Postoperative sepsis prediction in patients undergoing major cancer surgery.

BACKGROUND: Cancer patients are at increased risk for postoperative sepsis. However, studies addressing the issue are lacking. We sought to identify preoperative and intraoperative predictors of 30-d sepsis after major cancer surgery (MCS) and derive a postoperative sepsis risk stratification tool. METHODS: Patients undergoing one of nine MCSs (gastrointestinal, urological, gynecologic, or pulmonary) were identified within the American College of Surgeons National Surgical Quality Improvement Program (2005-2011, n = 69,169). Multivariable adjusted analyses (MVA) were performed to identify the predictors of postoperative sepsis. A composite sepsis risk score (CSRS) was constructed using the regression coefficients of predictors significant on MVA. The score was stratified into low, intermediate, and high risk, and its predictive accuracy for sepsis, septic shock, and mortality was assessed using the area under the curve analysis. RESULTS: Overall, 4.3% (n = 2954) of patients developed postoperative sepsis. In MVA, Black race (odds ratio [OR] = 1.30, P = 0.002), preoperative hematocrit <30 (OR = 1.40, P = 0.022), cardiopulmonary and cerebrovascular comorbidities (P < 0.010), American Society of Anesthesiologists score >3 (P < 0.05), operative time (OR = 1.002, P < 0.001), surgical approach (OR = 1.81, P < 0.001), and procedure type (P < 0.001) were significant predictors of postoperative sepsis. CSRS demonstrated favorable accuracy in predicting postoperative sepsis, septic shock, and mortality (area under the curve 0.72, 0.75, and 0.74, respectively). Furthermore, CSRS risk stratification demonstrated high concordance with sepsis rates, 1.3% in low-risk patients versus 9.7% in high-risk patients. Similarly, 30-d mortality rate varied from 0.5% to 5.5% (10-fold difference) in low-risk patients versus high-risk patients. CONCLUSIONS: Our study identifies the major risk factors for 30-d sepsis after MCS. These risk factors have been converted into a simple, accurate bedside sepsis risk score. This tool might facilitate improved patient-physician interaction regarding the risk of postoperative sepsis and septic shock.

Characteristics of heroin-dependent patients seeking asthma care in the ED.

BACKGROUND: Limited data suggest that heroin worsens asthma severity, but little is known about heroin-dependent patients who seek emergency department (ED) care for asthma. OBJECTIVES: To describe what heroin-dependent patients know about their asthma and how they use health care resources. METHODS: A prospective study of heroin-dependent patients seeking care for "asthma" at an urban ED with 130000 annual visits was conducted. Eligible subjects were English-speaking heroin-dependent adults seeking care for mild to moderate asthma symptoms. A closed-format survey instrument to assess opioid use, asthma knowledge, and health care use was developed by content experts, piloted for study performance, revised, and then administered to eligible patients prior to ED discharge. Descriptive analysis was done. RESULTS: Thirty subjects participated. Mean age was 47.5 years; 21 (70%) were male. Most used heroin several times weekly. Intranasal was the most common route (93%). Almost half (47%) stated that their asthma was diagnosed in the ED, 13% by a primary care physician, 13% by a lung specialist, and 27% did not know how diagnosed. The ED was used as the primary source for asthma medications in 73% cases; 43% used the ED for breathing issues at least once per month. Most subjects (77%) felt that heroin worsened their asthma symptoms. Only 7 (23%) also abused prescription opioids, and only 7 (23%) knew about prescription naloxone. CONCLUSION: Patients with heroin dependence frequently use the ED for their health care needs related to asthma. Most do not have other health care providers, most have limited health literacy, and all would benefit from referral to a primary care provider and substance abuse resources.

Intersectional implicit bias: Evidence for asymmetrically compounding bias and the predominance of target gender.

Little is known about implicit evaluations of complex, multiply categorizable social targets. Across five studies (N = 5,204), we investigated implicit evaluations of targets varying in race, gender, social class, and age. Overall, the largest and most consistent evaluative bias was pro-women/anti-men bias, followed by smaller but nonetheless consistent pro-upper-class/anti-lower-class biases. By contrast, we observed less consistent effects of targets' race, no effects of targets' age, and no consistent interactions between target-level categories. An integrative data analysis highlighted a number of moderating factors, but a stable pro-women/anti-men and pro-upper-class/anti-lower-class bias across demographic groups. Overall, these results suggest that implicit biases compound across multiple categories asymmetrically, with a dominant category (here, gender) largely driving evaluations, and ancillary categories (here, social class and race) exerting relatively smaller additional effects. We discuss potential implications of this work for understanding how implicit biases operate in real-world social settings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Shifting perceptions of social class: Race-based shifts in class-related occupations.

Based on social expectations associating White and Black racial categories with higher and lower ends of the social hierarchy, respectively, the criteria used in interpersonal judgments of social class categorizations should differ between White and Black targets, with Black targets needing objectively lower criteria than White targets to achieve a particular subjective level of social class. In an analysis of the occupations assigned to Working- and Middle-Class targets, respondents assigned occupations of higher financial and educational attainment, higher social status, more influence, and greater desirability to a White target than to a comparably described Black target. Despite this pattern, however, respondents judged the occupations assigned to a Black target as lower in prestige than those they assigned to a White target. The results are discussed in the context of interracial perceptions of social standing and motivations for societal change.

Resident and Staff Satisfaction of Pediatric Graduate Medical Education Training on Transition to Adult Care of Medically Complex Patients.

Introduction: This study aims to describe the quantity and satisfaction current residents and experienced pediatricians have with graduate medical education on transitioning medically complex patients to adult care. There is an increasing need for transitioning medically complex adolescents to adult care. Over 90% now live into adulthood and require transition to adult healthcare providers. The 2010 National Survey of Children with Special Health Care Needs found that only 40% of youth 12-17 yr receive the necessary services to appropriately transition to adult care. Materials and Methods: Prospective, descriptive, anonymous, web-based survey of pediatric residents and staff pediatricians at Army pediatric residency training programs was sent in March 2017. Questions focused on assessing knowledge of transition of care, satisfaction with transition training, and amount of education on transition received during graduate medical education training. Results: Of the 145 responders (310 potential responders, 47% response rate), transition was deemed important with a score of 4.3 out of 5. The comfort level with transition was rated 2.6/5 with only 4.2% of participants receiving formal education during residency. The most commonly perceived barriers to implementing a curriculum were time constraints and available resources. Of the five knowledge assessment questions, three had a correct response rate of less than 1/3. Conclusions: The findings show the disparity between the presence of and perceived need for a formal curriculum on transitioning complex pediatric patients to adult care. This study also highlighted the knowledge gap of the transition process for novice and experienced pediatricians alike.

Integrated pest management in an urban community: a successful partnership for prevention.

Pesticides, applied in large quantities in urban communities to control cockroaches, pose potential threats to health, especially to children, who have proportionately greater exposures and unique, developmentally determined vulnerabilities. Integrated pest management (IPM) relies on nonchemical tools--cleaning of food residues, removal of potential nutrients, and sealing cracks and crevices. Least toxic pesticides are used sparingly. To evaluate IPM's effectiveness, the Mount Sinai Children's Environmental Health and Disease Prevention Research Center, in partnership with two community health centers in East Harlem, New York City (NY, USA), undertook a prospective intervention trial. Families (n = 131) enrolled when mothers came to the centers for prenatal care. Household cockroach infestation was measured by glue traps at baseline and 6 months afterward. The intervention group received individually tailored IPM education, repairs, least-toxic pest control application, and supplies, with biweekly pest monitoring for 2 months and monthly for 4 months. The control group, residing in East Harlem and demographically and socioeconomically similar to the intervention group, received an injury prevention intervention. The proportion of intervention households with cockroaches declined significantly after 6 months (from 80.5 to 39.0%). Control group levels were essentially unchanged (from 78.1 to 81.3%). The cost, including repairs, of individually tailored IPM was equal to or lower than traditional chemically based pest control. These findings demonstrate that individually tailored IPM can be successful and cost-effective in an urban community.

Complicating race: the relationship between prejudice, race, and social class categorizations.

Although racial stereotyping and prejudice research have received considerable attention, the important element of social class has been largely excluded from social psychological research. Using the Statement Recognition Procedure, two experiments investigated social categorization along race and social class dimensions, the influence of racial and social class prejudice on these categorizations, and differences between White and Black perceivers. Analyses conducted at the subtype of race and social class memberships demonstrated differing patterns of categorization based on subtype membership. For example, lowerclass Black targets were primarily categorized by race, whereas middle-class Black targets were primarily categorized by social class. The results demonstrate the importance of considering social class membership independent of and in conjunction with race. Theoretical and methodological implications regarding the study for race and social class categorizations are discussed.

Are we prepared for Affordable Care Act provisions of care coordination? Case managers' self-assessments and views on physicians' roles.

PURPOSE OF STUDY: Care coordination, traditionally the purview of the case management field, is recognized as a national priority for improving health care delivery and patient outcomes. With reforms of the Affordable Care Act (ACA) of 2010, case managers face new challenges and opportunities in providing care coordination services. The evolving roles of case managers as members of interprofessional care teams will be influenced by new policies that enable physicians to be reimbursed for care coordination. This qualitative study aimed to evaluate case managers' self-assessed readiness for ACA reforms of care coordination and their perceptions of physicians' understanding of case management and ability to lead care coordination efforts in evolving models. PRIMARY PRACTICE SETTINGS: Provisions of care coordination in the ACA affect case managers in all practice settings. The majority of this study's participants represented hospital and managed care settings. METHODOLOGY AND SAMPLE: An invitation to complete an 11-item online survey was sent by e-mail to 8,110 case managers in an opt-in database maintained by a health care continuing education company. Survey questions were designed to assess respondents' (1) self-reported levels of knowledge and preparation for ACA care coordination provisions and (2) beliefs about the readiness and abilities of physicians to administer care coordination services. In addition, demographic data and open-ended comments regarding physicians' roles in conducting care coordination were collected. Over a restricted 9-day period, 834 case managers representing various health care settings responded to the survey. RESULTS: The majority of respondents (63%) indicated that more than 50% of their day is dedicated to performing care coordination activities. However, 80% of all respondents reported being "not at all knowledgeable" or only "somewhat knowledgeable" about the new care coordination provisions in the ACA. Only 8% admitted to being "very prepared" to implement ACA changes. The majority of respondents (68%) perceive their case management departments to be at least "somewhat prepared" to implement necessary changes. Whereas 67% of respondents expect physicians to have at least a "moderate role" in implementing care coordination services, only 12% believe that physicians have more than "some" understanding of the processes of care coordination and case managers' roles. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: These qualitative study findings suggest that case managers from multiple practice settings perceive a lack of preparedness, knowledge, and understanding among themselves and physicians regarding ACA reforms that may significantly affect the delivery of care coordination services. The findings call for new initiatives in interprofessional education to address the knowledge gaps and enhance understanding of the collaborative roles among case managers and physicians.