Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012

Introduction A decrease in disease-specific mortality over the last twenty years has been reported for patients admitted to United States (US) hospitals, but data for intensive care patients are lacking. The aim of this study was to describe changes in hospital mortality and case-mix using clinical data for patients admitted to multiple US ICUs over the last 24 years. Methods We carried out a retrospective time series analysis of hospital mortality using clinical data collected from 1988 to 2012. We also examined the impact of ICU admission diagnosis and other clinical characteristics on mortality over time. The potential impact of hospital discharge destination on mortality was also assessed using data from 2001 to 2012. Results For 482,601 ICU admissions there was a 35% relative decrease in mortality from 1988 to 2012 despite an increase in age and severity of illness. This decrease varied greatly by diagnosis. Mortality fell by \u3e60% for patients with chronic obstructive pulmonary disease, seizures and surgery for aortic dissection and subarachnoid hemorrhage. Mortality fell by 51% to 59% for six diagnoses, 41% to 50% for seven diagnoses, and 10% to 40% for seven diagnoses. The decrease in mortality from 2001 to 2012 was accompanied by an increase in discharge to post-acute care facilities and a decrease in discharge to home. Conclusions Hospital mortality for patients admitted to US ICUs has decreased significantly over the past two decades despite an increase in the severity of illness. Decreases in mortality were diagnosis specific and appear attributable to improvements in the quality of care, but changes in discharge destination and other confounders may also be responsible

The association between care co-ordination and emergency department use in older managed care enrollees

OBJECTIVE: To investigate the association between care co-ordination and use of the Emergency Department (ED) in older managed care enrollees. DESIGN: Nested case-control with 103 cases (used the ED) and 194 controls (did not use the ED). PATIENTS AND METHODS: Older patients with multiple chronic illnesses enrolled in a care management programme of a large group-model health maintenance organisation with more than 50,000 members over the age of 64. Better care co-ordination was defined as timely follow-up after a change in treatment; fewer decision-makers involved with the care plan; and a higher patient-perceived rating of overall care co-ordination. Logistic regression was used to assess the relationship between ED use (the outcome variable) and measures of care co-ordination (the predictor variables). RESULTS: Self-reported care co-ordination was not significantly different between cases and controls for any of the four classifications of inappropriate ED use. Similarly, no differences were found in the number of different physicians or medication prescribers involved in the patients' care. Four-week follow-up after potentially high-risk events for subsequent ED use, including changes in chronic disease medications, missed encounters, and same day encounters, did not differ between subjects with inappropriate ED use and controls. CONCLUSION: Existing measures of care co-ordination were not associated with inappropriate ED use in this study of older adults with complex care needs. The absence of an association may, in part, be attributable to the paucity of validated measures to assess care co-ordination, as well as the methodological complexity inherent in studying this topic. Future research should focus on the development of new measures and on approaches that better isolate the role of care co-ordination from other potential variables that influence utilisation

Precision timing of PSR J1012+5307 and strong-field GR tests

We report on the high precision timing analysis of the pulsar-white dwarf binary PSR J1012+5307. Using 15 years of multi-telescope data from the European Pulsar Timing Array (EPTA) network, a significant measurement of the variation of the orbital period is obtained. Using this ideal strong-field gravity laboratory we derive theory independent limits for both the dipole radiation and the variation of the gravitational constant.Comment: 3 pages, Proceedings of the 12th Marcel Grossmann Meeting on General Relativity (MG 12

Development and testing of a measure designed to assess the quality of care transitions

BACKGROUND: To improve the quality of care delivered to older persons receiving care across multiple settings, interventions are needed. However, the absence of a patient-centred measure specifically designed to assess this care has constrained innovation. OBJECTIVE: To develop a rigorously designed and tested measure, the Care Transition Measure (CTM). SETTING: A large, integrated managed care organisation in Colorado with approximately 55,000 members over the age of 65 years. PARTICIPANTS: Patients 65 years and older who were recently discharged from hospital and received subsequent skilled nursing care in a facility or in the home. METHODS: Six focus groups of older persons and their caregivers (n=49) were established. Standard qualitative analytic techniques were applied to written transcripts and four key domains were identified: (1) information transfer; (2) patient and caregiver preparation; (3) self-management support; and (4) empowerment to assert preferences. Specific CTM items were developed, pilot tested, and refined. Psychometric testing, conducted in a different population but selected using the same entry criteria (n=60), included content and construct validity, intra-item variation, and floor/ceiling properties. RESULTS: Older patients and clinicians found the measure to be highly relevant and comprehensive (i.e. content validity). Construct validity was assessed by comparing items from the CTM to selected items from a measure developed by Hendriks and colleagues (Medical Care 2001; 39(3): 270–283). Inter-item Spearman correlations ranged 0.388–0.594. No significant floor or ceiling effects were detected. CONCLUSIONS: The CTM was developed with substantial input from older patients and their caregivers. Psychometric testing suggested that the measure was valid. The CTM may serve to fill an important gap in health system performance evaluation by measuring the quality of care delivered across settings

Increased ICU workload is not associated with increased inpatient mortality

Poster Presented at ATS 2008 in Toronto, OntarioRationale: Although ICUs with higher overall patient volume may achieve better outcomes, there are few data on the effects of increasing patient loads on patients within the ICU. Methods: We examined 198,877 patients in 108 ICUs in 2002 - 2005 using conditional logistic regression with an ICU-specific fixed effect Main Results: Patients admitted on high census days had the same odds of inpatient mortality or transfer to another hospital as patients admitted on average or on low census days. Conclusions: The ICUs in this data set are able to function as high-reliability organizations.http://deepblue.lib.umich.edu/bitstream/2027.42/61402/1/ATS08_occupancy_poster_v02.pd

Study protocol of an investigation of attention and prediction error as mechanisms of action for latent inhibition of dental fear in humans

Background Evidence suggests that dental anxiety and phobia are frequently the result of direct associative fear conditioning but that pre-exposure to dental stimuli prior to conditioning results in latent inhibition of fear learning. The mechanisms underlying the pre-exposure effect in humans, however, are poorly understood. Moreover, pain sensitivity has been linked to dental fear conditioning in correlational investigations and theory suggests it may moderate the latent inhibition effect, but this hypothesis has not been directly tested. These gaps in our understanding are a barrier to the development of evidence-based dental phobia prevention efforts. Methods Healthy volunteers between the ages of 6 and 35 years will be enrolled across two sites. Participants will complete a conditioning task in a novel virtual reality environment, allowing for control over pre-exposure and the examination of behaviour. A dental startle (a brief, pressurized puff of air to a tooth) will serve as the unconditioned stimulus. Using a within-subjects experimental design, participants will experience a pre-exposed to-be conditioned stimulus, a non-pre-exposed to-be conditioned stimulus, and a neutral control stimulus. Two hypothesized mechanisms, changes in prediction errors and attention, are expected to mediate the association between stimulus condition and fear acquisition, recall, and retention. To ascertain the involvement of pain sensitivity, this construct will be measured through self-report and the cold pressor task. Discussion Dental phobia negatively affects the dental health and overall health of individuals. This study aims to determine the mechanisms through which pre-exposure retards conditioned dental fear acquisition, recall, and retention. A randomized control trial will be used to identify these mechanisms so that they can be precisely targeted and maximally engaged in preventative efforts

X-ray and Radio Timing of the Pulsar in 3C 58

We present timing data spanning 6.4 yr for the young and energetic PSR J0205+6449, in the supernova remnant 3C 58. Data were obtained with the Rossi X-ray Timing Explorer, the Jodrell Bank Observatory and the Green Bank Telescope. We present phase-coherent timing analyses showing timing noise and two spin-up glitches with fractional frequency increases of ~3.4E-7 near MJD 52555, and ~3.8E-6 between MJDs 52777 and 53062. These glitches are unusually large if the pulsar was created in the historical supernova in 1181 as has been suggested. For the X-ray timing we developed a new unbinned maximum-likelihood method for determining pulse arrival times which performs significantly better than the traditional binned techniques. In addition, we present an X-ray pulse profile analysis of four years of RXTE data showing that the pulsar is detected up to ~40 keV. We also present the first measurement of the phase offset between the radio and X-ray pulse for this source, showing that the radio pulse leads the X-ray pulse by phi=0.10+/-0.01 in phase. We compile all known measurements of the phase offsets between radio and X-ray and radio and gamma-ray pulses for X-ray and gamma-ray pulsars. We show that there is no relationship between pulse period and phase offset, supported by our measurement of the phase offset for PSR J0205+6449.Comment: 19 pages, 12 figures. Published in the Astrophysical Journal. Includes additional data analysis and two new figure

Polymer multilayer tattooing for enhanced DNA vaccination

DNA vaccines have many potential benefits but have failed to generate robust immune responses in humans. Recently, methods such as in vivo electroporation have demonstrated improved performance, but an optimal strategy for safe, reproducible, and pain-free DNA vaccination remains elusive. Here we report an approach for rapid implantation of vaccine-loaded polymer films carrying DNA, immune-stimulatory RNA, and biodegradable polycations into the immune-cell-rich epidermis, using microneedles coated with releasable polyelectrolyte multilayers. Films transferred into the skin following brief microneedle application promoted local transfection and controlled the persistence of DNA and adjuvants in the skin from days to weeks, with kinetics determined by the film composition. These ‘multilayer tattoo’ DNA vaccines induced immune responses against a model HIV antigen comparable to electroporation in mice, enhanced memory T-cell generation, and elicited 140-fold higher gene expression in non-human primate skin than intradermal DNA injection, indicating the potential of this strategy for enhancing DNA vaccination.Howard Hughes Medical Institute (Investigator)Ragon Institute of MGH, MIT, and HarvardNational Institutes of Health (U.S.) (NIH AI095109)United States. Dept. of Defense. Institute for Soldier Nanotechnologies (contract W911NF-07-D-0004)United States. Dept. of Defense. Institute for Soldier Nanotechnologies (contract W911NF-07-0004