Triage.

BACKGROUND: A majority of sepsis cases originate in the home and community. Home health clinicians play an important role in the early identification and timely treatment of sepsis. LOCAL PROBLEM: A home health care provider sought to prevent hospital readmissions due to sepsis by implementing a sepsis-screening protocol and quality improvement initiative. METHODS: The provider conducted a retrospective chart review of 33 264 sepsis screens of 7242 patients. INTERVENTIONS: A sepsis-screening protocol, clinician and patient/caregiver sepsis education, physician and emergency department communication, and emergency medical services collaboration procedure were implemented. RESULTS: A majority (69.2%) of positive sepsis screens resulted in patients receiving early medical intervention and avoiding hospitalization. CONCLUSIONS: Having a formal sepsis-screening program in place prompts home health clinicians to communicate the patient's symptoms to their primary care provider, which can positively impact hospital readmission rates and associated medical costs.

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

(Reprinted with permission from Am J Psychiatry 2018; 175:86-90).

The Transcription Factors COUP-TFI and COUP-TFII have Distinct Roles in Arealisation and GABAergic Interneuron Specification in the Early Human Fetal Telencephalon.

In human telencephalon at 8-12 postconceptional weeks, ribonucleic acid quantitative sequencing and immunohistochemistry revealed cortical chicken ovalbumin upstream promotor-transcription factor 1 (COUP-TFI) expression in a high ventro-posterior to low anterior gradient except for raised immunoreactivity in the anterior ventral pallium. Unlike in mouse, COUP-TFI and SP8 were extensively co-expressed in dorsal sensory neocortex and dorsal hippocampus whereas COUPTFI/COUPTFII co-expression defined ventral temporal cortex and ventral hippocampus. In the ganglionic eminences (GEs) COUP-TFI immunoreactivity demarcated the proliferative zones of caudal GE (CGE), dorsal medial GE (MGE), MGE/lateral GE (LGE) boundary, and ventral LGE whereas COUP-TFII was limited to ventral CGE and the MGE/LGE boundary. Co-labeling with gamma amino butyric acidergic interneuron markers revealed that COUP-TFI was expressed in subpopulations of either MGE-derived (SOX6+) or CGE-derived (calretinin+/SP8+) interneurons. COUP-TFII was mainly confined to CGE-derived interneurons. Twice as many GAD67+ cortical cells co-labeled for COUP-TFI than for COUP-TFII. A fifth of COUP-TFI cells also co-expressed COUP-TFII, and cells expressing either transcription factor followed posterior or anterio-lateral pathways into the cortex, therefore, a segregation of migration pathways according to COUP-TF expression as proposed in mouse was not observed. In cultures differentiated from isolated human cortical progenitors, many cells expressed either COUP-TF and 30% also co-expressed GABA, however no cells expressed NKX2.1. This suggests interneurons could be generated intracortically from progenitors expressing either COUP-TF.

PRISM-E: comparison of integrated care and enhanced specialty referral models in depression outcomes.

OBJECTIVE: This study, entitled Primary Care Research in Substance Abuse and Mental Health for the Elderly, examined six-month outcomes for older primary care patients with depression who received different models of treatment. METHODS: Clinical outcomes were compared for patients who were randomly assigned to integrated care or enhanced specialty referral. Integrated care consisted of mental health services co-located in primary care in collaboration with primary care physicians. Enhanced specialty referral consisted of referral to physically separate, clearly identified mental health or substance abuse clinics. RESULTS: A total of 1,531 patients were included; their mean age was 73.9 years. Remission rates and symptom reduction for all depressive disorders were similar for the two models at the three- and six-month follow-ups. For the subgroup with major depression, the enhanced specialty referral model was associated with a greater reduction in depression severity than integrated care, but rates of remission and change in function did not differ across models of care for major depression. CONCLUSIONS: Six-month outcomes were comparable for the two models. For the subgroup with major depression, reduction in symptom severity was superior for those randomly assigned to the enhanced specialty referral group.

Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use.

OBJECTIVE: The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. METHOD: This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N=70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). RESULTS: Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. CONCLUSIONS: Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.