Managing Patient Dissatisfaction and Billing Reconsideration Requests in Outpatient Clinics.

Nurse leaders in many settings are responsible for clinic operations. Knowing the medical and financial stakes of each patient encounter, it is not surprising to encounter patients requesting reconsideration of bills after services are provided. This article provides recommendations on how to successfully navigate billing reconsideration requests in outpatient settings.

Occurrence of polybrominated diphenyl ethers and benzotriazole UV stabilizers in the hadal amphipod Hirondellea gigas.

The accumulation of polybrominated diphenyl ethers (PBDEs) and benzotriazole UV stabilizers (BZT-UVs) were examined in the hadal amphipod Hirondellea gigas caught from a near-land trench off the Japan island (9200 m). H. gigas were collected from two distinct sites: one is located at the outlet of submarine canyons directly connected to land and the other is apart from the outlet and geographically isolated from the first site. The level of the PBDEs in H. gigas at the canyon outlet (mean 219 ng/g lipid weight (l.w.)) was significantly higher than that in the isolated site (mean 42 ng/g l.w.) and BZT-UVs were only detected within the first site (mean 1.5 ng/g wet weight). In addition to vertical transport from the surface water, near-land trenches associated with submarine canyons and troughs may have more complex influx of contaminants through horizontal transportation from the land, resulting in more severe contamination.

Occurrence and levels of polybrominated diphenyl ethers (PBDEs) in deep-sea sharks from Suruga Bay, Japan.

Few studies have investigated the prevalence of polybrominated diphenyl ethers (PBDEs) in deep-sea sharks. In this study, the levels and profiles of PBDEs were determined in liver samples of eight different species of deep-sea sharks collected in Suruga Bay, Japan. Widespread contamination of PBDEs in the deep-sea environment was reconfirmed in this study as these persistent organic pollutants (POPs) were detected in all specimens analyzed. Mean ΣPBDE levels in the deep-sea sharks ranged from 7 to 517 ng/g of lipid weight. The distribution patterns of BDE homologues were similar in all species where tetra-BDEs provided the dominant contribution to total PBDEs (46%). PBDEs levels were similar to, or higher than, those seen in other deep-sea sharks from different regions. The levels of PBDEs were likely to reflect their feeding preferences as higher PBDE levels were seen in species with higher trophic positions.

Massive occurrence of benthic plastic debris at the abyssal seafloor beneath the Kuroshio Extension, the North West Pacific.

The abyss (3500-6500 m) covers the bulk of the deep ocean floor yet little is known about the extent of plastic debris on the abyssal seafloor. Using video imagery we undertook a quantitative assessment of the debris present on the abyssal seafloor (5700-5800 m depth) beneath the Kuroshio Extension current system in the Northwest Pacific. This body of water is one of the major transit pathways for the massive amounts of debris that are entering the North Pacific Ocean from Asia. Shallower sites (1400-1500 m depth) were also investigated for comparison. The dominant type of debris was single-use plastics - mainly bags and food packaging. The density of the plastic debris (mean 4561 items/km2) in the abyssal zone was the highest recorded for an abyssal plain suggesting that the deep-sea basin in the Northwest Pacific is a significant reservoir of plastic debris.

Preventable Patient Harm: a Multidisciplinary, Bundled Approach to Reducing Clostridium difficile Infections While Using a Glutamate Dehydrogenase/Toxin Immunochromatographic Assay/Nucleic Acid Amplification Test Diagnostic Algorithm.

Health care facility-onset Clostridium difficile infections (HO-CDI) are an important national problem, causing increased morbidity and mortality. HO-CDI is an important metric for the Center for Medicare and Medicaid Service's (CMS) performance measures. Hospitals that fall into the worst-performing quartile in preventing hospital-acquired infections, including HO-CDI, may lose millions of dollars in reimbursement. Under pressure to reduce CDI and without a clear optimal method for C. difficile detection, health care facilities are questioning how best to use highly sensitive nucleic acid amplification tests (NAATs) to aid in the diagnosis of CDI. Our institution has used a two-step glutamate dehydrogenase (GDH)/toxin immunochromatographic assay/NAAT algorithm since 2009. In 2016, our institution set an organizational goal to reduce our CDI rates by 10% by July 2017. We achieved a statistically significant reduction of 42.7% in our HO-CDI rate by forming a multidisciplinary group to implement and monitor eight key categories of infection prevention interventions over a period of 13 months. Notably, we achieved this reduction without modifying our laboratory algorithm. Significant reductions in CDI rates can be achieved without altering sensitive laboratory testing methods.

Quality Initiative Program in Its Sixth Year: Has It Become Part of Our Radiology Culture?

PURPOSE: The study sought to determine if the Quality Initiative Program (QUIP) has become part of the radiology culture at our institution. METHODS: After Research Ethics approval, QUIPs from January 2009 to December 2014 were assessed. We evaluated the response rates of radiologists receiving QUIPs to ensure they reviewed them. We performed a survey of radiologists and trainees to gain feedback regarding their perception of QUIPs in February 2014 and in June 2015. RESULTS: Response rates of radiologists receiving a QUIP improved, with 76% response rate in 2014 up from 66% in the first year and 42% in the second year. Based on the 2015 survey including radiologists and trainees, 75% agreed that QUIPs were educational, compared with 67% 16 months earlier. Fifty percent of respondents had changed their overall practice of reporting based on feedback from the QUIP in 2015 compared with 32% in 2014. In both surveys, 100% of respondents indicated that QUIPs have not been used against them for any disciplinary measure (or other negatively perceived action). When asked if there was a perceived decrease in stigma felt when a QUIP was received, 71% agreed or were neutral and 28% disagreed. CONCLUSIONS: The QUIP is educational to radiologists and trainees, leading to positive changes in clinical practice. The majority accepts this program but there is still a stigma felt when a QUIP is received, particularly among residents. Nevertheless, we feel that QUIP has been integrated into our radiology culture and, hopefully, imminent transition to commercial quality software will be smooth.

Isolation and Characterization of Microsatellite DNA Markers in the Deep-Sea Amphipod Paralicella tenuipes by Illumina MiSeq Sequencing.

Here, we describe the development of 16 polymorphic microsatellite markers using an Illumina MiSeq sequencing approach in the deep-sea amphipod Paralicella tenuipes A total of 25 577 844 DNA sequences were filtered for microsatellite motifs of which 197 873 sequences were identified. From these sequences, 64 had sufficient flanking regions for primer design and 16 of these loci were polymorphic. Between 5 and 30 alleles were detected per locus, with an average of 13.63 alleles per locus, across a total of 120 individuals from 5 separate deep sea trenches from the Pacific Ocean. For the 16 loci, observed and expected heterozygosity values ranged from 0.116 to 0.414 and 0.422 to 0.820, respectively, with one locus displaying significant deviation from Hardy-Weinberg equilibrium. The microsatellite loci that have been isolated and described here are the first molecular markers developed for deep sea amphipods and will be invaluable for elucidating the genetic population structure and the extent of connectivity between deep ocean trenches.

Pilot study: introducing a quality assurance process for a team-centered approach involving nonphysician providers in radiology.

PURPOSE: The objective of this study was to introduce 3 new quality initiatives in radiology that engage various members of the department including radiologists, residents, technologists, and booking clerks. These pilot programs provide work-related learning opportunities in semiautomated, easy-to-use, email-based, standardized forms that are used to identify cases where imaging could have been performed in a more optimal way (either due to technical reasons or a different protocol could have been chosen). In the case of the Kudos quality initiative program (QUIP), this is used to provide positive feedback to an individual in the department for a job well done. METHODS: Since inception in January 2012 to September 2013, we reviewed Technical QUIPs, protocols under questions (PUQ), and Kudos QUIPs. These were collated through receipt of standardized emails for each category. RESULTS: A total of 62 Kudos QUIPs, 8 Technical QUIPs, and 58 PUQs were received in the abdominal and pelvic imaging division since inception. CONCLUSIONS: Though still a relatively new pilot programs, PUQs and Technical QUIPs have afforded technologists and booking clerks opportunities to become engaged in improving patient care as well as learning from their own performance gaps. Future standardization of received data for each modality still needs to be established as well as an action plan to implement long-term changes.

Loss of hemolysin expression in Staphylococcus aureus agr mutants correlates with selective survival during mixed infections in murine abscesses and wounds.

During the screening of a Staphylococcus aureus signature-tagged mutagenesis library, it was noted that nonhemolytic bacteria became more abundant as time passed in murine abscess and wound models, but not within organ tissues associated with systemic infections. To examine this further, a mixed population of hyperhemolytic, hemolytic, and nonhemolytic S. aureus strain RN6390 cells were inoculated into mice using abscess, wound, and systemic models of infection. After 7 days in the abscess, the hyperhemolytic group markedly declined, whereas the nonhemolytic population increased significantly. A similar phenomenon occurred in murine wounds, but not during the systemic infection. Sequencing of several of the signature-tagged mutants indicated mutations in the agrC gene or within the agrA-agrC intergenic region. Both alpha-hemolysin and delta-hemolysin activity was curtailed in these mutants, but beta-hemolysin activity was unaffected. Single strain comparisons between wild-type strain 8325-4 and strain DU1090 (hla-) as well as between strain RN6911 (agr) and wild-type strain RN6390 were performed using the same three animal models of infection. The agr mutant strain and the hla mutant strain showed no difference in bacterial counts in murine wounds compared to their respective parent strains. The same held true in murine abscesses at day 4, but strain RN6911 counts then declined at day 7. Considerable clearing of the hla mutant strain and the agr mutant strain occurred in the systemic model of infection. Mixed infections with the DU1090 and 8325-4 strains in the abscess model showed a slight advantage given to the DU1090 population, but a distinct selection for the parental 8325-4 strain in the liver. These results suggest that agr mutations cause reductions in the expression of several secreted proteins, including alpha- and delta-hemolysin, which in turn contribute to a growth advantage of this agr mutant group within a mixed population of S. aureus cells residing in abscesses and wounds.

The promise of the internet for disability: a study of on-line services and web site accessibility at Centers for Independent Living.

The Internet provides individuals with disabilities numerous tools to live independently. In the convenience of the home, a person can access an abundance of information, an electronic community, updates on the latest disability advocacy news, education through distance-learning classes, and on-line shopping for books, clothes, assistive technology, and a host of other consumer goods. Centers for Independent Living (CILs) are consumer-run, non-profit grassroots disability service organizations at the forefront of the disability rights movement. Providing services to individuals across the range of disabilities, CILs have begun to use the Internet as a complement to their traditional service delivery methods. This article examines the emerging trend of independent living services on the web. The investigation examines 200 CIL Internet sites across the United States during the period of April to August 2001. Information is collected and analyzed about how CILs are using the Internet to provide their services and programs. In addition, the article examines the technological accessibility of their web sites. Implications of the findings for CILs, consumers with disabilities, and disability policy are examined.

Technology for independence: a community-based resource center.

Despite the prominence of the disability civil rights model--with its values of inclusion and empowerment--the majority of social and policy research conducted to date has not sufficiently included the perspective of persons with disabilities in the research process and as uniquely qualified researchers themselves. This article describes a new project, "Technology for Independence: A Community-Based Resource Center" (CBRC). Over a five-year period, the CBRC will attempt to enhance community and consumer-directed disability organizations to design, implement, and disseminate research that promotes access to and use of assistive technology (AT). The CBRC will use strategies such as leadership training, participatory action research, technical assistance, web-assisted training, and annual symposia. A primary goal of the CBRC is to increase the capacity of community organizations to conduct research on AT that is scientifically rigorous and relevant to disability services, policy, and law.

Applicability of the ADA to "Ticket to Work" employment networks. Americans with Disabilities Act.

This article examines the applicability of the antidiscrimination provisions of the Americans with Disabilities Act (ADA) of 1990 to The Ticket to Work and Work Incentives Improvement Act (TWWIIA) passed in 1999. Among other policy changes, under the Ticket to Work program, eligible recipients of disability insurance (SSDI) and supplemental income (SSI) receive a voucher or "ticket" to obtain services from qualified employment networks (ENs). ENs provide employment services and supports to designated beneficiaries and must meet certain qualification requirements. The ADA is applicable to ENs in several ways: primarily, in the EN's responsibility to provide appropriate access and services to program participants. This article discusses application of the ADA to the Ticket Program as ENs begin to serve program beneficiaries.