A Retrospective Cohort Study of the Impact of Nurse Practitioners on Hospitalized Patient Outcomes.

The role of advanced practice providers has expanded in the hospital setting. However, little data exist examining the impact of these providers. Our purpose was to determine the effect of adding nurse practitioners in a complementary role on the quality and efficiency of care of hospitalized patients. A retrospective cohort study evaluated adult patients admitted by private physicians (without house staff or non-physician providers) to a general medical-surgical unit in an academic medical center. The admissions department allocated patients as beds became available and nurse practitioners were assigned to patients until their caseload was reached. Outcomes included length of hospital stay, in-hospital mortality, admission costs, 30-day readmissions, transfer to a more intensive care level, and discharge order time. Of the 382 patients included in this study, 263 were assigned to the nurse practitioner group. Hospital mortality was lower in the nurse practitioner group [OR 0.11 (95% CI 0.02-0.51)] as was transfer to more intensive care level [OR 0.39 (95% CI 0.20-0.75)]; however, the nurse practitioner group had longer length of stay (geometric mean = 5.80 days for nurse practitioners, 3.63 days for no nurse practitioners; p < 0.0001) and higher cost per patient (geometric mean = USD 6631 vs. USD 5121; p = 0.005). The results were unchanged when models were adjusted for potential confounders. Adding nurse practitioners can yield improved clinical outcomes (lower hospital mortality and fewer transfers to intensive care), but with a potential economic expense (longer hospital stays and higher costs).

Smoking Cessation.

Tobacco smoking is the leading cause of preventable death in the United States, and its harms are well established. Physicians have more evidence-based resources than ever before to effectively treat smoking, including new uses and combinations of U.S. Food and Drug Administration-approved pharmacotherapies and expanded community programs. In addition, electronic nicotine delivery systems are potential treatment tools, but their safety and efficacy need to be established. Finally, high-priority groups, such as persons with cancer diagnoses or hospitalized patients, may benefit from particular attention to their tobacco use.

c-Myc-Dependent Cell Competition in Human Cancer Cells.

Cell Competition is an interaction between cells for existence in heterogeneous cell populations of multicellular organisms. This phenomenon is involved in initiation and progression of cancer where heterogeneous cell populations compete directly or indirectly for the survival of the fittest based on differential gene expression. In Drosophila, cells having lower dMyc expression are eliminated by cell competition through apoptosis when present in the milieu of cells having higher dMyc expression. Thus, we designed a study to develop c-Myc (human homolog) dependent in vitro cell competition model of human cancer cells. Cells with higher c-Myc were transfected with c-myc shRNA to prepare cells with lower c-Myc and then co-cultured with the same type of cells having a higher c-Myc in equal ratio. Cells with lower c-Myc showed a significant decrease in numbers when compared with higher c-Myc cells, suggesting "loser" and "winner" status of cells, respectively. During microscopy, engulfment of loser cells by winner cells was observed with higher expression of JNK in loser cells. Furthermore, elimination of loser cells was prevented significantly, when co-cultured cells were treated with the JNK (apoptosis) inhibitor. Above results indicate elimination of loser cells in the presence of winner cells by c-Myc-dependent mechanisms of cell competition in human cancer cells. This could be an important mechanism in human tumors where normal cells are eliminated by c-Myc-overexpressed tumor cells. J. Cell. Biochem. 118: 1782-1791, 2017. © 2016 Wiley Periodicals, Inc.

Implementation of a Mini-CEX Requirement Across All Third-Year Clerkships.

PROBLEM: Direct observation of medical students performing clinical tasks, such as eliciting a patient history or examining a patient, and the provision of feedback, are foundational to student improvement but have been reported to occur infrequently. The mini clinical evaluation exercise (mini-CEX) is a tool that can facilitate direct observation and feedback. This study assessed the impact of a mini-CEX requirement across all 3rd-year clerkships on student report of direct observation by faculty and objectively measured clinical skills. INTERVENTION: A mini-CEX requirement across all 3rd-year clerkships was implemented in the 2012-2013 academic year. The impact of the mini-CEX requirement on student report of direct observation was assessed by end-of-clerkship surveys and Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) items on direct observation. The impact on students' clinical skills was assessed by a summative Objective Structured Clinical Examination (OSCE). Pre/post comparisons were assessed with chi-square and Fisher's exact tests. CONTEXT: A mini-CEX requirement had been in place for the internal medicine clerkship, and student reports of direct observation were historically higher for the internal medicine clerkship than for other clerkships. Faculty, residents, and students at each of the clinical sites across all 6 clerkships were oriented to the use of the mini-CEX; the feasibility of its use during usual patient interaction settings and the importance of direct observation and feedback for student improvement were emphasized during these sessions. OUTCOME: Adherence to the mini-CEX requirement was high: 92% of required forms were completed, and 78% of completed forms indicated that specific feedback was given. The proportion of students reporting direct observation of physical examination significantly increased in all clerkships, with the largest relative increase occurring in surgery (from 49% to 87%), χ2(1, N = 225) = 37.70, p < .0001. Significant increases were seen in faculty observation of history taking in pediatrics, surgery, and psychiatry. Direct observation rates also increased on the AAMC GQ items for history taking and physical exam for all clerkships. Failures on the summative OSCE decreased from 12% preintervention to 2% postintervention (p = .0046). LESSONS LEARNED: Institution of a mini-CEX requirement was feasible across all 3rd-year clerkships and was associated with a significant increase in student report of direct observation by faculty and a decrease in summative OSCE failure rates.

In the Clinic. Smoking Cessation.

This issue provides a clinical overview of smoking cessation, focusing on health consequences of smoking, prevention of smoking-related disease, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Antitumor activity of Pogostemon benghalensis Linn. on ehrlich ascites carcinoma tumor bearing mice.

BACKGROUND: Pogostemon benghalensis has been used traditionally as anticancer in India. AIM OF THE STUDY: The present study was undertaken to investigate the antitumor activity of hydroethanolic extract of P. benghalensis (HEEPB) and aqueous extract of P. benghalensis (AEPB) on ehrlich ascites carcinoma (EAC) tumor bearing mice. MATERIALS AND METHODS: For antitumor effect, treatments with HEEPB and AEPB at doses of 250 mg/kg and 500 mg/kg/day orally were started after 24 h of intraperitoneal inoculation of EAC cells. After the treatment period, median survival time (MST), hematological parameters and solid tumor volume were used to evaluate antitumor activity of the extracts. RESULTS: Both, HEEPB and AEPB, have increased MST (P<0.05), reduced solid tumor volume (P<0.05) and normalized hematological parameters (P<0.05) significantly. CONCLUSION: As HEEPB and AEPB were effective in reducing the severity of morphological and biochemical parameters induced by EAC cells, this study justifies the traditional use of this plant in cancer.

Evidence review: periprocedural use of blood products.

Blood product transfusion has not been subject to rigorous clinical study, and great practice variations exist. Of particular concern to hospitalists is the use of red blood cells, plasma, and platelets prior to invasive procedures to correct anemia or perceived bleeding risk. We summarize the known risks associated with periprocedural anemia, prolonged international normalized ratio (INR), and thrombocytopenia, as well as the effects of blood product administration on clinical outcomes. Clinical trial evidence argues for a restrictive red blood cell transfusion threshold (a hemoglobin level of 7-8 g/dL or symptomatic anemia) for most perioperative patients. There are no high-quality data to guide plasma and platelet transfusions around the time of procedures. Available data do not support the use of prothrombin time/INR to guide prophylactic administration of plasma, and there are scarce data to guide platelet use around the time of an invasive procedure. Therefore, we rely on current consensus expert opinion, which recommends administration of plasma in moderate- to high-risk procedures when INR is >1.5. We recommend platelet transfusion in low-risk procedures when platelet count is <20,000/µL, for average-risk procedures when platelet count is <50,000/µL, and for procedures involving the central nervous system when the platelet count is <100,000/µL.

Medical complications of obesity and optimization of the obese patient for colorectal surgery.

Obesity is a medical epidemic with an enormous impact on disease prevalence and health care utilization. In the preoperative period, an awareness of medical issues associated with obesity is an important part of the planning for surgical procedures. The authors highlight the diagnostic and treatment options for medical conditions commonly affecting the obese patient including diabetes, hypertension, coronary artery disease, and deep venous thrombosis.

Anemia in the preoperative patient.

Anemia is commonly encountered in the preoperative patient. Determination of the cause of the anemia can affect perioperative surgical and medical management and outcome. Red blood cell transfusions are often administered during the perioperative time period in patients with preoperative anemia, although evidence to support the optimal transfusion threshold is limited. The authors review the evaluation of anemia and evidence regarding perioperative blood transfusions. Recommendations on the treatment of anemia, including perioperative blood transfusions, are outlined.

Anemia in the preoperative patient.

Anemia is commonly encountered in the preoperative patient. Determination of the cause of the anemia can affect perioperative surgical and medical management and outcome. Red blood cell transfusions are often administered during the perioperative time period in patients with preoperative anemia, although evidence to support the optimal transfusion threshold is limited. The authors review the evaluation of anemia and evidence regarding perioperative blood transfusions. Recommendations on the treatment of anemia, including perioperative blood transfusions, are outlined.