Medicare meets the cloud: the development of a secure platform for the storage and analysis of claims data.

Introduction: Cloud-based solutions are a modern-day necessity for data intense computing. This case report describes in detail the development and implementation of Amazon Web Services (AWS) at Emory-a secure, reliable, and scalable platform to store and analyze identifiable research data from the Centers for Medicare and Medicaid Services (CMS). Materials and Methods: Interdisciplinary teams from CMS, MBL Technologies, and Emory University collaborated to ensure compliance with CMS policy that consolidates laws, regulations, and other drivers of information security and privacy. Results: A dedicated team of individuals ensured successful transition from a physical storage server to a cloud-based environment. This included implementing access controls, vulnerability scanning, and audit logs that are reviewed regularly with a remediation plan. User adaptation required specific training to overcome the challenges of cloud computing. Conclusion: Challenges created opportunities for lessons learned through the creation of an end-product accepted by CMS and shared across disciplines university-wide.

Enhancing the Stability and Efficiency of Inverted Perovskite Solar Cells with a Mixed Ammonium Ligands Passivation Strategy.

The perovskite solar cell (PSC), which has achieved efficiencies of more than 26%, is expected to be a promising technology that can alternate silicon-based solar cells. However, the performance of PSCs is still limited due to defects and ion migration that occur at the large number of grain boundaries present in perovskite thin films. In this study, the mixed ammonium ligands passivation strategy (MAPS) is demonstrated, which combines n-octylammonium iodide (OAI) and 1,3-diaminopropane (DAP) can effectively suppress the grain boundary defects and ion migration through grain boundaries by the synergistic effect of OAI and DAP, resulting in improved efficiency and stability of PSCs. It has also been revealed that MAPS not only enhances crystallinity and reduces grain boundaries but also improves charge transport while suppressing charge recombination. The MAPS-based opaque PSC shows the best power conversion efficiency (PCE) of 21.29% with improved open-circuit voltage (VOC ) and fill factor (FF), and retained 84% of its initial PCE after 1900 h at 65 °C in N2 atmosphere. Amazingly, the MAPS-based semi-transparent PSC (STP-PSC) retained 94% of their maximum power (21.00% at around 10% AVT) after 1000 h under 1 sun illumination and MAPS-based perovskite submodule (PSM) achieved a PCE of 19.59%, which is among the highest values reported recently.

Autonomic responses during bladder hydrodistention under general versus spinal anaesthesia in patients with interstitial cystitis/bladder pain syndrome: a randomized clinical trial.

Blocking the abrupt increase in systolic blood pressure associated with autonomic response during bladder hydrodistention in patients with interstitial cystitis/bladder pain syndrome (IC/BPS) is essential for patient safety. We conducted this study to compare autonomic responses during bladder hydrodistention in patients with IC/BPS under general and spinal anaesthesia. Thirty-six patients were randomly allocated to a general anaesthesia (GA, n = 18) or a spinal anaesthesia (SA, n = 18) group. Blood pressure and heart rate were measured continuously and ΔSBP, defined as maximum increases in SBP during bladder hydrodistention from baseline, was compared between groups. Heart rate variability was analysed using electrocardiograms. The post-anaesthesia care unit assessed postoperative pain using a numeric (0-10) rating scale. Our analyses yield a significantly greater ΔSBP (73.0 [26.0-86.1] vs. 2.0 [- 4.0 to 6.0] mmHg), a significantly lower root-mean-square of successive differences in heart rate variability after bladder hydrodistention (10.8 [7.7-19.8] vs. 20.6 [15.1-44.7] ms), and significantly higher postoperative pain scores (3.5 [0.0-5.5] vs. 0.0 [0.0-0.0]) in the GA compared to the SA group. These findings suggest that SA has advantages over GA for bladder hydrodistention in preventing an abrupt increase in SBP and postoperative pain in IC/BPS patients.

Effective Removal of Acetaldehyde Using Piperazine/Nitric Acid Co-Impregnated Bead-Type Activated Carbon.

Acetaldehyde (CH3CHO) in the atmosphere is associated with adverse health effects. Among the various options for use in removing CH3CHO, adsorption is often employed because of its convenient application and economical processes, particularly when using activated carbon. In previous studies, the surface of activated carbon has been modified with amines to remove CH3CHO from the atmosphere via adsorption. However, these materials are toxic and can have harmful effects on humans when the modified activated carbon is used in air-purifier filters. Therefore, in this study, a customized bead-type activated carbon (BAC) with surface modification options via amination was evaluated for removing CH3CHO. Various amounts of non-toxic piperazine or piperazine/nitric acid were used in amination. Chemical and physical analyses of the surface-modified BAC samples were performed using Brunauer-Emmett-Teller measurements, elemental analyses, and Fourier transform infrared and X-ray photoelectron spectroscopy. The chemical structures on the surfaces of the modified BACs were analyzed in detail using X-ray absorption spectroscopy. The amine and carboxylic acid groups on the surfaces of the modified BACs are critical in CH3CHO adsorption. Notably, piperazine amination decreased the pore size and volume of the modified BAC, but piperazine/nitric acid impregnation maintained the pore size and volume of the modified BAC. In terms of CH3CHO adsorption, piperazine/nitric acid impregnation resulted in a superior performance, with greater chemical adsorption. The linkages between the amine and carboxylic acid groups may function differently in piperazine amination and piperazine/nitric acid treatment.

Toward ensuring care quality and safety across settings: examining time pressure in a nursing home with observational time motion study metrics based on the Omaha system.

BACKGROUND: Meaningful data to determine safe and efficient nursing workload are needed. Reasoning a nurse can accomplish a finite number of interventions and location changes per hour, examination of time pressure using time motion study (TMS) methods will provide a comparable indication of safe and efficient workload for an individual nurse. METHODS: An observer shadowed 11 nurses at a 250-bed nursing home in the Southeastern United States and recorded 160 h of observations using TimeCaT, web-based TMS data recording software. Predefined Omaha System nursing interventions (N = 57) and locations (N = 8) were embedded within TimeCaT. The time-stamped data were downloaded from TimeCaT and analyzed using descriptive and inferential statistics. Five time pressure metrics were derived from previous TMS findings in acute care settings. RESULTS: Overall, nurses spent 66 s for each intervention, performed 65 interventions per hour, stayed 130 s at each location, changed locations 28 times per hour, and multitasked for 29% of working time. Computed hourly time pressure metrics enabled visualization of variability in time pressure metrics over time, with differences in multitasking by licensure, unit/role, and observation session time. CONCLUSIONS: Nursing home nurses consistently experienced a high degree of time pressure, especially multitasking for one-third of their working time. To inform staffing decision making and improve the quality of care, resident outcomes, and nurse satisfaction, it is critical to identify ways to mitigate time pressure. Additional research is needed to refine and extend the use of the time pressure metrics.

Nurse Work Environment and Hospital-Onset Clostridioides difficile Infection.

BACKGROUND: Clostridioides difficile is the leading cause of hospital-onset diarrhea and is associated with increased lengths of stay and mortality. While some hospitals have successfully reduced the burden of C. difficile infection (CDI), many still struggle to reduce hospital-onset CDI. Nurses-because of their close proximity to patients-are an important resource in the prevention of hospital-onset CDI. OBJECTIVE: Determine whether there is an association between the nurse work environment and hospital-onset CDI. METHODS: Survey data of 2016 were available from 15,982 nurses employed in 353 acute care hospitals. These data, aggregated to the hospital level, provided measures of the nurse work environments. They were merged with 2016 hospital-onset CDI data from Hospital Compare, which provided our outcome measure-whether a hospital had a standardized infection ratio (SIR) above or below the national average SIR. Hospitals above the average SIR had more infections than predicted when compared to the national average. RESULTS: In all, 188 hospitals (53%) had SIRs higher than the national average. The odds of hospitals having higher than average SIRs were significantly lower, with odds ratios ranging from 0.35 to 0.45, in hospitals in the highest quartile for all four nurse work environment subscales (managerial support, nurse participation in hospital governance, physician-nurse relations, and adequate staffing) than in hospitals in the lowest quartile. CONCLUSIONS: Findings show an association between the work environment of nurses and hospital-onset CDI. A promising strategy to lower hospital-onset CDI and other infections is a serious and sustained commitment by hospital leaders to significantly improve nurse work environments.

Interventions Employed By Licensed Nurses in Nursing Homes: Refinement and Validation of an Existing Omaha System Nursing Intervention Set.

Background and Purpose: Demands on long-term services and supports for older adults are growing, although geriatric workforce shortages have persisted for decades. Methods to define and quantify practice of licensed nurses in nursing homes are needed for work optimization within limited nurse resources available in nursing homes. This study aimed to refine and validate observable nursing interventions for nursing homes, using the Omaha System. Methods: Based on the existing corpus of Omaha System interventions for acute care nursing, this multi-phase, multi-method study included a mapping procedure of interviews from licensed nurses in nursing homes, the evaluation of content validity and coding of the interventions using a survey, and inter-observer reliability assessment using TimeCaT. Results: This study validated 57 observable interventions for nursing homes. Of the previously identified acute care nursing interventions, eight interventions were deemed out of scope. One additional intervention was identified. Refined intervention definitions were related to procedures common in acute care settings such as tracheal intubations/extubations and nasogastric tube insertion that were not performed in nursing homes. Expert agreement for content validity and coding of the interventions was high (S-CVI = 0.97), and inter-observer reliability levels (Cohen's κ value >0.4; proportion agreement >60%) were acceptable for all case studies. Implications for Practice: The validated observable Omaha System nursing interventions for nursing home practice have potential for use in future studies of nursing home practice to understand evidence-based practice, and gaps in care provided. The methodology may be extended to define observable interventions for other roles and settings.

Nationwide monitoring of cyclic and linear siloxanes in sediment and bivalves from Korean coastal waters: Occurrence, geographical distribution, and bioaccumulation potential.

Contamination of coastal environments by siloxanes is of growing concern. Sediment and bivalves were collected from 50 locations along the Korean coast to assess the geographical distribution, sources, and bioaccumulation potential of siloxanes. Cyclic and linear siloxanes were detectable in all sediment and bivalve samples. The highest siloxane concentrations were detected in sediment (656 ng/g dw) and bivalves (3273 ng/g dw) from highly industrialized bays and harbor-zones, suggesting that industrial and shipping activities are major sources of siloxanes in coastal environment. The geographical distribution of siloxanes was similar in sediment and bivalves. Sedimentary siloxanes were dominated by cyclic siloxanes, while linear siloxanes were predominant in bivalves. Bioaccumulation of linear siloxanes in bivalves originated mainly from the sedimentary environment. Mean biota-sediment accumulation factors (BSAFs) of seven siloxanes ranged from 1.26 to 6.03, indicating potential for bioaccumulation. This is the first report on the nationwide survey on siloxanes in Korean coastal waters.

INTERPROFESSIONAL ROLES AND COLLABORATIONS TO ADDRESS COVID-19 PANDEMIC CHALLENGES IN NURSING HOMES.

Nursing home experts and informatics nurses collaborated to develop guidelines for nursing homes that revealed partnership principles in action during the COVID-19 pandemic. This article describes efforts to define interprofessional nursing home staff roles within the partnership-based COVID-19 Response Guideline, and to examine changes in nursing practice compared to the pre-pandemic practice of nurses. The qualitative process of identification of nursing home staff roles revealed the extensive scope of interprofessional partnership needed to respond to the pandemic. Using the Omaha System structure, we compared these collective COVID-19 response interventions of Nursing Service roles with nursing interventions of RNs and LPN/LVNs defined in previous nursing home studies. This comparison showed the necessary transformation and collaboration among nurses needed for the pandemic response in nursing homes. The Omaha System Pandemic Guideline is available online and in the Omaha System Guidelines app for immediate use as COVID-19 response practice guidelines and references for interprofessional roles in nursing homes, as well as for multidisciplinary roles across diverse care settings. The guideline is an exemplar of how informatics can facilitate interprofessional and multidisciplinary partnership for nursing homes and other care settings. Future use of the guidelines for decision making and documentation related to infection prevention and control in nursing homes may improve care quality and health outcomes of residents and population.

Refinement, reliability and validity of the Time Capture Tool (TimeCaT) using the Omaha System to support data capture for time motion studies.

AIM: To refine and assess the inter-rater reliability and content validity of the embedded interface of nursing/midwifery activities in the Time Capture Tool (TimeCaT) using an interface terminology, the Omaha System. METHODS: This methodological study was conducted in two Family Health Centers (FHCs) in Turkey with a total of 13 nurses and midwives. In phase one, five nurses/midwives in a FHC were observed for a total of 80 hr, and 84 nursing/midwifery activities were generated and validated with 15 content experts. In phase two, the nursing/midwifery activities were mapped to the Omaha System and inter-rater reliability of the mapping was assessed. The mapping was validated with seven content experts. The nursing/midwifery activities were embedded in the interface of the TimeCaT. In phase three, the embedded interface of the TimeCaT was evaluated while observing eight nurses and midwives in the other FHC. RESULTS: The scale-level content validity index was 0.98 for the generated activities in phase one and 0.96 for the mapped activities in phase two. Kappa statistics for inter-rater reliability was 0.88 for Omaha System problems, 0.83 for categories and 0.83 for targets. The nursing/midwifery activities were adequately mapped to the Omaha System. The embedded interface of the TimeCaT has acceptable inter-rater reliability and content validity values for using in the Turkish FHC context. CONCLUSION: The study results confirm that the TimeCaT using the Omaha System is a valid and reliable tool to measure nursing/midwifery workflow in FHC settings.

BCG instillation versus radical cystectomy for high-risk NMIBC with squamous/glandular histologic variants.

This study aims to evaluate the effect of Bacillus Calmette-Guérin (BCG) instillation and radical cystectomy on high-risk NMIBC with squamous or glandular variants. We retrospectively reviewed the data of high-risk (T1 or CIS or HG or TaG1/G2 with multiple, recurrent, large tumor) NMIBC patients from January 2000 to December 2017. Comparative analysis of radical cystectomy, intravesical BCG, and observation groups was conducted in high-risk NMIBC with squamous or glandular histologic variants. Among the 1263 high-risk NMIBC patient, 62 (4.9%) were reported squamous or glandular histologic variants. Thirty patients underwent BCG instillation and 15 patients were subjected to radical cystectomy. Statistically significant differences were found between the three treatment groups in terms of underlying hypertension (p = 0.031), T stage (p = 0.022) and tumor multiplicity (p = 0.019). Similar 5-year OS (p = 0.893) and CSS (p = 0.811) were observed in each of BCG instillation and radical cystectomy group. BCG instillation showed survival benefit in both OS (p = 0.019) and CSS (p = 0.038) than in the observation group. In high-risk patients diagnosed with NMIBC bladder cancer with squamous or glandular histologic variants, both intravesical BCG and radical cystectomy showed survival gain. In conclusion, BCG instillation represents an appropriate treatment option in high-risk NMIBC with squamous or glandular histologic variant.

A wide variation of the quality of colonoscopy reporting system in the real clinical practice in southeastern area of Korea.

BACKGROUND/AIMS: Establishment of a colonoscopy reporting system is a prerequisite to determining and improving quality. This study aimed to investigate colonoscopists' opinions and the actual situation of a colonoscopy reporting system in a clinical practice in southeastern area of Korea and to assess the factors predictive of an inadequate reporting system. METHODS: Physicians who performed colonoscopies in the Daegu-Gyeongbuk province of Korea and were registered with the Korean Society of Gastrointestinal Endoscopy (KSGE) were interviewed via mail about colonoscopy reporting systems using a standardized questionnaire. RESULTS: Of 181 endoscopists invited to participate, 125 responded to the questionnaires (response rate, 69%). Most responders were internists (105/125, 84%) and worked in primary clinics (88/125, 70.4%). Seventy-one specialists (56.8%) held board certifications for endoscopy from the KSGE. A median of 20 colonoscopies (interquartile range, 10-47) was performed per month. Although 88.8% of responders agreed that a colonoscopy reporting system is necessary, only 18.4% (23/125) had achieved the optimal reporting system level recommended by the Quality Assurance Task Group of the National Colorectal Cancer Roundtable. One-third of endoscopists replied that they did not use a reporting document for the main reasons of "too busy" and "inconvenience." Non-endoscopy specialists and primary care centers were independent predictive factors for failure to use a colonoscopy reporting system. CONCLUSIONS: The quality of colonoscopy reporting systems varies widely and is considerably suboptimal in actual clinical practice settings in southeastern Korea, indicating considerable room for quality improvements in this field.

3-V Solid-State Flexible Supercapacitors with Ionic-Liquid-Based Polymer Gel Electrolyte for AC Line Filtering.

State-of-the-art solid-state flexible supercapacitors with sufficiently fast response speed for AC line filtering application suffer from limited energy density. One of the main causes of the low energy density is the low cell voltage (1 V), which is limited by aqueous-solution-based gel electrolytes. In this work, we demonstrate for the first time a 3-V flexible supercapacitor for AC line filtering based on an ionic-liquid-based polymer gel electrolyte and carbon nanotube electrode material. The flexible supercapacitor exhibits an areal energy density that is more than 20 times higher than that of the previously demonstrated 1-V flexible supercapacitor (0.66 vs 0.03 µWh/cm(2)) while maintaining excellent capacitive behavior at 120 Hz. The supercapacitor shows a maximum areal power density of 1.5 W/cm(2) and a time constant of 1 ms. The improvement of the cell voltage while maintaining the fast-response capability greatly improves the potential of supercapacitors for high-frequency applications in wearable and/or portable electronics.

Old age at diagnosis is associated with favorable outcomes in korean patients with inflammatory bowel disease.

BACKGROUND/AIMS: Despite the rising incidence and prevalence of inflammatory bowel disease (IBD) in Asian populations, data regarding clinical characteristics of patients in Asia based on age at diagnosis are relatively sparse. The aim of this study was to compare clinical characteristics based on the age at diagnosis according to the Montreal Classification in Korean IBD patients. METHODS: We recruited consecutive patients with IBD at two tertiary hospitals and retrospectively reviewed their medical information. Patients were divided into three groups according to their age at diagnosis: youth (<17 years), young adult (17-40 years), and middle-old (>40 years). The main clinical characteristics for comparison were the achievement of a remission state at the last follow-up visit, cumulative rate of surgery, and cumulative use of immunomodulators and tumor necrosis factor-α (TNFα) blockers during the follow-up period. RESULTS: In total, 346 IBD patients were included (Crohn's disease [CD] 146 and ulcerative colitis 200; 36 youth, 202 young adult, and 113 middle-old). The middle-old group with CD was characterized by a predominance of uncomplicated behavior (P=0.013) and a lower frequency of perianal disease (P=0.009). The middle-old group was associated more with a less aggressive disease course than the younger group, as shown by more frequent remission (P=0.004), being less likely to undergo surgery (P<0.001), and lower cumulative use of immunomodulators and TNFα blockers (P<0.001). CONCLUSIONS: Age at diagnosis according to the Montreal Classification is an important prognostic factor for Korean IBD patients.

Is the environment of the endoscopy unit a reservoir of pathogens?

BACKGROUND/AIMS: Given the characteristic procedures involved in the endoscopy unit, the spread of pathogens is much more frequent in this unit than in other environments. However, there is a lack of data elucidating the existence of pathogens in the endoscopy unit. The aim of this study was to detect the presence of possible pathogens in the endoscopy unit. METHODS: We performed environmental culture using samples from the endoscopy rooms of 2 tertiary hospitals. We used sterile cotton-tipped swabs moistened with sterile saline to swab the surfaces of 197 samples. Then, we cultured the swab in blood agar plate. Samples from the colonoscopy room were placed in thioglycollate broth to detect the presence of anaerobes. After 2 weeks of culture period, we counted the colony numbers. RESULTS: The most commonly contaminated spots were the doctor's keyboard, nurse's cart, and nurse's mouse. The common organisms found were non-pathogenic bacterial microorganisms Staphylococcus, Micrococcus, and Streptococcus spp.. No definite anaerobe organism was detected in the colonoscopy room. CONCLUSIONS: Although the organisms detected in the endoscopy unit were mainly non-pathogenic organisms, they might cause opportunistic infections in immunocompromised patients. Therefore, the environment of the endoscopy room should be managed appropriately; moreover, individual hand hygiene is important for preventing possible hospital-acquired infections.

Vesicoenteric fistula due to bladder squamous cell carcinoma.

Vesicoenteric fistula is a rare complication of bladder squamous cell carcinoma. We report the case of a 70-year-old male who complained of painless, total gross hematuria. Abdominopelvic computed tomography (CT) revealed an approximately 2.7-cm lobulated and contoured enhancing mass in the bladder dome. We performed partial cystectomy of the bladder dome after transurethral resection of the bladder. The biopsy result was bladder squamous cell carcinoma, with infiltrating serosa histopathologically, but the resection margin was free. Postoperatively, follow-up CT was done after 3 months. Follow-up CT revealed an approximately 4.7-cm×4.0-cm lobulated, contoured, and heterogeneous mass in the bladder dome. A vesicoenteric fistula was visible by cystography. Here we report this case of a vesicoenteric fistula due to bladder squamous cell carcinoma.

Efficacy of Bicalutamide 150-mg Monotherapy Compared With Combined Androgen Blockade in Patients With Locally Advanced Prostate Cancer.

PURPOSE: We compared the efficacy, survival rate, and adverse events between bicalutamide 150-mg monotherapy and combined androgen blockade (CAB) in men with locally advanced prostate cancer. MATERIALS AND METHODS: From March 2003 to July 2012, we retrospectively included 74 patients who were treated for more than 3 months and were followed up for more than 6 months. 25 men were treated with bicalutamide 150-mg only (group 1) and 49 men received CAB (group 2). Serum prostate-specific antigen (PSA) change, survival rate, and adverse events were compared between the 2 groups. RESULTS: The PSA levels before and after treatment were 37.0±32.8 ng/mL and 9.5±27.0 ng/mL in group 1 (p<0.001) and 50.2±40.0 ng/mL and 20.0±35.8 ng/mL in group 2 (p<0.001). Mean survival rates were 78.9% in group 1 and 52.3% in group 2 (p=0.055). There were no statistically significant differences in adverse events between the 2 groups (p=0.304). The International Index of Erectile Function 5 (IIEF-5) score before treatment was 19.3±5.9 in group 1 and 18.3±5.8 in group 2 (p=0.487). The IIEF-5 score after treatment was 17.1±6.3 in group 1 and 14.0±6.1 in group 2, which was a statistically significant difference (p=0.036). CONCLUSIONS: The PSA change, mean survival rate, and adverse events in patients with locally advanced prostate cancer treated with bicalutamide 150-mg and CAB did not differ significantly. However, sexual function was better in the bicalutamide 150-mg group. Therefore, bicalutamide 150-mg monotherapy could be considered as a treatment for locally advanced prostate cancer in patients concerned about sexual function.

Single-walled carbon nanotubes alter soil microbial community composition.

Recent developments in nanotechnology may lead to the release of nanomaterials into the natural environment, such as soils, with largely unknown consequences. We investigated the effects of single-walled carbon nanotubes (SWCNTs), one of the most widely used nanomaterials, on soil microbial communities by incubation of soils to which powder or suspended forms of SWCNTs were added (0.03 to 1 mg g(-1) soil). To determine changes in soil microbial community composition, phospholipid fatty acid (PLFA) profiles were analyzed at 25th day of the incubation experiment. The biomass of major microbial groups including Gram-positive and Gram-negative bacteria, and fungi showed a significant negative relationship with SWCNT concentration, while the relative abundance of bacteria showed a positive relationship with SWCNT concentration. Furthermore, soils under distinct concentrations of SWCNT treatments had PLFA profiles that were significantly different from one another. Our results indicate that the biomass of a broad range of soil microbial groups is negatively related with SWCNT concentration and upon entry into soils, SWCNTs may alter microbial community composition. Our results may serve as foundation for scientific guideline on regulating the discharge of nanomaterials such as SWCNTs to the soil ecosystem.

Fabrication of a stretchable solid-state micro-supercapacitor array.

We fabricated a stretchable micro-supercapacitor array with planar SWCNT electrodes and an ionic liquid-based triblock copolymer electrolyte. The mechanical stability of the entire supercapacitor array upon stretching was obtained by adopting strategic design concepts. First, the narrow and long serpentine metallic interconnections were encapsulated with polyimide thin film to ensure that they were within the mechanical neutral plane. Second, an array of two-dimensional planar micro-supercapacitor with SWCNT electrodes and an ion-gel-type electrolyte was made to achieve all-solid-state energy storage devices. The formed micro-supercapacitor array showed excellent performances which were stable over stretching up to 30% without any noticeable degradation. This work shows the strong potential of a stretchable micro-supercapacitor array in applications such as wearable computers, power dressing, electronic newspapers, paper-like mobile phones, and other easily collapsible gadgets.