The Evolving Practice of Hospital at Home in the United States.

Hospital at Home (HaH) provides hospital-level services in the home to eligible patients who would otherwise require facility-based hospitalization. In the last two decades, studies have shown that HaH can improve patient outcomes and satisfaction and reduce hospital readmissions. Improved technology and greater experience with the model have led to expansion in the scope of patients served and services provided by the model, but dissemination in the United States has been hampered by lack of insurance coverage until recently. HaH is likely at the tipping point for wide adoption in the United States. To realize its full benefits, HaH will need to continue volume expansion to achieve culture change in clinical practice as facilitated by increased insurance coverage, technological advancements, and improved workforce expertise. It is also essential that HaH programs maintain high-quality acute hospital care, ensure that their benefits can be accessed by hard-to-reach rural populations, and continue to advance health equity.

Qualitative Assessment of Implementation of a Discharge Prediction Tool Using RE-AIM Framework.

The implementation process in the routine clinical care of a new predictive tool based on machine learning algorithms has been investigated using the RE-AIM framework. Semi-structured qualitative interviews have been conducted with a broad range of clinicians to elucidate potential barriers and facilitators of the implementation process across five major domains: Reach, Efficacy, Adoption, Implementation, and Maintenance. The analysis of 23 clinician interviews demonstrated a limited reach and adoption of the new tool and identified areas for improvement in implementation and maintenance. Future implementation efforts of machine learning tools should support the proactive engagement of a wide range of clinical users since the very initiation of the predictive analytics project, provide higher transparency of the underlying algorithms, employ broader onboarding of all potential users on a periodic basis, and collect feedback from clinicians on an ongoing basis.

Racial Disparities in Documented Chief Complaints and Diagnoses in Sepsis Patients.

BACKGROUND: Using History and Physical Examination (H&P) notes, we investigated potential racial differences in documented chief complaints and problems among sepsis patients admitted to the intensive care unit. METHODS: Patient records from Medical Information Mart for Intensive Care (MIMIC-III) dataset indicating a diagnosis of sepsis were included. First recorded clinical notes for each hospital admission were assessed; free text information was specifically extracted on (1) chief complaints, and (2) problems recorded in the Assessment & Plan (A&P) section. The top 10 for each were compared between Black and White patients. RESULTS: In initial H&P notes of 17 434 sepsis patients (n = 1229 Black and n = 9806 White), the top 10 most common chief complaints were somewhat similar between Black and White patients. However, relative differences existed in terms of ranking, specifically for altered mental status which was more commonly reported in Black versus White patients (11.7% vs 7.8% P < .001). Among text in the A&P, sepsis was documented significantly less frequently among Black versus White patients: 11.8% versus 14.3%, P = .001. Racial differences were not detected in vital signs and laboratory values. CONCLUSIONS: This analysis supports the hypothesis that there may be racial differences in early sepsis presentation and possible provider interpretation of these complaints.

Adherence to fluid resuscitation guidelines and outcomes in patients with septic shock: Reassessing the "one-size-fits-all" approach.

OBJECTIVE: The Surviving Sepsis Campaign and Centers for Medicare and Medicaid Services (CMS) Severe Sepsis and Septic Shock Management Bundle (SEP-1) recommend rapid crystalloid infusion (≥30 mL/kg) for patients with sepsis-induced hypoperfusion or septic shock. We aimed to assess compliance with this recommendation, factors associated with non-compliance, and how compliance relates to mortality. DESIGN: Retrospective, observational study. SETTING: 1136-bed academic and 235-bed community hospital (January 2015-June 2016). PATIENTS: Patients with septic shock. INTERVENTIONS: Crystalloid infusion (≥30 mL/kg) within 6 h of identification of septic shock as required by CMS. MEASUREMENTS: Associations with compliance and how compliance associates with mortality; odds ratios (OR) and 95% confidence intervals (CI) reported. MAIN RESULTS: Overall, 1027 septic shock patients were included. Of these, 486 (47.3%) met the 6-hour 30 ml/kg fluid requirement. Compliance was lower in patients with congestive heart failure (CHF) (40.9%), chronic kidney disease (CKD) (42.3%) or chronic liver disease (38.5%) and among those that were identified in the inpatient setting (35.4%) rather than in the emergency department (51.7%). When adjusting for relevant covariates, compliance (compared to non-compliance) was not associated with in-hospital mortality: OR 1.03 CI 0.76-1.41. CONCLUSIONS: These findings question a "one-size-fits-all" approach to fluid administration and performance measures for patients with sepsis.

Cognitive impairment in older adults with heart failure: prevalence, documentation, and impact on outcomes.

BACKGROUND: Despite the fact that 80% of patients with heart failure are aged more than 65 years, recognition of cognitive impairment by physicians in this population has received relatively little attention. The current study evaluated physician documentation (as a measure of recognition) of cognitive impairment at the time of discharge in a cohort of older adults hospitalized for heart failure. METHODS: We performed a prospective cohort study of older adults hospitalized with a primary diagnosis of heart failure. Cognitive status was evaluated with the Folstein Mini-Mental State Examination at the time of hospitalization. A score of 21 to 24 was used to indicate mild cognitive impairment, and a score of ≤20 was used to indicate moderate to severe impairment. To evaluate physician documentation of cognitive impairment, we used a standardized form with a targeted keyword strategy to review hospital discharge summaries. We calculated the proportion of patients with cognitive impairment documented as such by physicians and compared characteristics between groups with and without documented cognitive impairment. We then analyzed the association of cognitive impairment and documentation of cognitive impairment with 6-month mortality or readmission using Cox proportional hazards regression. RESULTS: A total of 282 patients completed the cognitive assessment. Their mean age was 80 years of age, 18.8% were nonwhite, and 53.2% were female. Cognitive impairment was present in 132 of 282 patients (46.8% overall; 25.2% mild, 21.6% moderate-severe). Among those with cognitive impairment, 30 of 132 (22.7%) were documented as such by physicians. Compared with patients whose cognitive impairment was documented by physicians, those whose impairment was not documented were younger (81.3 vs 85.2 years, P<.05) and had less severe impairment (median Mini-Mental State Examination score 22.0 vs 18.0, P<.01). After multivariable adjustment, patients whose cognitive impairment was not documented were significantly more likely to experience 6-month mortality or hospital readmission than patients without cognitive impairment. CONCLUSIONS: Cognitive impairment is common in older adults hospitalized for heart failure, yet it is frequently not documented by physicians. Implementation of strategies to improve recognition and documentation of cognitive impairment may improve the care of these patients, particularly at the time of hospital discharge.

Intronic alterations in BRCA1 and BRCA2: effect on mRNA splicing fidelity and expression.

Germline mutations in the human breast cancer susceptibility genes BRCA1 and BRCA2 account for the majority of hereditary breast and ovarian cancer. In spite of the large number of sequence variants identified in BRCA1 and BRCA2 mutation analyses, many of these genetic alterations are still classified as variants of unknown significance (VUS). In this study, we evaluated 12 BRCA1/2 intronic variants in order to differentiate their pathogenic or polymorphic effects on the mRNA splicing process. We detected the existence of aberrant splicing in three BRCA1 variants (c.301-2delA/IVS6-2delA, c.441+1G>A/IVS7+1G>A, and c.4986+6T>G/IVS16+6T>G) and two BRCA2 variants (c.8487+1G>A/IVS19+1G>A and c.8632-2A>G/IVS20-2A>G). All but one of the aberrant transcripts arise from mutations affecting the conserved splice acceptor or donor sequences and all would be predicted to result in expression of truncated BRCA1 or BRCA2 proteins. However, we demonstrated that four of these splice-site mutations (i.e., c.301-2delA, c.441+1G>A, c.4986+6T>G, and c.8632-2A>G) with premature termination codons were highly unstable and were unlikely to encode for abundant expression of a mutant protein. Three variants of BRCA1 (c.212+3A>G/IVS5+3A>G, c.593+8A>G/IVS9+8A>G, and c.4986-20A>G/IVS16-20A>G) and four variants of BRCA2 (c.516-19C>T/IVS6-19C>T, c.7976-4_7976_3delTT/IVS17-4delTT, c.8487+19A>G/IVS19+19A>G, and c.9256- 18C>A/IVS24- 18C>A) in our studies show no effects on the normal splicing process, and they are considered to be benign polymorphic alterations. Our studies help to clarify the aberrant splicing in BRCA1 and BRCA2 as well as provide information that can be used clinically to help counsel breast/ovarian cancer prone families.

The change in thick of centre - cornea in angle closure glaucoma pre - and post - trabeculectomy

The author measured the thick of centre-cornea for 42 patients angle closure glaucoma and 16 patients open angle glaucoma. The results: Centre-cornea in angle closure glaucoma and high IOP is clearly thicker than open angle glaucoma and than angle closure glaucoma potential. In the angle closure glaucoma, the thick of centre-cornea decrease and come to normal after the operation 3 months. Thick of centre-cornea in open angle glaucoma high IOP, potential and Vietnamese normal are equivalent. In patient open angle glaucoma, the thick of centre-cornea is not changing after the trabeculectomy

Some comments about the changes of centre corneal thickness in angle closure glaucoma

On 108 eyes of 54 patients (19 males, 35 females, aged 45-75) thickness of cornea was measured. 40 patients with 1 eye acute glaucoma and the 2nd eye has not glaucoma (potential angle closure), 14 other patients with both 2 eyes of high ocular pressure (entire closure of vertibular angle). Results showed that the centre corneal thickness got an important change in angle closure glaucoma, it had a lineary relation with ocular pressure. In the crisis of acute angle closure glaucoma, corneal thickness accounted for x = 0.5730.053 mm and the crisis of potential angle closure glaucoma x = 0.5310.031 mm. With an increase of pressure of 1 mmHg, corneal thickness increases by 0.038 mm

Remarks on the modified trabeculectomy of sclerotica

30 eyes of 28 patients (18 female, 10 male, aged 45-75) of primary glaucoma (25 eyes with closed angle glaucoma and 5 eyes with opened angle glaucoma) at the National Institute of Ophtalmology were operated. No complications occurred. In postoperative period, there were 4 eyes with low interocular pressure and very shallow vestibule. In discharge, 46.6% eyes got a visual acuity of 4/10 to >6/10, and 13.3% <1/10, interocular pressure was regulated with X=18.20.8 mmHg. All operated eyes had scars. After 1 year, acuity visual had been re-examined on 28 eyes, no change of visual acuity, vision field and scars. Interoculary pressure was normal level of X=19.61.2 mmHg

Phacoemulsification lsification technique for white opaque criptalline catarract

The study carries on 48 patients opered glaucoma by technique phacoemulsification at central eye institute. If at tense capsulotomy is complete, all tenses later are very advantage. This technique used source of cold-lean light of endophthalmen lamp to tear one central small capsule, then tear rearward when dispose cataract artificial. It shoud combine blue reagent to tear capsule more advantage. For cases that it observes difficult, can use head-straw to clear, thence can pump mucous substance under capsule of cataract to fill out capsule and tear following. Technique phacoemulsification can apply for eyes with white cataract, bring high vision for patients but it is necessary to have some technique support as tense capsulotomy and crush nuclear when it is sclerosis