Optimizing Inpatient Blood Utilization Using Real-Time Clinical Decision Support.

BACKGROUND: Red blood cell (RBC) transfusion is a common medical procedure. While it offers clinical benefits for many, hemodynamically stable patients are often subjected to unwarranted transfusions, with the potential to lead to adverse consequences. We created a real-time clinical decision support (CDS) tool in the electronic health record system to address this problem and optimize transfusion practice as part of an institutional multidisciplinary, team-based patient blood management program. METHODS: The real-time CDS tool incorporated the transfusion guidelines published by the AABB. The tool was deployed as a dynamic order set within the computerized provider order entry interface. Prior to implementation, extensive education and outreach to increase provider engagement were provided. The CDS tool was launched in September 2015. RESULTS: The percentage of guideline-indicated RBC transfusions increased from a baseline of 43.6 to 54.2% while the percentage of multiunit (≥ 2 units) RBC transfusions decreased from 31.3 to 22.7% between September 2014 and July 2019. The estimated minimum cost saving over the entire study period was $36,519.36. CONCLUSION: Our intervention increased guideline-indicated transfusions by 10.6% and reduced multiunit transfusions by 8.6%. The adoption of a dynamic order set for the CDS tool, as opposed to an interruptive alert that displays static alert messages, allowed for more customized and tighter control of RBC orders, leading to a sustained improvement in our transfusion practice.

Improving Communication About Resuscitation Preference for Patients Discharged from Hospital to Nursing Home: A Quality Improvement Project.

Background: Physician Orders for Life-Sustaining Treatment (POLST) can help ensure continuity of do-not-resuscitate (DNR) decisions and other care preferences after discharge from the hospital. Objective: We aimed to improve POLST completion rates for patients with DNR orders who were being discharged to a nursing home (NH) after an acute hospitalization at our institution. Design: We implemented an interprofessional quality improvement intervention involving education, communication skills, and nursing and case manager cues regarding POLST use. The intervention was later augmented with performance feedback and financial incentives for resident physicians who completed a POLST at NH transfer. Measure: Whether patients with DNR orders at hospital discharge have a POLST at NH transfer. Results: The intervention resulted in increased POLST use for patients with DNR orders discharged to NH: baseline 25/65 (38%), intervention 36/71 (51%), and augmented intervention 44/63 (70%) (p < 0.01). Conclusions: An interdisciplinary intervention can increase POLST use for patients with DNR orders transitioning to NH. Multiple components, including financial incentives and performance feedback, may be needed to effect statistically significant change.

Delivering environmental benefit from the use of Environmental Quality Standards: why we need to focus on implementation.

The UK has adopted a broader approach to the introduction of Environmental Quality Standard (EQS) for the aquatic environment than many other jurisdictions around the world, with a greater focus on the implementation of scientifically derived standards. This follows the publication of a report by the Royal Commission on Environmental Pollution in 1998 which drew attention to the need to recognise that whilst an EQS is often just viewed as a numerical value, it also has other important characteristics that need to be recognised if it is to be a practical and effective regulatory tool. One of the aspects that has not always been recognised was that of implementation assessment, i.e. the steps needed to ensure that a standard actually delivers environmental benefit or improvements. In many jurisdictions, there is considerable technical and sometimes political emphasis on the numerical value of the EQS (e.g. the critical concentration in an environmental matrix like water), including the method of derivation, the scrutiny of the reliability and relevance of the ecotoxicity test data and extensive deliberations of unquantified uncertainties in relation to the choice of assessment factor. The regulatory value of an EQS only comes through a comparison against a measured environmental concentration, yet only relatively limited regulatory effort has historically been expended on this component of the classic environmental risk assessment paradigm. For example, there needs to be an acceptable (i.e. small) uncertainty in the EQS, an appropriate analytical method and detection limit in the correct matrix, a method to deliver a comparison with the EQS and a robust statistical method to draw unbiased conclusions about environmental risk. In addition, we argue that there is a case for checking the consequences of introducing a standard against field data, wherever possible. This validation of the EQS rarely happens currently. We explain what implementation assessment is and why it is needed. We give examples of how implementation assessment can be integrated with EQS derivation and also present examples of what happens when the focus is only upon the derivation of a numerical value. It is clear from this evidence that advances in derivation methods need to be coupled with practical solutions of implementation if we are to realise environmental benefit from an EQS in a cost-effective manner.

The effect of implementing a care coordination program on team dynamics and the patient experience.

OBJECTIVES: Care coordination programs are frequently implemented in the redesign of primary care systems, focused on improving patient outcomes and reducing utilization. However, redesign can be disruptive, affect patient experiences, and undermine elements in the patient-centered medical home, such as team-based care. STUDY DESIGN: Case-controlled study with difference-in-differences (DID) and cross-sectional analyses. METHODS: The phased implementation of a care coordination program permitted evaluation of a natural experiment to compare measures of patient experience and teamwork in practices with and without care coordinators. Patient experience scores were compared before and after the introduction of care coordinators, using DID analyses. Cross-sectional data were used to compare teamwork, based on the relational coordination survey, and physician-perceived barriers to coordinated care between clinics with and without care coordinators. RESULTS: We evaluated survey responses from 459 staff and physicians and 13,441 patients in 26 primary care practices. Practices with care coordinators did not have significantly different relational coordination scores compared with practices without care coordinators, and physicians in these practices did not report reduced barriers to coordinated care. After implementation of the program, patients in practices with care coordinators reported a more positive experience with staff over time (DID, 2.6 percentage points; P = .0009). CONCLUSIONS: A flexible program that incorporates care coordinators into the existing care team was minimally disruptive to existing team dynamics, and the embedded care coordinators were associated with a small increase in patient ratings that reflected a more positive experience with staff.

Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic.

PURPOSE: To test a simultaneous care model for palliative care for patients with advanced cancer by embedding a palliative care nurse practitioner (NP) in an oncology clinic. METHODS: We evaluated the effect of the intervention in two oncologists' clinics beginning March 2014 by using implementation strategies, including use of a structured referral mechanism, routine symptom screening, integration of a psychology-based cancer supportive care center, implementation team meetings, team training, and a metrics dashboard for continuous quality improvement. After 1 year of implementation, we evaluated key process and outcome measures for supportive oncology and efficiency of the model by documenting tasks completed by the NP during a subset of patient visits and time-motion studies. RESULTS: Of approximately 10,000 patients with active cancer treated in the health system, 2,829 patients had advanced cancer and were treated by 42 oncologists. Documentation of advance care planning increased for patients of the two intervention oncologists compared with patients of the other oncologists. Hospice referral before death was not different at baseline, but was significantly higher for patients of intervention oncologists compared with patients of control oncologists (53% v 23%; P = .02) over the intervention period. Efficiency evaluation revealed that approximately half the time spent by the embedded NP potentially could have been completed by other staff (eg, a nurse, a social worker, or administrative staff). CONCLUSION: An embedded palliative care NP model using scalable implementation strategies can improve advance care planning and hospice use among patients with advanced cancer.

Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.

BACKGROUND: Organisational culture affects physician behaviours. Patient safety culture surveys have previously been used to drive care improvements, but no comparable survey of high-value care culture currently exists. We aimed to develop a High-Value Care Culture Survey (HVCCS) for use by healthcare leaders and training programmes to target future improvements in value-based care. METHODS: We conducted a two-phase national modified Delphi process among 28 physicians and nurse experts with diverse backgrounds. We then administered a cross-sectional survey at two large academic medical centres in 2015 among 162 internal medicine residents and 91 hospitalists for psychometric evaluation. RESULTS: Twenty-six (93%) experts completed the first phase and 22 (85%) experts completed the second phase of the modified Delphi process. Thirty-eight items achieved ≥70% consensus and were included in the survey. One hundred and forty-one residents (83%) and 73 (73%) hospitalists completed the survey. From exploratory factor analyses, four factors emerged with strong reliability: (1) leadership and health system messaging (α=0.94); (2) data transparency and access (α=0.80); (3) comfort with cost conversations (α=0.70); and (4) blame-free environment (α=0.70). In confirmatory factor analysis, this four-factor model fit the data well (Bentler-Bonett Normed Fit Index 0.976 and root mean square residual 0.056). The leadership and health system messaging (r=0.56, p<0.001), data transparency and access (r=0.15, p<0.001) and blame-free environment (r=0.37, p<0.001) domains differed significantly between institutions and positively correlated with Value-Based Purchasing Scores. CONCLUSIONS: Our results provide support for the reliability and validity of the HVCCS to assess high-value care culture among front-line clinicians. HVCCS may be used by healthcare groups to identify target areas for improvements and to monitor the effects of high-value care initiatives.

Development and Validation of an Automated Method to Identify Patients Undergoing Radical Cystectomy for Bladder Cancer Using Natural Language Processing.

INTRODUCTION: Measurement for quality improvement relies on accurate case identification and characterization. With electronic health records now widely deployed, natural language processing, the use of software to transform text into structured data, may enrich quality measurement. Accordingly we evaluated the application of natural language processing to radical cystectomy procedures for patients with bladder cancer. METHODS: From a sample of 497 procedures performed from March 2013 to October 2014 we identified radical cystectomy for primary bladder cancer using the approaches of 1) a natural language processing enhanced algorithm, 2) an administrative claims based algorithm and 3) manual chart review. We also characterized treatment with robotic surgery and continent urinary diversion. Using chart review as the reference standard we calculated the observed agreement (kappa statistic), sensitivity, specificity, positive predictive value and negative predictive value for natural language processing and administrative claims. RESULTS: We confirmed 84 radical cystectomies were performed for bladder cancer, with 50.0% robotic and 38.6% continent diversions. The natural language processing enhanced and claims based algorithms demonstrated 99.8% (κ=0.993, 95% CI 0.979-1.000) and 98.6% (κ=0.951, 95% CI 0.915-0.987) agreement with manual review, respectively. Both approaches accurately characterized robotic vs open surgery, with natural language processing enhanced algorithms showing 98.8% (κ=0.976, 95% CI 0.930-1.000) and claims based 90.5% (κ=0.810, 95% CI 0.686-0.933) agreement. For urinary diversion natural language processing enhanced algorithms correctly specified 96.4% of cases (κ=0.924, 95% CI 0.839-1.000) compared with 83.3% (κ=0.655, 95% CI 0.491-0.819). CONCLUSIONS: Natural language processing enhanced and claims based algorithms accurately identified radical cystectomy cases at our institution. However, natural language processing appears to better classify specific aspects of cystectomy surgery, highlighting a potential advantage of this emerging methodology.

Delivering On Accountable Care: Lessons From A Behavioral Health Program To Improve Access And Outcomes.

Patients with behavioral health disorders often have worse health outcomes and have higher health care utilization than patients with medical diseases alone. As such, people with behavioral health conditions are important populations for accountable care organizations (ACOs) seeking to improve the efficiency of their delivery systems. However, ACOs have historically faced numerous barriers in implementing behavioral health population-based programs, including acquiring reimbursement, recruiting providers, and integrating new services. We developed an evidence-based, all-payer collaborative care program called Behavioral Health Associates (BHA), operated as part of UCLA Health, an integrated academic medical center. Building BHA required several innovations, which included using our enterprise electronic medical record for behavioral health referrals and documentation; registering BHA providers with insurance plans' mental health carve-out products; and embedding BHA providers in primary care practices throughout the UCLA Health system. Since 2012 BHA has more than tripled the number of patients receiving behavioral health services through UCLA Health. After receiving BHA treatment, patients had a 13 percent reduction in emergency department use. Our efforts can serve as a model for other ACOs seeking to integrate behavioral health care into routine practice.

Defining a Patient Population With Cirrhosis: An Automated Algorithm With Natural Language Processing.

OBJECTIVES: The objective of this study was to use natural language processing (NLP) as a supplement to International Classification of Diseases, Ninth Revision (ICD-9) and laboratory values in an automated algorithm to better define and risk-stratify patients with cirrhosis. BACKGROUND: Identification of patients with cirrhosis by manual data collection is time-intensive and laborious, whereas using ICD-9 codes can be inaccurate. NLP, a novel computerized approach to analyzing electronic free text, has been used to automatically identify patient cohorts with gastrointestinal pathologies such as inflammatory bowel disease. This methodology has not yet been used in cirrhosis. STUDY DESIGN: This retrospective cohort study was conducted at the University of California, Los Angeles Health, an academic medical center. A total of 5343 University of California, Los Angeles primary care patients with ICD-9 codes for chronic liver disease were identified during March 2013 to January 2015. An algorithm incorporating NLP of radiology reports, ICD-9 codes, and laboratory data determined whether these patients had cirrhosis. Of the 5343 patients, 168 patient charts were manually reviewed at random as a gold standard comparison. Positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of the algorithm and each of its steps were calculated. RESULTS: The algorithm's PPV, NPV, sensitivity, and specificity were 91.78%, 96.84%, 95.71%, and 93.88%, respectively. The NLP portion was the most important component of the algorithm with PPV, NPV, sensitivity, and specificity of 98.44%, 93.27%, 90.00%, and 98.98%, respectively. CONCLUSIONS: NLP is a powerful tool that can be combined with administrative and laboratory data to identify patients with cirrhosis within a population.

Predictors of Out-of-ACO Care in the Medicare Shared Savings Program.

IMPORTANCE: Patients treated outside of their Medicare Shared Savings Program (MSSP) accountable care organization (ACO) likely benefit less from the ACO's integration of care. Consequently, the MSSP's open-network design may preclude ACOs from improving value in care. OBJECTIVES: Quantify out-of-ACO care in a single urban ACO and examine associations between patient-level predictors and out-of-ACO expenditures. RESEARCH DESIGN: Secondary data analysis using Centers for Medicare and Medicaid ACO Program Claim and Claim Line Feed dataset (dates of service January 1, 2013-December 31, 2013). Two-part modeling was used to examine associations between patient-level predictors and likelihood and level of out-of-ACO expenditures. SUBJECTS: Patients were included if they were prospectively assigned to the MSSP in 2013. Patients were excluded if they declined to share data with the ACO, were not retrospectively confirmed to be in the ACO, or had missing data on covariates. Analytic sample included 11,922 patients. MEASURES: Total out-of-ACO expenditures and out-of-ACO expenditures by place of service. RESULTS: Of total expenditures, 32.9% were paid to out-of-ACO providers, and 89.8% of beneficiaries had out-of-ACO expenditures. The presence of almost all medical comorbidities increased out-of-ACO expenditures ($800-$3000 per comorbidity) across the study population. Racial/ethnic minority groups spent between $1076 and $1422 less outside of the ACO than white patients, which was driven by less out-of-ACO outpatient office expenditures ($417-$517 less for each racial/ethnic minority group). CONCLUSIONS: Out-of-ACO expenditures represented a significant portion of expenditures for the study population. Medically complex patients spent more outside of the ACO and represent an important population to study further.

Testing an Adapted Modified Delphi Method: Synthesizing Multiple Stakeholder Ratings of Health Care Service Effectiveness.

BACKGROUND: The Affordable Care Act incentivizes health systems for better meeting patient needs, but often guidance about patient preferences for particular health services is limited. All too often vulnerable patient populations are excluded from these decision-making settings. A community-based participatory approach harnesses the in-depth knowledge of those experiencing barriers to health care. METHOD: We made three modifications to the RAND-UCLA appropriateness method, a modified Delphi approach, involving patients, adding an advisory council group to characterize existing knowledge in this little studied area, and using effectiveness rather than "appropriateness" as the basis for rating. As a proof of concept, we tested this method by examining the broadly delivered but understudied nonmedical services that community health centers provide. RESULTS: This method created discrete, new knowledge about these services by defining 6 categories and 112 unique services and by prioritizing among these services based on effectiveness using a 9-point scale. Consistent with the appropriateness method, we found statistical convergence of ratings among the panelists. DISCUSSION: Challenges include time commitment and adherence to a clear definition of effectiveness of services. This diverse stakeholder engagement method efficiently addresses gaps in knowledge about the effectiveness of health care services to inform population health management.

Innovative approach to patient-centered care coordination in primary care practices.

OBJECTIVES: Although care coordination is an essential component of the patient-centered medical home structure, current case manager models have limited usefulness to population health because they typically serve a small group of patients defined based on disease or utilization. Our objective was to support our health system's population health by implementing and evaluating a program that embedded nonlicensed coordinators within our primary care practices to support physicians in executing care plans and communicating with patients. STUDY DESIGN: Matched case-control differences-in-differences. METHODS: Comprehensive care coordinators (CCC) were introduced into 14 of the system's 28 practice sites in 2 waves. After a structured training program, CCCs identified, engaged, and intervened among patients within the practice in conjunction with practice primary care providers. We counted and broadly coded CCC activities that were documented in the intervention database. We examined the impact of CCC intervention on emergency department (ED) utilization at the practice level using a negative binomial multivariate regression model controlling for age, gender, and medical complexity. RESULTS: CCCs touched 10,500 unique patients over a 1-year period. CCC interventions included execution of care (38%), coordination of transitions (32%), self-management support/link to community resources (15%), monitor and follow-up (10%), and patient assessment (1%). The CCC intervention group had a 20% greater reduction in its prepost ED visit rate compared with the control group (P < .0001). CONCLUSIONS: Our CCC intervention demonstrated a significant reduction in ED visits by focusing on the centrality of the primary care provider and practice. Our model may serve as a cost-effective and scalable alternative for care coordination in primary care.

Building the Infrastructure for Value at UCLA: Engaging Clinicians and Developing Patient-Centric Measurement.

PROBLEM: Evolving payer and patient expectations have challenged academic health centers (AHCs) to improve the value of clinical care. Traditional quality approaches may be unable to meet this challenge. APPROACH: One AHC, UCLA Health, has implemented a systematic approach to delivery system redesign that emphasizes clinician engagement, a patient-centric scope, and condition-specific, clinician-guided measurement. A physician champion serves as quality officer (QO) for each clinical department/division. Each QO, with support from a central measurement team, has developed customized analytics that use clinical data to define targeted populations and measure care across the full treatment episode. OUTCOMES: From October 2012 through June 2015, the approach developed rapidly. Forty-three QOs are actively redesigning care delivery protocols within their specialties, and 95% of the departments/divisions have received a customized measure report for at least one patient population. As an example of how these analytics promote systematic redesign, the authors discuss how Department of Urology physicians have used these new measures, first, to better understand the relationship between clinical practice and outcomes for patients with benign prostatic hyperplasia and, then, to work toward reducing unwarranted variation. Physicians have received these efforts positively. Early outcome data are encouraging. NEXT STEPS: This infrastructure of engaged physicians and targeted measurement is being used to implement systematic care redesign that reliably achieves outcomes that are meaningful to patients and clinicians-incorporating both clinical and cost considerations. QOs are using an approach, for multiple newly launched projects, to identify, test, and implement value-oriented interventions tailored to specific patient populations.

Defining and Rating the Effectiveness of Enabling Services Using a Multi-stakeholder Expert Panel Approach.

The Affordable Care Act provides opportunities to reimburse non-medical enabling services that promote the delivery of medical care for patients with social barriers. However, limited evidence exists to guide delivery of these services. We addressed this gap by convening community health center patients, providers, and other stakeholders in two panels that developed a framework for defining and evaluating these services. We adapted a group consensus method where the panelists rated services for effectiveness in increasing access to, use, and understanding of medical care. Panelists defined six broad categories, 112 services, and 21 variables including the type of provider delivering the service. We identified 16 highest-rated services and found that the service provider's level of training affected effectiveness for some but not all services. In a field with little evidence, these findings provide guidance to decision-makers for the targeted spread of services that enable patients to overcome social barriers to care.

Tool used to assess how well community health centers function as medical homes may be flawed.

The patient-centered medical home model holds the potential for reducing disease complications and improving health, and the federal government is now promoting the adoption of the model within federally qualified community health centers. In a group of Los Angeles community health centers, we found that all would have qualified as patient-centered medical homes under a widely used assessment tool developed by the National Committee for Quality Assurance and endorsed by the federal government for the community health center program. However, we also found that there was no significant relationship between how well these centers performed on the assessment and whether they achieved a range of process or outcome measures for diabetes care. These findings suggest that the federal government is promoting medical home redesign that may not be sensitive to, or inclusive of, services that will actually improve diabetes care for low-income patients. Therefore, additional methods are required for measuring and improving the capabilities of community health centers to function as medical homes and to deliver the scope of services that impoverished patients genuinely need.

Effect of closure of a local safety-net hospital on primary care physicians' perceptions of their role in patient care.

PURPOSE We examined how the closure of a large safety-net hospital in Los Angeles County, California, affected local primary care physicians. METHODS We conducted semistructured interviews with 42 primary care physicians who practiced in both underserved and nonunderserved settings in Los Angeles County. Two investigators independently reviewed and coded transcripts. Three investigators used pile-sorting to sort the codes into themes. RESULTS Overall, 28 of 42 physicians (67%) described some effect of the hospital closure on their practices. Three major themes emerged regarding the impact of the closure on the affected physicians: (1) reduced local access to specialist consultations, direct hospital admissions, and timely emergency department evaluation; (2) more patient delays in care and worse health outcomes because of poor patient understanding of the health care system changes; and (3) loss of colleagues and opportunities to teach residents and medical students. CONCLUSIONS Physicians in close proximity to the closed hospital-even those practicing in nonunderserved settings-reported difficulty getting their patients needed care that extended beyond the anticipated loss of inpatient services. There is a need for greater recognition of and support for the role primary care physicians play in coordinating care; promoting continuity of care; and informing patients, clinic administrators and policy makers about system changes during such transitions.

Brachylophora, a new brachypterous genus of Rhopalophorini (Coleoptera, Cerambycidae)

Brachylophora, a new brachypterous genus of Rhopalophorini (Coleoptera, Cerambycidae). Brachylophora auricollis (Bruch, 1918) comb. nov. = Pasiphyle auricollis Bruch, 1918, originally described from Argentina (Salta), is redescribed and illustrated. Although with reduced elytra, the genus is transferred from Rhinotragini to Rhopalophorini based on the following characters: eyes well separated in both sexes, frons between eyes depressed and lacking frontal suture; pro-, meso-, and metasternum planar; mesothorax parallel-sided, not at all declivous before mesosternal process; metasternum large, together with mesosternum twice length of prosternum, metepisternum very wide, entire suture separating it from metasternum clearly visible when viewed from below; female ovipositor shortened with short cylindrical styles; and, more generally, structural features of hind legs, and surface ornamentation. Habitus similar to Coremia group. Bolivian specimens were netted as they visited flowers of Croton sp. (Euphorbiaceae).

Brachylophora, gênero braquíptero de Rhopalophorini (Coleoptera, Cerambycidae). Brachylophora auricollis (Bruch, 1918) comb. nov. = Pasiphyle auricollis Bruch, 1918, originalmente descrito de Argentina (Salta), é redescrito e ilustrado. Embora com élitros reduzidos, o gênero é incluído em Rhopalophorini com base nos seguintes caracteres: olhos bem afastados em ambos os sexos, fronte deprimida entre os lobos inferiores e sem sutura frontal, pro-, meso- e metasterno no mesmo nível, mesosterno com bordas laterais paralelas e sem declive antes do processo, metasterno amplo, junto com o mesosterno, duas vezes mais longo que prosterno, metepisterno largo, sutura metepisternal inteiramente visível, ovipositor encurtado com estilos pouco alongados e cilídricos e pela estrutura das pernas posteriores. Habitus semelhante do grupo Coremia. Os exemplares da Bolívia foram coletados quanto estavam visitando as flores de Croton sp. (Euphorbiaceae).

Risk factors for thrombocytopenia in HIV-infected persons in the era of potent antiretroviral therapy.

OBJECTIVE: Before potent antiretroviral therapy, thrombocytopenia was observed frequently. Little is known about risk factors for or severity and consequences of thrombocytopenia since establishment of highly effective therapy for HIV. METHODS: We conducted a retrospective-matched case-control study of HIV-infected adult outpatients with and without thrombocytopenia to elucidate the contribution of HIV viremia, hepatitis C infection, and other potential risk factors for thrombocytopenia. Seventy-three cases with thrombocytopenia (platelet count <100 x 10(9)/L persistent for >3 months) were matched by age, sex, and first clinic visit with 73 nonthrombocytopenic controls. Risk factors and outcomes were assessed using conditional logistic regression. RESULTS: Nadir platelet counts in cases were 400 copies/ml, hepatitis C virus infection, and cirrhosis were significantly associated with thrombocytopenia with adjusted odds ratios of 5.3 [confidence interval (CI) 1.6-17.1, P = 0.006], 6.1 (CI 1.6-22.6, P = 0.007), and 24.0 (CI 1.7-338, P = 0.019), respectively. Thrombocytopenia was significantly associated with major bleeding events and nonbleeding-related death. CONCLUSIONS: Thrombocytopenia in the era of potent antiretroviral therapy is associated with hepatitis C virus infection, cirrhosis, and uncontrolled HIV replication, and serious complications including major bleeding and death.

Life cycle of Phoebemima ensifera Tippmann (Coleoptera, Cerambycidae) / Ciclo vital de Phoebemima ensifera Tippmann (Coleoptera, Cerambycidae)

An account of host plant selection, larval development and behaviour, and behaviour of adult Phoebemima ensifera. Illustrations of the host plant, plant parts, larva, pupa, and adult are provided.

Descreve-se a seleção da planta hospedeira, desenvolvimento e comportamento larval, e comportamento do adulto de Phoebemima ensifera. Ilustrações da planta-hospedeira, larva, pupa e adultos são fornecidas.