Improving Communication in Outpatient Consultations in People With Cirrhosis: The Development of a Question Prompt List (QPL).

BACKGROUND AND AIMS: Liver health professionals have difficulty discussing liver cirrhosis and its prognosis with patients and families. Question Prompt Lists (QPLs), which are evidence-based lists of "recommended questions," may improve communication but need to be designed specifically for the target population. This study aimed to develop and pilot a QPL for patients with cirrhosis. METHODS: A mixed-methods design in 3 phases. In phase 1 (item generation), potential questions for inclusion in the QPL were identified from 3 sources-a scoping literature review; an online survey; and interviews with patients, family members, and health professionals. In phase 2 (QPL construction), a multidisciplinary expert panel finalized the selection of questions and the format of the QPL. In phase 3 (pilot study), the QPL was assessed for acceptability and feasibility in a hepatology outpatient clinic population. RESULTS: From 258 topics initially identified, 30 questions were included in the first draft of the QPL. After review by a multidisciplinary expert panel including patients, the QPL was reduced to 22 questions. In the pilot study, 133/215 eligible patients consented to participate, although only 67/133 used the QPL in their clinic appointment. Among those who used the QPL, all questions were asked at least once. The most commonly asked question related to life expectancy. Most participants expressed support for the content of the QPL. CONCLUSIONS: A QPL, suitable for use in patients with liver cirrhosis attending hepatology outpatient clinics, has been developed and piloted. The QPL seems to be feasible to use and acceptable to patients and clinicians. Further work is needed to evaluate its effectiveness and to determine optimum delivery in clinical practice.

Preconception Paternal Stress in Rats Alters Brain and Behavior in Offspring.

Whereas environmental challenges during gestation have been repeatedly shown to alter offspring brain architecture and behavior, exploration examining the consequences of paternal preconception experience on offspring outcome is limited. The goal of this study was to examine the effects of preconception paternal stress (PPS) on cerebral plasticity and behavior in the offspring. Several behavioral assays were performed on offspring between postnatal days 33 (P33) and 101 (P101). Following behavioral testing, the brains were harvested and dendritic morphology (dendritic complexity, length, and spine density) were examined on cortical pyramidal cells in medial prefrontal cortex (mPFC), orbital frontal cortex (OFC), parietal cortex (Par1), and the CA1 area of the hippocampus. As anticipated, behavior was altered on both the activity box assay and elevated plus maze and performance was impaired in the Whishaw tray reaching task. Neuroanatomical measures revealed a heavier brain in stressed animals and dendritic changes in all regions measured, the precise effect varying with the measure and cerebral region. Thus, PPS impacted both behavior and neuronal morphology of offspring. These effects likely have an epigenetic basis given that in a parallel study of littermates of the current animals we found extensive epigenetic changes at P21.

Breast Implant-Associated Infections: The Role of the National Surgical Quality Improvement Program and the Local Microbiome.

BACKGROUND: The most common cause of surgical readmission after breast implant surgery remains infection. Six causative organisms are principally involved: Staphylococcus epidermidis and S. aureus, Escherichia, Pseudomonas, Propionibacterium, and Corynebacterium. The authors investigated the infection patterns and antibiotic sensitivities to characterize their local microbiome and determine ideal antibiotic selection. METHODS: A retrospective review of 2285 consecutive implant-based breast procedures was performed. Included surgical procedures were immediate and delayed breast reconstruction, tissue expander exchange, and cosmetic augmentation. Patient demographics, chemotherapy and/or irradiation status, implant characteristics, explantation reason, time to infection, microbiological data, and antibiotic sensitivities were reviewed. RESULTS: Forty-seven patients (2.1 percent) required inpatient admission for antibiotics, operative explantation, or drainage by interventional radiology. The infection rate varied depending on surgical procedure, with the highest rate seen in mastectomy and immediate tissue expander reconstruction (6.1 percent). The mean time to explantation was 41 days. Only 50 percent of infections occurred within 30 days of the indexed National Surgical Quality Improvement Program operation. The most commonly isolated organisms were coagulase-negative Staphylococcus (27 percent), methicillin-sensitive S. aureus (25 percent), methicillin-resistant S. aureus (7 percent), Pseudomonas (7 percent), and Peptostreptococcus (7 percent). All Gram-positive organisms were sensitive to vancomycin, linezolid, tetracycline, and doxycycline; all Gram-negative organisms were sensitive to gentamicin and cefepime. CONCLUSIONS: Empiric antibiotics should be vancomycin (with the possible inclusion of gentamicin) based on their broad effectiveness against the authors' unique microbiome. Minor infections should be treated with tetracycline or doxycycline as a second-line agent. National Surgical Quality Improvement Program data are adequate for monitoring and comparing breast infections but certainly not comprehensive. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Outcomes of medicaid beneficiaries with schizophrenia receiving clozapine only or antipsychotic combinations.

OBJECTIVE: Patients with treatment-resistant schizophrenia commonly receive nonrecommended drug regimens, including antipsychotic polypharmacy, sometimes in lieu of clozapine. This analysis compared utilization and cost outcomes for cohorts of Medicaid beneficiaries treated with clozapine monotherapy and with antipsychotic polypharmacy. METHODS: Data were from the Medicaid MarketScan database. Patients (age 18-64) initiated second-generation antipsychotic polypharmacy or clozapine monotherapy between July 2006 and January 2009, had continuous Medicaid coverage from six months before (preperiod) through 12 months after (postperiod) treatment initiation, and had a diagnosis of schizophrenic disorder (ICD-9-CM code 295.XX). Study outcomes included disease-specific and all-cause hospitalization, emergency department use, and Medicaid payments. Logistic regression analyses and generalized linear models controlled for demographic factors, preperiod utilization, and comorbidities. RESULTS: Characteristics associated with use of clozapine monotherapy (N=479) instead of antipsychotic polypharmacy (N=2,440) included younger age, fewer comorbidities, lower preperiod utilization rates, nonwhite race, and male sex. When the analysis controlled for baseline differences, clozapine monotherapy was associated with lower odds of mental disorder-related (odds ratio [OR]=.75, 95% confidence interval [CI]=.60-.95) or schizophrenia-related (OR=.70, CI=.54-.90) emergency department use but not with hospitalization or all-cause emergency department use. Total Medicaid payments were significantly lower for the clozapine group than for the polypharmacy group: reductions of $21,315 for all-cause, $17,457 for mental disorder-related, and $10,582 for schizophrenia-related payments. CONCLUSIONS: Among nonelderly adult Medicaid beneficiaries with schizophrenia, treatment with clozapine instead of antipsychotic polypharmacy was associated with reduced disease-specific emergency department use and with reduced disease-specific and all-cause health care costs.

Adult hemiparkinsonian rats do not benefit from tactile stimulation.

Tactile stimulation (TS) applied to adult rats after cortical injury (medial frontal cortex aspiration or sensorimotor pial stripping stroke model) has been previously shown to ameliorate behavioral impairments and to improve morphological parameters like dendritic length of prefrontal cortical neurons (Gibb et al., 2010). The purpose of this study was to examine the effect of TS on healthy and hemiparkinsonian adult rats. Therefore, the animals received TS for 14 days and 15 min three times daily. At different time points rats were tested in various behavioral tests (amphetamine-induced rotation, cylinder test, staircase test). Finally, rats were sacrificed, their brains removed, and processed for Golgi-Cox analyses, tyrosine hydroxylase immunohistochemistry and quantitative RT-PCR. We found that the striatal 6-OHDA lesion itself induced a long-term increase of astroglial Fgf2 transcript levels, but was not further increased by TS. In contrast TS applied to healthy rats elicited a transient short-term increase of Fgf2 in the striatum and Bdnf, Grin1, and Fgf2 in the hippocampus. Moreover, behavioral and histological analyses do not support a beneficial effect of TS for hemiparkinsonian rats, applied for two weeks starting one day after partial striatal 6-OHDA lesion.

Early exposure to haloperidol or olanzapine induces long-term alterations of dendritic form.

Exposure of the developing brain to a wide variety of drugs of abuse (e.g., stimulants, opioids, ethanol, etc.) can induce life-long changes in behavior and neural circuitry. However, the long-term effects of exposure to therapeutic, psychotropic drugs have only recently begun to be appreciated. Antipsychotic drugs are little studied in this regard. Here, we quantitatively analyzed dendritic architecture in adult mice treated with paradigmatic typical- (haloperidol) or atypical (olanzapine) antipsychotic drugs at developmental stages corresponding to fetal or fetal plus early childhood stages in humans. In layer 3 pyramidal cells of the medial and orbital prefrontal cortices and the parietal cortex and in spiny neurons of the core of the nucleus accumbens, both drugs induced significant changes (predominantly reductions) in the amount and complexity of dendritic arbor and the density of dendritic spines. The drug-induced plasticity of dendritic architecture suggests changes in patterns of neuronal connectivity in multiple brain regions that are likely to be functionally significant.

Surgical site infections after arthroscopy: Outbreak investigation and case control study.

PURPOSE: The goal of this study was to determine the causes of increased post-arthroscopy surgical site infections (SSIs) and to define risk factors for infection. TYPE OF STUDY: Outbreak investigation and case control study at a university-affiliated community hospital from 1994 to 1996, with surveillance through 1999. METHODS: Demographic, clinical, and microbiological data were collected on 27 post-arthroscopy SSIs from 1994 through 1999. Risk factors for SSI were identified by case-control analysis and presented as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Initial investigation revealed an increased annual rate of post-arthroscopy SSIs in 1995 (1.3%). Infection control deficiencies were identified, and feedback was provided to surgeons and staff. Instrument sterilization was standardized, flash sterilization prohibited, and preoperative shaving discouraged. Case-control analysis of 10 cases (from 1994 to 1996) found a statistically significant increase in risk of SSI with intra-articular corticosteroid joint injection (OR, 9.33; 95% CI, 1.6 to 64.9); other risk factors did not reach statistical significance. SSI rates dropped after feedback and education (0.34% in 1996). Continued surveillance revealed 2 smaller outbreaks, in December 1997 (1997 rate, 1.13%) and September 1998 (1998 rate, 1.09%). Case-control analysis of the 17 cases occurring in 1997 through 1999 was also performed. The 1997 outbreak appeared to be related to preoperative razor shaving (P =.003), which was then prohibited by hospital policy. One scrub nurse was also associated with 75% of these cases, which were culture-positive for coagulase-negative Staphylococcus. The cases in the 1998 outbreak shared prolonged procedure duration and conversion to arthrotomy. Of 27 cases, 24 required repeat hospitalization and repeat surgery, at an average excess cost of $9,154.84 per case. All received prolonged courses of intravenous or oral antibiotics. CONCLUSIONS: Post-arthroscopy SSIs are associated with significant morbidity and cost. Although small numbers make finding statistical significance difficult in case-control studies, infection control and CDC-recommended interventions can lower SSI rates. Careful definitions, ongoing surveillance, and long-term follow-up are helpful in reporting results of infection control interventions.

Risk factors for spinal surgical-site infections in a community hospital: a case-control study.

OBJECTIVE: To characterize risk factors for surgical-site infection after spinal surgery. DESIGN: A case-control study. SETTING: A 113-bed community hospital. METHOD: From January 1998 through June 2000, the incidence of surgical-site infection in patients undergoing laminectomy, spinal fusion surgery, or both increased at community hospital A. We compared 13 patients who acquired surgical-site infections after laminectomy, spinal fusion surgery, or both with 47 patients who were operated on during the same time period but did not acquire a surgical-site infection. Information collected included demographics, risk factors, personnel involved in the operations, length of hospital stay, and hospital costs. RESULTS: Of 13 case-patients, 9 (69%) were obese, 9 (69%) had spinal compression, 5 (38.5%) had a history of tobacco use, and 4 (31%) had diabetes. Oxacillin-sensitive Staphylococcus aureus (6 of 13; 46%) was the most common organism isolated. Significant risk factors for postoperative spinal surgical-site infection were dural tear during the surgical procedure and the use of glue to cement the dural patch (3 of 13 [23%] vs 1 of 47 [2.1%]; P = .02) and American Society of Anesthesiologists risk class of 3 or more (6 of 13 [46.2%] vs 7 of 47 [15%]; P = .02). Case-patients were more likely to have prolonged length of stay (median, 16 vs 4 days; P< .001). The average excess length of stay was 11 days and the excess cost per case was $12,477. CONCLUSION: Dural tear and the use of glue should be evaluated as potential risk factors for spinal surgical-site infection. Systematic observation for potential lapses in sterile technique and surgical processes that may increase the risk of infection may help prevent spinal surgical-site infection.