Targeted care coordination towards patients with a history of multiple readmissions effectively reduces readmissions.

BACKGROUND: To decrease hospital readmission rates, clinical practices create a transition of care (TOC) process to assess patients and coordinate care postdischarge. As current evidence suggests lack of universal benefit, this study's objectives are to determine what patient and process factors associate with hospital readmissions, as well as construct a model to decrease 30-day readmissions. METHODS: Three months of retrospective discharged patient data (n = 123) were analysed for readmission influences including: patient-specific comorbidities, admission-specific diagnoses, and TOC components. A structured intervention of weekly contact, the Care Coordination Cocoon (CCC), was created for multiply readmitted patients (MRPs), defined as ≥2 readmissions. Three months of postintervention data (n = 141) were analysed. Overall readmission rates and patient- and process-specific characteristics were analysed for associations with hospital readmission. RESULTS: Standard TOC lacked significance. Patient-specific comorbidities of cancer (odds ratio [OR] 6.27; 95% confidence interval [CI] 1.73-22.75) and coronary artery disease (OR 6.71; 95% CI 1.84-24.46), and admission-specific diagnoses within pulmonary system admissions (OR 7.20; 95% CI 1.96-26.41) were associated with readmissions. Post-CCC data demonstrated a 48-h call (OR 0.21; 95% CI 0.09-0.50), answered calls (OR 0.16; CI 0.07-0.38), 14-day scheduled visit (OR 0.20; 95% CI 0.07-0.54), and visit arrival (OR 0.39; 95% CI 0.17-0.91) independently associated with decreased readmission rate. Patient-specific (hypertension-OR 3.65; CI 1.03-12.87) and admission-specific (nephrologic system-OR 3.22; CI 1.02-10.14) factors associated with readmissions which differed from the initial analysis. CONCLUSIONS: Targeting a practice's MRPs with CCC resources improves the association of TOC components with readmissions and rates decreased. This is a more efficient use of TOC resources.

Changes in children's dental fear after restorative treatment under different sedation types: Associations with parents' experiences and dental health.

BACKGROUND: Dentists often use sedative medications such as nitrous oxide inhaled sedation and general anesthesia (GA) to help decrease patient fear and manage paediatric patients' behavior during treatment. AIM: The goal of this study was to examine factors associated with dental fear changes after restorative dental treatment under nitrous oxide or GA in children 4-12 years old. DESIGN: A prospective cohort study of 124 children examined changes in dental fear, number of treatment visits, and parental factors among children receiving restorative dental treatment under nitrous oxide (n = 68) or GA (n = 56) sedation. Data were collected at pretreatment (T1), 16 weeks post-treatment (T2), and at 29-month follow-up (T3). RESULTS: Dental fear increased slightly, but not significantly, under both forms of sedation between T1 and T3. Children's dental fear was associated with parents' poor dental experiences and oral health, but not with number of treatment visits. CONCLUSIONS: Progression of children's dental fear seems not dependent solely on the type of sedation used but is likely predicted by factors including pretreatment dental fear and dental needs. Dentists recommending sedation for children's dental care may consider pretreatment dental need, fear levels, and parental factors when determining which type of sedation to use.

An Emerging Model for Community Health Worker-Based Chronic Care Management for Patients With High Health Care Costs in Rural Appalachia.

Community health workers (CHWs) can improve patients' health by providing them with ongoing behavioral support during the health care experience, and they help decrease health care costs, especially among patients whose starting costs are high and among underserved and minority populations. We developed a CHW-based care model with the aim of improving outcomes and lowering costs for high-risk diabetes patients in rural Appalachia. Enrolled patients experienced a mean decrease in HbA1c of 2.4 percentage points, and 60% or more of patients with diabetes lowered their blood glucose between baseline and 6 to 12 months after enrollment. As health care providers and patients became familiar with this model of care management, enrollment in the program accelerated.

Multiscale modeling reveals poisoning mechanisms of MgO-supported Au clusters in CO oxidation.

Catalyst deactivation mechanisms on MgO-supported Au(6) clusters are studied for the CO oxidation reaction via first-principle kinetic Monte Carlo simulations and shown to depend on support vacancies. In defect-poor MgO or in the presence of a Mg vacancy, O(2) does not bind to the clusters and the catalyst is poisoned by CO. On Au clusters interacting with O vacancies of the support, O(2) can be chemisorbed and transient activity is observed. In this case, an unexpected catalyst "breathing" mechanism (restructuring) leads to carbonate formation and catalyst deactivation, rationalizing several experimental observations. Our study underscores the importance of the cluster's charge state and dynamics on catalytic activity.

Development and Pilot Testing of a Nurse Care Manager Role in Coordinated Specialty Care for Early Psychosis.

Coordinated specialty care (CSC) improves mental health and functional outcomes among individuals with first-episode psychosis but lacks a standardized approach to addressing chronic disease risk. The authors used community-based participatory intervention mapping with nine CSC teams to implement a nurse care manager role for the team in order to identify and address chronic disease risk factors. The role was piloted at one CSC site to explore its feasibility and acceptability. The nurse care manager role was highly acceptable to clients, team members, and leadership. More than one-quarter of the nurse's time was spent on nonbillable activities, and lack of a clear plan for financial sustainability was the primary barrier to implementation.

Soluble fiber dextrin enhances the satiating power of beverages.

This study compared the effects of four types of fiber on satiety and energy intakes at the next meal using a standard double-blinded preload study design. Study participants (14 men and 22 women) each took part in 6 study sessions. Study preloads were a combination of a solid snack and a liquid beverage (energy range 0.78-0.83 MJ) containing four different types of fiber: soluble fiber dextrin (12 g), soluble corn fiber (11.8 g), polydextrose (11.8 g), and resistant starch (11.2g). All four fibers were compared to two control conditions of equal volume: an isoenergetic, low-fiber preload and a lower-energy, low-fiber preload. All preloads were presented twice for a total of 0.35-1.65 MJ and 1-24 g fiber. Satiety ratings were collected for 20 min intervals for 220 min during the morning testing session. A test meal was served at 1200 h and plate waste measured. The five higher-energy preloads led to higher fullness and lower hunger ratings compared to the low-energy control but were not significantly different from each other. Relative to the isoenergetic control, only soluble fiber dextrin significantly suppressed energy intakes (p=0.023). Supplementing beverages with soluble fiber dextrin affects short term energy intake and may have implications for weight control.

Longitudinal Analysis of Children's Oral Health-Related Quality of Life After Restorative Dental Treatment.

Purpose: To document mid- and long-term changes in oral health-related quality of life (OHRQoL) following dental intervention in a sample of restorative treatment-naïve children receiving different levels of care, with and without general anesthesia (GA). Methods: This prospective cohort study followed 132 children. Parents completed the pediatric OHRQoL instrument (POQL) before, 16 weeks after (i.e., posttreatment), and 18 to 45 (mean equals 29.5) months after (i.e., follow-up) child receipt of treatment. Parents provided child demographic and oral health information. The number of restored surfaces and anesthesia type were abstracted from dental records. The mean differences in POQL scores were compared across groups. Results: The sample was 49 percent female (age range equals four to 12 years; mean±standard deviation equals 5.8±1.8). Overall, from pretreatment to posttreatment, mean POQL scores decreased by 4.5 points (P<0.001), representing improved OHRQoL. Only among children with 10 or more surfaces restored or who received GA did follow-up POQL scores remain significantly lower than pretreatment scores (mean difference equals -7.4 and -8.0, respectively, P<0.01). Overall, follow-up scores were significantly higher than posttreatment scores, representing a decline from the initial improvement. Conclusions: Regardless of disease severity, children experience an immediate improvement in OHRQoL following restorative treatment. Improvements in OHRQoL are sustained over the long-term only among children with more extensive pretreatment needs.

The Thalamus Regulates Retinoic Acid Signaling and Development of Parvalbumin Interneurons in Postnatal Mouse Prefrontal Cortex.

GABAergic inhibitory neurons in the prefrontal cortex (PFC) play crucial roles in higher cognitive functions. Despite the link between aberrant development of PFC interneurons and a number of psychiatric disorders, mechanisms underlying the development of these neurons are poorly understood. Here we show that the retinoic acid (RA)-degrading enzyme CYP26B1 (cytochrome P450 family 26, subfamily B, member 1) is transiently expressed in the mouse frontal cortex during postnatal development, and that medial ganglionic eminence (MGE)-derived interneurons, particularly in parvalbumin (PV)-expressing neurons, are the main cell type that has active RA signaling during this period. We found that frontal cortex-specific Cyp26b1 knock-out mice had an increased density of PV-expressing, but not somatostatin-expressing, interneurons in medial PFC, indicating a novel role of RA signaling in controlling PV neuron development. The initiation of Cyp26b1 expression in neonatal PFC coincides with the establishment of connections between the thalamus and the PFC. We found that these connections are required for the postnatal expression of Cyp26b1 in medial PFC. In addition to this region-specific role in postnatal PFC that regulates RA signaling and PV neuron development, the thalamocortical connectivity had an earlier role in controlling radial dispersion of MGE-derived interneurons throughout embryonic neocortex. In summary, our results suggest that the thalamus plays multiple, temporally separate roles in interneuron development in the PFC.

Sexual dimorphism in obesity-related genes in the epicardial fat during aging.

Aging increases the risk of cardiovascular disease and metabolic syndrome. Alterations in epicardial fat play an important pathophysiological role in coronary artery disease and hypertension. We investigated the impact of normal aging on obesity-related genes in epicardial fat. Sex-specific changes in obesity-related genes with aging in epicardial fat (EF) were determined in young (6 months) and old (30/36 months) female and male, Fischer 344 × Brown Norway hybrid (FBN) rats, using a rat obesity RT2 PCR Array. Circulating sex hormone levels, body and heart weights were determined. Statistical significance was determined using two-tailed Student's t test and Pearson's correlation. Our results revealed sex-specific differences in obesity-related genes with aging. Dramatic changes in the expression profile of obesity-related genes in EF with aging in female, but not in male, FBN rats were observed. The older (30 months) female rats had more significant variations in the abundance of obesity-related genes in the EF compared to that seen in younger female rats or both age groups in male rats. A correlation of changes in obesity-related genes in EF to heart weights was observed in female rats, but not in male rats with aging. No correlation was observed to circulating sex hormone levels. Our findings indicate a dysfunctional EF in female rats with aging compared to male rats. These findings, with further functional validation, might help explain the sex differences in cardiovascular risk and mortality associated with aging observed in humans.

College student heavy drinking in social contexts versus alone.

Heavy drinking is common among college students and typically occurs in social contexts. Heavy drinking when alone, however, is less common. The present study hypothesized that students who drink heavily when alone (HD-Alone) would differ from college students who only drink heavily in social contexts (Social HD). Forty-nine HD-Alone students (at least one heavy-drinking episode when alone), 213 Social HDs, and 63 non-heavy drinkers (Non-HDs) were compared on alcohol-related consequences, drinking milestones, alcohol-outcome expectancies, and symptoms of depression. HD-Alone students reported more negative drinking consequences, earlier onset of regular drinking, more alcohol expectancies, less self-efficacy and motivation to reduce drinking, and higher depression scores than Social HDs and Non-HDs. Findings imply individual differences among heavy-drinking college students according to their drinking context.

Knowledge and perceptions of the Affordable Care Act by uninsured patients at a free clinic.

The Affordable Care Act (ACA) has as one of its main objectives to reduce the number of uninsured Americans. The understanding of the ACA reforms by uninsured patients will likely influence the degree of success in achieving this objective. This study assessed the basic knowledge and opinions regarding the ACA of patients at a free clinic and the impact of a brief educational intervention on respondents' knowledge and opinions. One hundred uninsured adult patients completed a brief survey about the ACA before and after viewing a video outlining the major features of the act. The study cohort initially performed worse than national polls on all knowledge questions. Significant improvement was observed after the educational video. Our study suggests a need for educational efforts directed at those individuals most likely to benefit from the ACA. We demonstrated that a brief intervention during a routine office visit may improve knowledge of the ACA.