A narrow repertoire of transcriptional modules responsive to pyogenic bacteria is impaired in patients carrying loss-of-function mutations in MYD88 or IRAK4.

Loss of function of the kinase IRAK4 or the adaptor MyD88 in humans interrupts a pathway critical for pathogen sensing and ignition of inflammation. However, patients with loss-of-function mutations in the genes encoding these factors are, unexpectedly, susceptible to only a limited range of pathogens. We employed a systems approach to investigate transcriptome responses following in vitro exposure of patients' blood to agonists of Toll-like receptors (TLRs) and receptors for interleukin 1 (IL-1Rs) and to whole pathogens. Responses to purified agonists were globally abolished, but variable residual responses were present following exposure to whole pathogens. Further delineation of the latter responses identified a narrow repertoire of transcriptional programs affected by loss of MyD88 function or IRAK4 function. Our work introduces the use of a systems approach for the global assessment of innate immune responses and the characterization of human primary immunodeficiencies.

Impact of an electronic medium delivery of warfarin education in a low income, minority outpatient population: a pilot intervention study.

BACKGROUND: Warfarin is classified as a high-alert medication for ambulatory healthcare and safe guards for high-alert medications are necessary, including the practice of mandatory patient education. The high cost of hospitalizations related to adverse events combined with the average bleeding event rate of 7-8% in spite of routine patient education, suggests the importance of new approaches to standardized health education on warfarin. We sought to evaluate the impact of a warfarin educational video using an electronic tablet on patient knowledge and to determine patients' satisfaction with the use of an electronic tablet for educational purposes in outpatient clinics serving a low income, minority population. METHODS: A warfarin educational video delivered on an electronic tablet (iPad) was delivered at two pharmacist-managed anticoagulation clinics to uninsured patients whose annual income is equal or less than two hundred percent below the poverty level were offered. Patients (n = 18) completed a pre-video and post-video knowledge test on warfarin before and after viewing the warfarin educational video on an electronic tablet and a follow-up test to measure the retention of knowledge and a patient satisfaction survey at 60 days. The primary outcome was change in knowledge test scores. Other outcome measures included adherence rates, adverse events, time in therapeutic INR range, and patient-reported satisfaction scores. RESULTS: The majority of patients were uninsured men taking warfarin for atrial fibrillation (n = 5). The median scores at post-video knowledge test and follow-up knowledge test were significantly higher than that for the pre-knowledge test (12 (11-12) vs. 10(8-11), p < 0.001). The study group had a 'time in therapeutic INR' range of 56.3%, a rate of adverse events of 24.5%, and a self-reported adherence rate to warfarin of 94.1%. The majority of patients also had positive responses to the patient satisfaction survey. CONCLUSIONS: Patient education delivered via iPad to facilitate knowledge of medication can serve as a useful tool for educating patients about warfarin and warfarin therapy. Use of an electronic medium may be a unique way to provide standard medication education to patients. TRIAL REGISTRATION: The study was retrospectively registered with: NCT03650777 ; 9/18/18.

Utilization of high donor sequence number grafts in cardiac transplantation.

Donor sequence number (DSN) represents the number of candidates to whom a graft was offered and declined prior to acceptance for transplantation. We sought to investigate the outcomes of patients receiving high DSN grafts. Consecutive isolated adult cardiac transplantations performed at a single-center were reviewed. Recipients were grouped into standard (≤75th percentile) DSN and high (>75th percentile) DSN. A previously validated donor risk index was used to quantify the risk associated with donor grafts, and recipient outcomes were assessed. Overall, 254 patients were included: 194 standard DSN (range 1-79) and 60 high DSN (range 82-1723). High DSN grafts were harvested at greater distance (P < .001) with increased ischemia time (P < .001), resulting in a modest increase in donor risk index (1 point median difference, P = .014). High DSN recipients were less frequently listed as UNOS status 1A (P < .001). Despite a nonsignificant trend toward increased in-hospital/30-day mortality in high DSN recipients, there were no differences in primary graft dysfunction or 1-year survival (high DSN 89% vs standard DSN 88%, P = .82). After adjustment for risk factors, high DSN was not associated with increased 1-year mortality (hazard ratio 1.18, 95%-CI 0.54-2.58, P = .68).

The effect of vertical split-flow patient management on emergency department throughput and efficiency.

BACKGROUND: To address emergency department overcrowding operational research seeks to identify efficient processes to optimize flow of patients through the emergency department. Vertical flow refers to the concept of utilizing and assigning patients virtual beds rather than to an actual physical space within the emergency department to care of low acuity patients. The aim of this study is to evaluate the impact of vertical flow upon emergency department efficiency and patient satisfaction. METHODS: Prospective pre/post-interventional cohort study of all intend-to-treat patients presenting to the emergency department during a two-year period before and after the implementation of a vertical flow model. RESULTS: In total 222,713 patient visits were included in the analysis with 107,217 patients presenting within the pre-intervention and 115,496 in the post-intervention groups. The results of the regression analysis demonstrate an improvement in throughput across the entire ED patient population, decreasing door to departure time by 17 min (95% CI 15-18) despite an increase in patient volume. No statistically significant difference in patient satisfaction scores were found between the pre- and post-intervention. CONCLUSIONS: Initiation of a vertical split flow model was associated with improved ED efficiency.

The Effect of Delayed Cord Clamping on Moderate and Early Late-Preterm Infants.

OBJECTIVE: This study aims to evaluate the clinical consequences of protocol-driven delayed umbilical cord clamping (DCC) implementation in moderate and early late-preterm (MELP) infants born between 320/7 and 346/7 weeks gestation. STUDY DESIGN: We conducted a prospective cohort study with a historic control cohort comparison. The prospective study period was 1 year when DCC was performed for 60 seconds duration (DCC cohort, n = 106). The study period for historic control cohort with no DCC was also 1 year before DCC implementation (historic cohort, n = 137). RESULTS: The mean hematocrit at birth was significantly higher in the DCC cohort compared with the historic cohort (49.1 ± 14.9 vs. 45.7 ± 15.7; p = 0.01). Fewer infants in the DCC cohort were admitted to neonatal intensive care unit (NICU) on respiratory support compared with the historic cohort (17.9 vs. 29.9%; p = 0.04). The incidence of respiratory distress syndrome was significantly lower in the DCC cohort compared with the historic cohort (2.8 vs. 14.6%; p = 0.002). There were no differences in the incidence of phototherapy or NICU length of stay (LOS) between groups. CONCLUSION: In MELP infants, DCC was associated with increased hematocrit and better respiratory transition at birth. DCC was not associated with increased phototherapy or NICU LOS.

Implementation of an Automatic Stop Order and Initial Antibiotic Exposure in Very Low Birth Weight Infants.

Objective To evaluate if an antibiotic automatic stop order (ASO) changed early antibiotic exposure (use in the first 7 days of life) or clinical outcomes in very low birth weight (VLBW) infants. Study Design We compared birth characteristics, early antibiotic exposure, morbidity, and mortality data in VLBW infants (with birth weight <= 1500 g) born 2 years before (pre-ASO group, n = 313) to infants born in the 2 years after (post-ASO, n = 361) implementation of an ASO guideline. Early antibiotic exposure was quantified by days of therapy (DOT) and antibiotic use > 48 hours. Secondary outcomes included mortality, early mortality, early onset sepsis (EOS), and necrotizing enterocolitis. Results Birth characteristics were similar between the two groups. We observed reduced median antibiotic exposure (pre-ASO: 6.5 DOT vs. Post-ASO: 4 DOT; p < 0.001), and a lower percentage of infants with antibiotic use > 48 hours (63.4 vs. 41.3%; p < 0.001). There were no differences in mortality (12.1 vs 10.2%; p = 0.44), early mortality, or other reported morbidities. EOS accounted for less than 10% of early antibiotic use. Conclusion Early antibiotic exposure was reduced after the implementation of an ASO without changes in observed outcomes.

Effect of delayed cord clamping on very preterm infants.

OBJECTIVE: Despite significant proposed benefits, delayed umbilical cord clamping (DCC) is not practiced widely in preterm infants largely because of the question of feasibility of the procedure and uncertainty regarding the magnitude of the reported benefits, especially intraventricular hemorrhage (IVH) vs the adverse consequences of delaying the neonatal resuscitation. The objective of this study was to determine whether implementation of the protocol-driven DCC process in our institution would reduce the incidence of IVH in very preterm infants without adverse consequences. STUDY DESIGN: We implemented a quality improvement process for DCC the started in August 2013 in infants born at ≤32 weeks' gestational age. Eligible infants were left attached to the placenta for 45 seconds after birth. Neonatal process and outcome data were collected until discharge. We compared infants who received DCC who were born between August 2013 and August 2014 with a historic cohort of infants who were born between August 2012 and August 2013, who were eligible to receive DCC, but whose cord was clamped immediately after birth, because they were born before the protocol implementation. RESULTS: DCC was performed on all the 60 eligible infants; 88 infants were identified as historic control subjects. Gestational age, birthweight, and other demographic variables were similar between both groups. There were no differences in Apgar scores or admission temperature, but significantly fewer infants in the DCC cohort were intubated in delivery room, had respiratory distress syndrome, or received red blood cell transfusions in the first week of life compared with the historic cohort. A significant reduction was noted in the incidence of IVH in the DCC cohort compared with the historic control group (18.3% vs 35.2%). After adjustment for gestational age, an association was found between the incidence of IVH and DCC with IVH was significantly lower in the DCC cohort compared with the historic cohort; an odds ratio of 0.36 (95% confidence interval, 0.15-0.84; P < .05). There were no significant differences in deaths and other major morbidities. CONCLUSION: DCC, as performed in our institution, was associated with significant reduction in IVH and early red blood cell transfusions. DCC in very preterm infants appears to be safe, feasible, and effective with no adverse consequences.

Skin cancer evaluation in transplant patients: a physician opinion survey with recommendations.

BACKGROUND: Non-melanoma skin cancer is the most common malignancy in transplant patients. However, routine skin cancer evaluation is currently not the standard of care. OBJECTIVE: To investigate the current barriers among transplant physicians to skin cancer screening in their patients. To provide recommendations for appropriate routine skin surveillance. METHODS: A web-based survey was conducted among Baylor, Dallas transplant physicians. Thirty-seven of 46 responses were received, and 13 physicians (28%) were classified as "high screeners." RESULTS: The univariate analysis revealed three main barriers including the perception of difficulty in seeing a dermatologist (p = 0.017), skin cancer evaluation is not an important aspect of transplant care (p = 0.038), and thirdly, the belief that there is insufficient evidence to warrant universal skin cancer screening in transplant patients (p = 0.013). The fully adjusted multivariable analysis resulted in two significant conclusions; the most important predictor was the perceived lack of medical evidence for skin cancer screening. LIMITATIONS: The small sample size and all responses being from the same institution in Texas. CONCLUSION: The dermatologic evidence for regular skin cancer screening in transplant patients needs dissemination to our transplant colleagues. This is a significant practice gap which can be appropriately closed by integrating dermatologists into the transplant team.

Differences in antibody responses between trivalent inactivated influenza vaccine and live attenuated influenza vaccine correlate with the kinetics and magnitude of interferon signaling in children.

BACKGROUND: Live attenuated influenza vaccine (LAIV) and trivalent inactivated influenza vaccine (TIV) are effective for prevention of influenza virus infection in children, but the mechanisms associated with protection are not well defined. METHODS: We analyzed the differences in B-cell responses and transcriptional profiles in children aged 6 months to 14 years immunized with these 2 vaccines. RESULTS: LAIV elicited a significant increase in naive, memory, and transitional B cells on day 30 after vaccination, whereas TIV elicited an increased number of plasmablasts on day 7. Antibody titers against the 3 vaccine strains (H1N1, H3N2, and B) were significantly higher in the TIV group and correlated with number of antibody-secreting cells. Both vaccines induced overexpression of interferon (IFN)-signaling genes but with different kinetics. TIV induced expression of IFN genes on day 1 after vaccination in all age groups, and LAIV induced expression of IFN genes on day 7 after vaccination but only in children <5 years old. IFN-related genes overexpressed in both vaccinated groups correlated with H3N2 antibody titers. CONCLUSIONS: These results suggest that LAIV and TIV induced significantly different B-cell responses in vaccinated children. Early induction of IFN appears to be important for development of antibody responses.

A High Level of Patient Activation Is Observed But Unrelated to Glycemic Control Among Adults With Type 2 Diabetes.

OBJECTIVE: To measure patient activation and its relationship to glycemic control among adults with type 2 diabetes who had not participated in a formal diabetes self-management education program as a baseline assessment for tailoring diabetes education in a primary care setting. RESEARCH DESIGN AND METHODS: Patient activation was assessed in a stratified, cross-sectional study of adults with controlled (n = 21) and uncontrolled (n = 27) type 2 diabetes, who were receiving primary care at a unique family practice center of Baylor Health Care System in Dallas, Tex. RESULTS: The mean patient activation was 66.0 (95% confidence interval [CI] 60.8-71.2) among patients with uncontrolled diabetes and 63.7 (55.9-71.5) among those with controlled diabetes (P = 0.607). A significant association was observed between the self-management behavior score and activation among patients whose glycemia was under control (ρ = 0.73, P = 0.01) as well as among patients with uncontrolled glycemia (ρ = 0.48, P < 0.001). CONCLUSIONS: Although activation is correlated with self-management and may be important in tailored patient-centered approaches to improving diabetes care outcomes, the highest stage of activation may be necessary to achieve glycemic control. These findings reinforce the importance of conducting prerequisite needs assessments so diabetes educators are able to tailor their educational interventions to individual patients' needs and readiness to take action.

Meta-analysis of fall-risk tools in hospitalized adults.

OBJECTIVE: The aim of the study was to identify which fall-risk tool is most accurate for assessing adults in the hospital setting. BACKGROUND: Falls can have physical, emotional, social, and financial consequences. Risk assessment affords the first opportunity in prevention. METHODS: To standardize the use of a fall-risk tool across the Baylor Health Care System, nurse executives undertook a meta-analysis of published research on fall-risk assessment tools used with adult inpatients. RESULTS: Both random-effects and fixed-effects models showed that Morse Fall Scale had significantly higher sensitivity than St Thomas's Risk Assessment Tool (STRATIFY). Specificity of Morse Fall Scale was significantly lower than that of STRATIFY with the fixed-effects model, but the random-effects model showed the opposite. Morse Fall Scale had a significantly higher Youden index than STRATIFY with the fixed-effects model (P = .001), but the result from random-effects model indicated no significant difference (P = .117). The sensitivity, specificity, and Youden index fell within the 95% confidence intervals. CONCLUSIONS: Meta-analysis is a useful methodology for evaluating current evidence when variation exists in the literature.

Chemopreventive properties of pinoresinol-rich olive oil involve a selective activation of the ATM-p53 cascade in colon cancer cell lines.

UNLABELLED: The Mediterranean diet is rich in extra virgin olive oil (EVOO) and associated with a lower incidence of colorectal cancer. EVOO contains phenolic extracts with potential anticarcinogenic activity. AIM: To assess the anticancer properties of EVOO phenolic extracts using in vitro models. METHODS: Phenolic profiles of two different EVOOs (A and B) were determined. RKO and HCT116 (both p53 proficient), SW480 (p53 mutant) and HCT116(p53-/-) (p53 knocked out) cell lines were treated with EVOO extracts and assessed for cell viability. Apoptosis was determined by terminal deoxynucleotidyl transferase nick end labeling (TUNEL) assay and changes in Bax transcript levels. Cell cycle analysis was determined by flow cytometry and western blots. To confirm the data, analysis of cell viability and cell cycle was performed with purified pinoresinol. RESULTS: Chemical characterization showed that pinoresinol is the main phenol in EVOO-A, and oleocanthal predominates in EVOO-B. Only EVOO-A affected cell viability, which was significantly more pronounced in p53-proficient cells. At a concentration of 200 nM, p53-proficient cells showed increased apoptosis and G(2)/M arrest. In p53-proficient cells, ataxia telangiectasia mutated (ATM) and its downstream-controlled proteins were upregulated after treatment, with a parallel decrease of cyclin B/cdc2. Identical results on cell viability and cell cycle were obtained with purified pinoresinol, but this required a higher concentration than in EVOO-A. CONCLUSION: Our results demonstrate that pinoresinol-rich EVOO extracts have potent chemopreventive properties and specifically upregulate the ATM-p53 cascade. This result was achieved at substantially lower concentrations in EVOO than with purified pinoresinol, indicating a possible synergic effect between the various polyphenols in olive oil.

Improving quality and reducing inequities: a challenge in achieving best care.

The health care quality chasm is better described as a gulf for certain segments of the population, such as racial and ethnic minority groups, given the gap between actual care received and ideal or best care quality. The landmark Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century challenges all health care organizations to pursue six major aims of health care improvement: safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. "Equity" aims to ensure that quality care is available to all and that the quality of care provided does not differ by race, ethnicity, or other personal characteristics unrelated to a patient's reason for seeking care. Baylor Health Care System is in the unique position of being able to examine the current state of equity in a typical health care delivery system and to lead the way in health equity research. Its organizational vision, "culture of quality," and involved leadership bode well for achieving equitable best care. However, inequities in access, use, and outcomes of health care must be scrutinized; the moral, ethical, and economic issues they raise and the critical injustice they create must be remedied if this goal is to be achieved. Eliminating any observed inequities in health care must be synergistically integrated with quality improvement. Quality performance indicators currently collected and evaluated indicate that Baylor Health Care System often performs better than the national average. However, there are significant variations in care by age, gender, race/ethnicity, and socioeconomic status that indicate the many remaining challenges in achieving "best care" for all.

Effect of delay in cord clamping 45 versus 60 s on very preterm singleton infants.

BACKGROUND: In the range of timing suggested by American College of Obstetricians and Gynecologists 30 to 60 s, preterm infants may potentially derive more short and long-term benefits with delayed cord clamping (DCC) for at least 60 s. However, there are concerns with longer resuscitation delay in this vulnerable population. OBJECTIVE: To compare the clinical consequences of 45 versus 60 s delay in umbilical cord clamping in singleton infants born between 230/7 to 316/7 weeks gestation. STUDY DESIGN: We implemented DCC process in very preterm singleton infants, initially for 45 s and later, modified the policy to increase the delay to 60 s. We compared the infants born and received DCC (n = 60) during the 45 s study period (DCC-45 cohort), from Aug.19, 2013, to Aug.18, 2014 to the infants born and received DCC (n = 63) during the 60 s study period (DCC-60 cohort), from Feb.1, 2015, to Jan.31, 2016. RESULTS: The incidence of necrotizing enterocolitis in DCC-60 cohort was 0% compared to 8% in the DCC-45 cohort (P = 0.02). Similarly, incidence of culture-positive sepsis was significantly lower in the DCC-60 cohort compared to DCC-45 cohort (8% versus 18%; P = 0.04). Incidence of mortality and other major morbidities were similar between both groups. Length of stay was significantly lower in DCC-60 cohort compared to DCC-45 cohort. CONCLUSION: DCC for 60 s in very preterm singleton infants was safe, feasible and not associated with any adverse maternal or neonatal short-term outcomes compared to DCC for 45 s.

Salvage of severe primary graft dysfunction following heart transplantation using extracorporeal life support.

Primary graft dysfunction (PGD) is the leading cause of early mortality after heart transplantation. Typically, mechanical circulatory support is necessary to provide hemodynamic support and to enable graft recovery. However, both the reported incidence of PGD and the reported salvage rates with extracorporeal membrane oxygenation (ECMO) vary widely. This may partly be due to variations in the definition of PGD and its levels of severity. We analyzed a prospectively maintained database of 255 transplant recipients at our institution to determine the effectiveness of ECMO support in those who develop severe PGD as defined by the International Society for Heart and Lung Transplantation consensus guidelines. Nineteen (7.5%) patients (aged 32-69 years) developed severe PGD and were treated with veno-arterial (VA) ECMO, which was initiated in the operating room at the time of transplant in most patients. The majority received VA ECMO through femoral cannulation. Two patients required veno-venous ECMO for respiratory support after VA ECMO separation. The 30-day in-hospital survival rate following transplantation was 63% (n = 12). In conclusion, ECMO proved to be a viable option for early hemodynamic support in patients with severe PGD and has become our preferred modality for mechanical circulatory support in these patients.

Donor predicted heart mass as predictor of primary graft dysfunction.

BACKGROUND: Concern over the hazards associated with undersized donor hearts has impeded the utilization of otherwise viable allografts for transplantation. Previous studies have indicated predicted heart mass (PHM) may provide better size matching in cardiac transplantation than total body weight (TBW). We investigated whether size-matching donor hearts by PHM is a better predictor of primary graft dysfunction (PGD) than matching by TBW. METHODS: Records of consecutive adult cardiac transplants performed between 2012 and 2016 at a single-center academic hospital were reviewed. We compared patients implanted with hearts undersized by ≥30% with those implanted with donor hearts matched for size (within 30%), and performed the analysis both for undersizing by PHM and for undersizing by TBW. The primary outcome was moderate/severe PGD within 24 hours, according to the 2014 International Society for Heart and Lung Transplantation consensus. Secondary outcome was 1-year survival. RESULTS: Of 253 patients, 21 (8%) and 30 (12%) received hearts undersized by TBW and PHM, respectively. The overall rate of moderate/severe PGD was 13% (33 patients). PGD was associated with undersizing if performed by PHM (p = 0.007), but not if performed by TBW (p = 0.49). One-year survival was not different between groups (log-rank, p > 0.8). Multivariate analysis confirmed that undersizing donor hearts by PHM, but not by TBW, was predictive of moderate/severe PGD (OR 3.3, 95% CI 1.3 to 8.6). CONCLUSIONS: Undersized donor hearts by ≥30% by PHM may increase rates of PGD after transplantation, confirming that PHM provides more clinically appropriate size matching than TBW. Better size matching may ultimately allow for expanding the donor pool.

Relation of Vasoplegia in the Absence of Primary Graft Dysfunction to Mortality Following Cardiac Transplantation.

Vasoplegia following cardiac transplantation is associated with increased morbidity and mortality. Previous studies have not accounted for primary graft dysfunction (PGD). The definition of vasoplegia is based on pressor requirement at 48 hours, many PGD parameters may have normalized after the initial 24 hours on inotropes. We surmised that the purported negative effects of vasoplegia following transplantation may in part be driven by PGD. We reviewed 240 consecutive adult cardiac transplants at our center between 2012 and 2016. The severity of vasoplegia was evaluated as a risk factor for 1-year survival, and the analysis was repeated for the subgroup of 177 patients who did not develop PGD. Overall, 63 (26%) of patients developed mild, moderate, or severe PGD. In those without PGD, vasoplegia was associated with length of stay but not with short- or long-term mortality. Moderate and/or severe vasoplegia occurred in 35 (15%) patients and was associated with higher short-term mortality, length of stay, and PGD. Multivariate logistic regression identified body mass index ≥35 kg/m2, left ventricular assist device before transplantation, and use of extracorporeal membrane oxygenation as joint risk factors for vasoplegia. In patients without PGD, only left ventricular assist device before transplantation was associated with vasoplegia. In conclusion, our results show that, in the sizeable subgroup of patients with no signs of PGD, vasoplegia had a much more modest impact on post-transplant morbidity and no significant effect on 1- and 3-year survival. This suggests that PGD may be a confounder when assessing vasoplegia as a risk factor for adverse outcomes.

Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation.

OBJECTIVES: Prior sternotomy is associated with increased morbidity and mortality following heart transplantation. However, its effect on primary graft dysfunction (PGD), a major contributor to early mortality, is unknown. Herein, this effect is studied using the International Society for Heart and Lung Transplantation consensus definition for PGD. METHODS: Medical records of consecutive adult cardiac transplants between 2012 and 2016 were reviewed. Baseline characteristics, postoperative findings and 1-year survival were compared between patients with and without prior sternotomy. RESULTS: Among 255 total patients included, 139 (55%) had undergone prior sternotomy; these recipients were older, more often male, had higher body mass index, higher frequencies of united network for organ sharing (UNOS) 1A status and ischaemic cardiomyopathy and experienced longer waitlist times when compared with those without prior sternotomy (all P < 0.018). Postoperatively, the prior sternotomy group exhibited higher rates of mild to severe PGD (32% vs 18%; P = 0.015) and higher short-term mortality (P = 0.017) and 1-year mortality (P = 0.047). They required more blood transfusions, had more postoperative pneumonia, wound infection and longer hospital stays. A stepwise multivariable regression model identified prior sternotomy as a predictor of PGD (odds ratio 2.7). Multiple prior sternotomies was associated with even more UNOS 1A status, ischaemic cardiomyopathy and pneumonia. However, logistic modelling did not show a difference in the rate of PGD between those with 1 or ≥2 prior sternotomies. CONCLUSIONS: Our data suggest that prior sternotomy is a risk factor for PGD. Consistent with previous reports, prior sternotomy is associated with increased morbidity, blood product utilization and 1-year mortality following cardiac transplantation.

Improving delivery of clinical preventive services: a multi-year journey.

BACKGROUND: Adults in the United States typically do not receive all recommended clinical preventive services (CPS) for which they are eligible, missing opportunities for prevention and/or early detection. A multi-year quality improvement initiative targeting CPS delivery in a fee-for-service ambulatory care network is described. METHODS: Since 1999, HealthTexas Provider Network (HTPN) has implemented multiple initiatives to increase CPS delivery, including a flowsheet, a physician champion model, physician- and practice-level audit and feedback, and rapid-cycle quality improvement training. RESULTS: From 2000 to 2006, "recommended or done" CPS delivery increased from 68% to 92%, and "done" from 70% to 86% (2001 to 2006). "Perfect care" composite performance increased from 0.19 to 0.51 (2001 to 2006). CONCLUSIONS: Long-term, multistrategy approaches can achieve substantial sustained improvement in CPS delivery throughout a large ambulatory care provider network.

Reducing Length of Stay, Direct Cost, and Readmissions in Total Joint Arthroplasty Patients With an Outcomes Manager-Led Interprofessional Team.

The purpose of this quality improvement project was to determine whether an outcomes manager-led interprofessional team could reduce length of stay and direct cost without increasing 30-day readmission rates in the total joint arthroplasty patient population. The goal was to promote interprofessional relationships combined with collaborative practice to promote coordinated care with improved outcomes. Results from this project showed that length of stay (total hip arthroplasty [THA] reduced by 0.4 days and total knee arthroplasty [TKA] reduced by 0.6 days) and direct cost (THA reduced by $1,020 per case and TKA reduced by $539 per case) were significantly decreased whereas 30-day readmission rates of both populations were not significantly increased.