Bridge to transplant or recovery in cardiogenic shock in a developing country.

Background Durable mechanical support devices are prohibitively expensive in our health system and may be unsuitable for critically ill patients. CentriMag is an alternative bridge to transplantation or recovery. Methods We retrospectively reviewed 28 patients (23 males) aged 13-60 years who received CentriMag support. The etiology was ischemic in 13 (46%), dilated cardiomyopathy in 8 (29%), and others in 7 (25%). All patients were in Interagency Registry for Mechanically Assisted Circulatory Support class I, and 27 (96%) had multiorgan failure; 2 (7%) were post-cardiotomy and 12 (43%) had a previous cardiac arrest (mean arrest time 21 ± 17 min). Results Thirty-day post-implant survival was 79% (22 patients). Twenty (71%) patients were successfully bridged to transplantation or recovery. The mean support time was 40 days; 12 (43%) patients had >4-weeks' support (longest was 292 days). Eight (29%) patients died on support. Complications included bleeding in 10 (36%) cases, immediate stroke in 4 (14%), and dialysis in 8 (29%). There was no stroke during subsequent support. Eighteen (64%) patients underwent transplantation, and 17 of them were discharged. Two (7%) patients recovered and were discharged. Two-year survival was 62% ± 10%. Mean follow-up was 21 months (total follow-up 579 months). Two (7%) patients died during follow-up. All survivors were in New York Heart Association class I. Conclusions CentriMag is useful for medium-term support for cardiogenic shock in a developing country. Support for >4 weeks is feasible. The stroke rate is low during support. The major drawback is prolonged intensive care unit stay.

Development and evaluation of the CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey for in-center hemodialysis patients.

BACKGROUND: The US Centers for Medicare & Medicaid Services assess patient experiences of care as part of the end-stage renal disease prospective payment system and Quality Incentive Program. This article describes the development and evaluation of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) In-Center Hemodialysis Survey. STUDY DESIGN: We conducted formative research to generate survey questions and performed statistical analyses to evaluate the survey's measurement properties. SETTING & PARTICIPANTS: Formative research included focus groups, cognitive interviews, and field testing the survey with dialysis patients. MEASUREMENTS & OUTCOMES: We assessed internal consistency reliability (Cronbach alpha) and center-level reliability for 3 multi-item scales. We evaluated construct validity using correlations of the scales with global ratings of the kidney doctor, staff, and dialysis center. RESULTS: Response rate was 46% (1,454 completed surveys). Analyses support 3 multi-item scales: Nephrologists' Communication and Caring (7 items, alpha=0.89), Quality of Dialysis Center Care and Operations (22 items, alpha=0.93), and Providing Information to Patients (11 items, alpha=0.75). The communication scale was correlated the most strongly with the global rating of the "kidney doctor" (r=0.78). The Dialysis Center Care and Operations scale was correlated most strongly with global ratings of staff (r=0.75) and the center (r=0.69). Providing Information to Patients was correlated most strongly with the global rating of the staff (r=0.41). LIMITATIONS: A relatively small number of patients completed the survey in Spanish. CONCLUSIONS: This study provides support for the reliability and validity of the CAHPS In-Center Hemodialysis Survey for assessing patient experiences of care at dialysis facilities. The survey can be used to compare care provided at different facilities.

Knowledge and behavioral effects in cardiovascular health: Community Health Worker Health Disparities Initiative, 2007-2010.

INTRODUCTION: Cardiovascular disease is the leading cause of death in the United States, and disparities in cardiovascular health exist among African Americans, American Indians, Hispanics, and Filipinos. The Community Health Worker Health Disparities Initiative of the National Heart, Lung, and Blood Institute (NHLBI) includes culturally tailored curricula taught by community health workers (CHWs) to improve knowledge and heart-healthy behaviors in these racial/ethnic groups. METHODS: We used data from 1,004 community participants in a 10-session curriculum taught by CHWs at 15 sites to evaluate the NHLBI's health disparities initiative by using a 1-group pretest-posttest design. The curriculum addressed identification and management of cardiovascular disease risk factors. We used linear mixed effects and generalized linear mixed effects models to examine results. RESULTS: Average participant age was 48; 75% were female, 50% were Hispanic, 35% were African American, 8% were Filipino, and 7% were American Indian. Twenty-three percent reported a history of diabetes, and 37% reported a family history of heart disease. Correct pretest to posttest knowledge scores increased from 48% to 74% for heart healthy knowledge. The percentage of participants at the action or maintenance stage of behavior change increased from 41% to 85%. CONCLUSION: Using the CHW model to implement community education with culturally tailored curricula may improve heart health knowledge and behaviors among minorities. Further studies should examine the influence of such programs on clinical risk factors for cardiovascular disease.

Experiencia clínica con 53 trasplantes cardiacos consecutivos / Clinical experience with 53 consecutive heart transplants

Introduction: Heart transplantation is the therapy of choice for advance heart failure. Our group developed two transplant programs at Instituto Nacional del Tórax and Clínica Dávila. We report our clinical experience based on distinctive clinical policies. Patients and Methods: Fifty-three consecutive patients were transplanted between November 2008 and April 2013, representing 51% of all Chilean cases. Distinctive clinical policies include intensive donor management, generic immunosuppression and VAD (ventricular assist devices) insertion. Results: Ischemic or dilated cardiomyopathy were the main indications (23 (43%) each), age 48 ± 13 years and 48 (91%) were male. Transplant listing Status: IA 14 (26%) (VAD or 2 inotropes), IB 14 (26%) (1 inotrope) and II25 (47%) (no inotrope). Mean waiting time 70 ± 83 days. Twelve (24%) were transplanted during VAD support (median support: 36 days). Operative technique: orthotopic bicaval transplant with ischemia time: 175 ± 54 min. Operative mortality: 3 (6%), all due to right ventricular failure. Re-exploration for bleeding 2 (4%), stroke 3 (6%), mediastinitis 0 (0%), pneumonia 4 (8%), and transient dialysis 6 (11%). Mean follow-up was 21 ± 14 months. Three-year survival was 86 ± 6%. One patient died of Pneumocystis jirovecii pneumonia and the other died suddenly (non-compliance). Freedom from rejection requiring specific therapy was 80 ± 7% at 3 years of follow-up. Four hundred eighty four endomyocardial biopsies were done: 11 (2.3%) had 2R rejection. All survivors are in NYHA (New York Heart Association) functional class I and all but one have normal biventricular function. Conclusion: Mid-term results are similar to those reported by the registry of the International Society for Heart and Lung Transplantation. This experience has a higher proportion of VAD support than previous national series. Rejection rates are low in spite of generic immunosuppression.

[Clinical experience with 53 consecutive heart transplants]. / Experiencia clínica con 53 trasplantes cardiacos consecutivos.

INTRODUCTION: Heart transplantation is the therapy of choice for advance heart failure. Our group developed two transplant programs at Instituto Nacional del Tórax and Clínica Dávila. We report our clinical experience based on distinctive clinical policies. PATIENTS AND METHODS: Fifty-three consecutive patients were transplanted between November 2008 and April 2013, representing 51% of all Chilean cases. Distinctive clinical policies include intensive donor management, generic immunosuppression and VAD (ventricular assist devices) insertion. RESULTS: Ischemic or dilated cardiomyopathy were the main indications (23 (43%) each), age 48 ± 13 years and 48 (91%) were male. Transplant listing Status: IA 14 (26%) (VAD or 2 inotropes), IB 14 (26%) (1 inotrope) and II25 (47%) (no inotrope). Mean waiting time 70 ± 83 days. Twelve (24%) were transplanted during VAD support (median support: 36 days). OPERATIVE TECHNIQUE: orthotopic bicaval transplant with ischemia time: 175 ± 54 min. Operative mortality: 3 (6%), all due to right ventricular failure. Re-exploration for bleeding 2 (4%), stroke 3 (6%), mediastinitis 0 (0%), pneumonia 4 (8%), and transient dialysis 6 (11%). Mean follow-up was 21 ± 14 months. Three-year survival was 86 ± 6%. One patient died of Pneumocystis jirovecii pneumonia and the other died suddenly (non-compliance). Freedom from rejection requiring specific therapy was 80 ± 7% at 3 years of follow-up. Four hundred eighty four endomyocardial biopsies were done: 11 (2.3%) had 2R rejection. All survivors are in NYHA (New York Heart Association) functional class I and all but one have normal biventricular function. CONCLUSION: Mid-term results are similar to those reported by the registry of the International Society for Heart and Lung Transplantation. This experience has a higher proportion of VAD support than previous national series. Rejection rates are low in spite of generic immunosuppression.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) cultural competence (CC) item set.

BACKGROUND: There is a need for reliable and valid measures of cultural competence (CC) from the patient's perspective. OBJECTIVE: This paper evaluates the reliability and validity of the Consumer Assessments of Healthcare Providers and Systems (CAHPS) CC item set. RESEARCH DESIGN: Using 2008 survey data, we assessed the internal consistency of the CAHPS CC scales using the Cronbach α's and examined the validity of the measures using exploratory and confirmatory factor analysis, multitrait scaling analysis, and regression analysis. SUBJECTS: A random stratified sample (based on race/ethnicity and language) of 991 enrollees, younger than 65 years, from 2 Medicaid managed care plans in California and New York. MEASURES: CAHPS CC item set after excluding screener items and ratings. RESULTS: Confirmatory factor analysis (Comparative Fit Index=0.98, Tucker Lewis Index=0.98, and Root Mean Square Error or Approximation=0.06) provided support for a 7-factor structure: Doctor Communication--Positive Behaviors, Doctor Communication--Negative Behaviors, Doctor Communication--Health Promotion, Doctor Communication--Alternative Medicine, Shared Decision-Making, Equitable Treatment, and Trust. Item-total correlations (corrected for item overlap) for the 7 scales exceeded 0.40. Exploratory factor analysis showed support for 1 additional factor: Access to Interpreter Services. Internal consistency reliability estimates ranged from 0.58 (Alternative Medicine) to 0.92 (Positive Behaviors) and was 0.70 or higher for 4 of the 8 composites. All composites were positively and significantly associated with the overall doctor rating. CONCLUSIONS: The CAHPS CC 26-item set demonstrates adequate measurement properties and can be used as a supplemental item set to the CAHPS Clinician and Group Surveys in assessing culturally competent care from the patient's perspective.

Comparing physician and patient perceptions of quality in ambulatory care.

OBJECTIVE: If quality improvement interventions, value-based purchasing and/or certification are based on patient assessments, a common definition of quality should be shared by clinicians and patients. The study's objectives were to determine (i) how patients and clinicians define quality care, (ii) in what ways patients' and physicians' definitions differ and (iii) whether patients' definitions vary by ethnicity. DESIGN: We used the critical incident technique to interview participants about behaviors that resulted in office visits being considered either good or poor quality and compared the prevalence of different types of 'quality' behaviors reported to identify commonalities and differences. SETTING: Hawaii and Chicago. PARTICIPANTS: A total of 168 patients and 39 clinicians. RESULTS: We developed a taxonomy, comprising 9 major categories and 106 subcategories of behaviors responsible for quality visits. Almost all clinicians and patients agreed that clinical skill, rapport and health-related communication behaviors were key elements. Patients were more likely to report behaviors demonstrating thoroughness in routine examinations, spending enough time with them, engaging them and being treated with courtesy and respect as drivers of a quality office visit than were physicians. CONCLUSIONS: Increased clinician awareness of the behaviors that patients believe are the drivers of a quality office visit can help clinicians improve patients' experience of care and experience-based measures of quality.

Implication of NADPH oxidases in the early inflammation process generated by cystic fibrosis cells.

In cystic fibrosis (CF) patients, pulmonary inflammation is a major cause of morbidity and mortality. The aim of this study was to further investigate whether oxidative stress could be involved in the early inflammatory process associated with CF pathogenesis. We used a model of CFTR defective epithelial cell line (IB3-1) and its reconstituted CFTR control (S9) cell line cultured in various ionic conditions. This study showed that IB3-1 and S9 cells expressed the NADPH oxidases (NOXs) DUOX1/2 and NOX2 at the same level. Nevertheless, several parameters participating in oxidative stress (increased ROS production and apoptosis, decreased total thiol content) were observed in IB3-1 cells cultured in hypertonic environment as compared to S9 cells and were inhibited by diphenyleneiodonium (DPI), a well-known inhibitor of NOXs; besides, increased production of the proinflammatory cytokines IL-6 and IL-8 by IB3-1 cells was also inhibited by DPI as compared to S9 cells. Furthermore, calcium ionophore (A23187), which upregulates DUOX and NOX2 activities, strongly induced oxidative stress and IL-8 and IL-6 overexpression in IB3-1 cells. All these events were suppressed by DPI, supporting the involvement of NOXs in the oxidative stress, which can upregulate proinflammatory cytokine production by the airway CFTR-deficient cells and trigger early pulmonary inflammation in CF patients.

Enabling a survey of primary care to measure the health care experiences of adults with disabilities.

PURPOSE: To enable an existing survey on primary care so that it can be used to assess the healthcare experiences reported by adults living with disabilities, and to evaluate its properties. METHODS: Mixed-methods study. We first identified content areas for measurement as compared to the items in the existing instrument and then developed new candidate items. Cognitive testing was conducted in English and Spanish. After revisions to the primary care instrument based on the cognitive testing results, the draft-enabled instrument was field-tested by mail with telephone follow-up, in English and Spanish. RESULTS: Consumer focus groups and a technical expert panel identified eight content areas in primary care that are particularly important to maximise function and well-being of people of with disabilities. Cognitive testing also revealed serious problems with several items in the existing survey when answered by or about people with disabilities. Field testing yielded 1086 surveys, of which 40% were completed by a proxy respondent. Learning disabilities were reported by 38% of respondents. Item non-response for revised and new questions was less than 4%. CONCLUSIONS: It is feasible to enable a survey of primary care and its administration. Survey administration instructions should be modified to accommodate proxy respondents. The screener item to identify people with mobility impairments on walking a distance should be replaced with walking for 6 min. Adding questions from the American Community Survey about functional ability will allow survey sponsors to identify respondents with various limitations, and to compare their experiences to those of people with no limitations. Careful development and testing of the items with input from interested parties throughout the design and testing stages yielded a survey with good psychometric properties and content validity in multiple languages. Health delivery systems can use the survey data to identify clinical processes needing improvement to provide high quality care for people with disabilities.

Antibodies to mutated citrullinated vimentin for diagnosing rheumatoid arthritis in anti-CCP-negative patients and for monitoring infliximab therapy.

INTRODUCTION: Antibodies against cyclic citrullinated peptides (CCPs) are useful for diagnosing rheumatoid arthritis (RA). Antibodies to mutated citrullinated vimentin (MCV) were described recently in RA. The aims of this study were to evaluate the usefulness of anti-MCV for diagnosing RA in anti-CCP-negative patients and to monitor anti-MCV titres during infliximab therapy for RA. METHODS: We studied two groups of RA patients, one with (n = 80) and one without (n = 76) anti-CCP antibodies. The specificity of anti-MCV was evaluated by investigating 50 healthy controls and 158 patients with other rheumatic diseases (51 psoriatic rheumatism, 58 primary Sjögren syndrome, and 49 ankylosis spondylitis). Serum anti-MCV and anti-CCP titres were measured in 23 patients after 6, 12, 18, and 24 months of infliximab treatment. Anti-CCP2 and anti-MCV levels were assayed using a commercial enzyme-linked immunosorbent assay. IgM rheumatoid factor was determined by nephelometry. RESULTS: In accordance with the cutoff values recommended by the manufacturer, the specificity of anti-MCV antibodies was 90.9%. We adjusted the cutoff values to obtain the same specificity as that of anti-CCP antibodies (94.2%). With this optimal cutoff, anti-MCV antibodies were found in 11.8% (9/76) of RA patients without anti-CCP, and similarly, anti-CCP antibodies were found in 11.2% (9/80) of RA patients without anti-MCV. Anti-MCV antibodies were positive in 6 patients who tested negative for both anti-CCP and rheumatoid factor. Anti-MCV titres were significantly decreased after 18 and 24 months of infliximab therapy compared with baseline (P < 0.01) as a significant decrease of anti-CCP levels occurred only at 24 months (P < 0.04). Moreover, an anti-MCV decrease was significantly associated with DAS28 (disease activity score using 28 joint counts) improvements 12 months into therapy. CONCLUSIONS: Our results suggest that anti-MCV antibodies may be valuable for diagnosing RA in anti-CCP-negative patients without replacing them as an equivalent number of anti-CCP-positive RA patients test negative for anti-MCV. Moreover, anti-MCV antibodies could be useful for monitoring the effects of infliximab therapy.

Is procalcitonin a marker of critical illness in heatstroke?

OBJECTIVE: To study the effect of non-exertional heatstroke on serum procalcitonin (PCT) levels. DESIGN: Cohort study. SETTING: The emergency and intensive care departments of two academic tertiary-care hospitals, Paris, France PATIENTS: A total of 53 patients with defined heatstroke attending the emergency department and/or the intensive care unit during the August 2003 heat wave in France. INTERVENTIONS: None. MEASUREMENTS: Serum PCT measurement using a sensitive assay and vital and routine biological variables on arrival of patients presenting with classic heatstroke. Thirty-day mortality was recorded. RESULTS: Among the 53 patients included, 14 (26%) were admitted to an intensive care unit (ICU). At 30 days, 24 patients (45%) had died. Median PCT value was 0.58 microg/l (95% confidence interval 0.16-1.61) and 31 (58%) patients had PCT above 0.2 microg/l (PCT+). Temperature above or equal to 40 degrees C was the only variable significantly associated with fatal outcome. Median PCT values were 1.4 microg/l (0.16-4.71) and 0.18 microg/l (0.12-1.61) in the group of deceased and surviving patients respectively (p = 0.22). All patients admitted in ICU had elevated PCT values. Patients PCT+ initially presented with a more pronounced systemic inflammatory response. Microbiologically or clinically documented infection was not more frequent in PCT+ group. CONCLUSION: High serum PCT levels can be observed in heatstroke without any concomitant documented bacterial infection. The PCT is not a valid mortality predictor in heatstroke but could be an indicator of the severity of illness. Heatstroke could represent a model of a "non-septic" pathway of PCT synthesis.

Assessment of the equivalence of the Spanish and English versions of the CAHPS Hospital Survey on the quality of inpatient care.

OBJECTIVE: To describe translation and cultural adaptation procedures, and examine the degree of equivalence between the Spanish and English versions of the Agency for Healthcare Research and Quality's (AHRQ) Consumer Assessments of Healthcare Providers and Systems (CAHPS) Hospital Survey (H-CAHPS) of patient experiences with care. DATA SOURCES: Cognitive interviews on survey comprehension with 12 Spanish-speaking and 31 English-speaking subjects. Psychometric analyses of 586 responses to the Spanish version and 19,134 responses to the English version of the H-CAHPS survey tested in Arizona, Maryland, and New York in 2003. STUDY DESIGN: A forward/backward translation procedure followed by committee review and cognitive testing was used to ensure a translation that was both culturally and linguistically appropriate. Responses to the two language versions were compared to evaluate equivalence and assess the reliability and validity of both versions. DATA COLLECTION/EXTRACTION METHODS: Comparative analyses were carried out on the 32 items of the shortened survey version, focusing on 16 items that comprise seven composites representing different aspects of hospital care quality (communication with nurses, communication with doctors, communication about medicines, nursing services, discharge information, pain control, and physical environment); three items that rate the quality of the nursing staff, physician staff, and the hospital overall; one item on intention to recommend the hospital. The other 12 items used in the analyses addressed mainly respondent characteristics. Analyses included item descriptives, correlations, internal consistency reliability of composites, factor analysis, and regression analysis to examine construct validity. PRINCIPAL FINDINGS: Responses to both language versions exhibit similar patterns with respect to item-scale correlations, factor structure, content validity, and the association between each of the seven qualities of care composites with both the hospital rating and intention to recommend the hospital. Internal consistency reliability was slightly, yet significantly lower for the Spanish-language respondents for five of the seven composites, but overall the composites were generally equivalent across language versions. CONCLUSIONS: The results provide preliminary evidence of the equivalence between the Spanish and English versions of H-CAHPS. The translated Spanish version can be used to assess hospital quality of care for Spanish speakers, and compare results across these two language groups.

Envisioning the National Health Care Quality Report March 2001

This publication represents the quality of health care received by the people of the United States falls far short of what it should be. There is a gap between the health care services that should be provided based on current professional knowledge and technology and those that many patients actually receive. It is clear that all resources are not used effectively or safety. Study after study documents are overuse of many services-the provisions of services when the potential for harm overweighs possible benefits. At the same time studies also documents underuse of other services-the failure to provide services from which the patient would likely have benefited.