Severity of Illness and Prognosis of Liver Transplant Candidates at Yale

The increasing number of patients with end-stage liver disease (ESLD) listed for transplantation has forced physicians to examine the disparities in waiting times (WT) for this procedure across the US. The debate has centered upon whether physicians within regions with longer WT, such as that of Yale, are listing patients prematurely compared to regions with shorter WT . Using regional variations in WT, per this argument, to analyze access to organs is therefore misleading. To determine the appropriateness of listing practices at Yale, the authors applied stratification guidelines for liver transplant candidates adopted by the United Network for Organ Sharing (UNOS) on 1/19/98 to patients listed for transplantation at Yale as of 11/14/97. Medical records were reviewed to confirm clinical histories, and referring physicians were contacted to obtain data from within four months of 11/14/97. Patients were reclassified per UNOS guidelines and followed until 7/1/99 to determine prognosis. Of the original cohort of 89 patients, 8 patients had died prior to reclassification; 2 had been lost to follow-up. Of the remaining 79 patients, 40/79 (50.6%) met criteria for severe ESLD, and an additional 29/79 (36.7%) met minimal listing criteria (MLC); a total of 87.3% met criteria for listing for transplantation. Of the 10 patients who did not meet MLC, by 7/1/99. 4 were listed after appeal to the regional review board under circumstances not covered by UNOS guidelines, 4 clinically worsened and were actively listed, and 2 remained clinically well. By 7/1/99, 1 patient was found to meet MLC, but was clinically too well to offer transplantation, and 1 additional patient had been lost to follow up. On 7/1/99, 3/86 (3.4%) patients in the original cohort did not meet MLC for transplantation. There is no evidence that long WT have led to premature listing of liver transplant candidates at Yale

The role of SUMO pathway in pathophsiology of skeletal muscle

Skeletal muscles are highly evolved and essential organs comprising 40 % of the total human body weight. They are essential in maintaining posture, energy metabolism, secrete hormones and act as central reserves for amino acids. Despite many studies on muscle physiology, there is a lack of understanding in cellular and molecular mechanisms leading to muscle adaptation, regeneration and progression of muscular disorders. Post-translational modifications (PTMs) markedly regulate the quality and the functionality of proteins in eukaryotic cells. One such PTM is the reversible conjugation of a 12 kDa moiety called Small Ubiquitin-like Modifier, SUMO, onto targeted proteins in a process termed SUMOylation. Alterations in expression or activity of SUMO conjugating/de-conjugating enzymes in association with genetic point mutations in the SUMO consensus sequence of specific targets have been implicated in conditions like cancer, diabetes, brain ischaemia, and cardiomyopathies. Given to the reversible and rapid dynamic response to detect alterations in physiological conditions, SUMO pathway is being extensively studied as a potential therapeutic target for some conditions of brain and cardiac muscle protection from diseases. Our interests are to translate the significance of the SUMO pathway to skeletal muscle health, investigate its modulation as consequence of adaptation to new muscle activities and study disturbances in the SUMO reaction that alter the SUMO conjugation on specific target proteins which are associated to skeletal muscle diseases. Ventilator Induced Diaphragm Dysfunction (VIDD) is a condition characterized by muscle dysfunction that occurs as side effect of Mechanical Ventilation. In diaphragms isolated from rats exposed to Controlled Mechanical ventilated (CMV), we observed significant changes in the overall SUMO muscle proteins due to alteration in the abundance of SUMO enzymes transcripts resulting in determining a new subset of SUMO targets. We studied the beneficial use of the drug BGP-15 administrated during CMV treatment that recovered the muscle contractile function partially due to a reorganization of the SUMO reaction. We further identified and characterized some specific skeletal muscle proteins targeted by the SUMO, which are associated with particular muscle functions. Mainly, we focused the attention on the E3 muscle ubiquitin ligase, MuRF1. We described the specific SUMO target site, enzymes involved in the SUMO reaction and the consequence of this PTM related to the properties of this protein. This discovery will open new avenues to understand the multiple functions of MuRF1 in muscle physiology and contribute to better understanding of muscular disorders that result from deregulation of MuRF1 activities mediated by SUMO conjugation. Finally, we provided an important facet to the differences in abundance of SUMO enzyme transcripts that we found across the different skeletal muscles to control their specific role along the body position. In conclusion, we also provided strong evidence of how the SUMO cycle may also be used as a cellular pathway target for new treatments for various skeletal muscle diseases

Ethical Dilemmas Posed in the Care of Obese Patients in the Emergency Department

The rising prevalence of obesity represents a health care crisis. As the gateway to the health care system, the emergency department is the clinical setting where the difficulties posed by the care of obese patients are heightened. These difficulties include the increasing burden of obesity-related illnesses, the challenges posed in diagnostic evaluation and treatment and the known barriers to access to care seen in this patient population. The limitations posed by obesity on care in the emergency department, the one guaranteed access point for medical treatment, creates a series of ethical dilemmas for emergency physicians and the facilities in which they practice. This article will discuss how a combination of virtue and narrative approaches can guide an ethical framework to address the dilemmas posed by the care of obese patients in the emergency department

Screening, Brief Intervention and Referral to Treatment Implementation in the Emergency Department

We sought to qualitatively evaluate impediments in implementing a novel Screening, Brief Intervention and Referral to Treatment (SBIRT) protocol into normal emergency department (ED) workflow for patients with at-risk drug/alcohol behavior. From 2010, administrative and nursing champions trained nurses at a single ED (census: 50,000 visits/yr) in SBIRT and incorporated SBIRT into normal ED nursing workflow in 2012. To qualitatively analyze impediments in SBIRT implementation, we created a semi-structured questionnaire for protocol champions with subsequent follow-up. Investigators analyzed responses using qualitative methodology based on a modified grounded theory framework. In 2012, 47693 visits by 31525 patients met SBIRT protocol initiation criteria with a protocol execution rate of 83.4%. Interview data identified the following impediments: (1) Need for multi-layer leadership support; (2) Application of an overarching vision to constantly address personnel attitudes towards SBIRT appropriateness in the ED; (3) Continuous performance monitoring to address implementation barriers close to real time; (4) Strategic and adaptive SBIRT training; and (5) External systemic changes through internal leadership. Qualitative analysis suggests that impediments to SBIRT implementation in the ED include views of SBIRT appropriateness in the ED, need for continuous reinforcement/refinement of personnel training / protocol execution, and fostering of additional administrative/financial champions

Implementation of screening, brief intervention, and referral to treatment (SBIRT) in the emergency department without additional resources

Patients who misuse substances present in inordinate numbers for emergency department (ED) services. Therefore, EDs are an important environment for identifying, intervening and connecting patients with treatment and recovery support to improve patient health and reduce healthcare utilization. EDs have largely depended on external funding or additional personnel to execute SBIRT. Our aim was to integrate SBIRT into the ED workflow and coordinate transfer to treatment and community support programs without added monetary/staff resources. Beginning in 2010, we worked cooperatively with a local ED to integrate SBIRT into the normal ED workflow. This program of screening, brief interventions and warm-handoff referral is dubbed “Safe Landing.” Efforts have focused on: training staff; embedding SBIRT tools into existing data systems; nurturing relationships with community treatment and recovery providers; developing protocols for a “warm-handoff” that would ensure patients who, in the context of a health crisis, express an immediate interest in following a road to recovery; and securing reimbursement for services. Over one-and-a-half years since implementation, 45,770 patients have been screened, with 7,996 assessed, 2,058 receiving a brief intervention, and 137 referred to treatment or recovery support. Multiple staff trainings have resulted in a palpable culture shift to patient advocacy and increasing compliance with SBIRT protocols. Screening and BI tracking tools embedded in the ED data systems continue to be enhanced. ED reimbursement for SBIRT began 10/2012, and cooperative relationships with treatment and recovery providers have diversified. We will discuss the implementation strategies employed to overcome challenges in operationalizing SBIRT in the ED. Challenges to be discussed include changes in key personnel, embedding SBIRT into the labyrinth of data systems, initial staff scepticism and evolving area treatment and recovery services organizations. Regardless, Safe Landing perseveres, and commitment by the local ED is stronger than ever

Screening, Brief Intervention, and Referral to Treatment in the Emergency Department:An Examination of Health Care Utilization and Costs

BACKGROUND:There is increasing interest in deploying screening, brief intervention, and referral to treatment (SBIRT) practices in emergency departments (ED) to intervene with patients at risk for substance use disorders. However, the current literature is inconclusive on whether SBIRT practices are effective in reducing costs and utilization. OBJECTIVE:This study sought to evaluate the health care costs and health care utilization associated with SBIRT services in the ED. RESEARCH DESIGN:This study analyzed downstream health care utilization and costs for patients who were exposed to SBIRT services within an Allegheny County, Pennsylvania, ED through a program titled Safe Landing compared with 3 control groups of ED patients (intervention hospital preintervention, and preintervention and postintervention time period at a comparable, nonintervention hospital). SUBJECTS:The subjects were patients who received ED SBIRT services from January 1 to December 31 in 2012 as part of the Safe Landing program. One control group received ED services at the same hospital during a previous year. Two other control groups were patients who received ED services at another comparable hospital. MEASURES:Measures include total health care costs, 30-day ED visits, 1-year ED visits, inpatient claims, and behavioral health claims. RESULTS:Results found that patients who received SBIRT services experienced a 21% reduction in health care costs and a significant reduction in 1-year ED visits (decrease of 3.3 percentage points). CONCLUSIONS:This study provides further support that SBIRT programs are cost-effective and cost-beneficial approaches to substance use disorders management, important factors as policy advocates continue to disseminate SBIRT practices throughout the health care system

自立的な児童会活動と校内支援システムの構築 ― 委員会活動の活性化を通して ―

The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to US emergency departments in how they approach preparation for and management of potential patients with EVD