Predicting Emergency Department “Bouncebacks”: A Retrospective Cohort Analysis

Introduction: The short-term return visit rate among patients discharged from emergency departments (ED) is a quality metric and target for interventions. The ability to accurately identify which patients are more likely to revisit the ED could allow EDs and health systems to develop more focused interventions, but efforts to reduce revisits have not yet found success. Whether patients with a high number of ED visits are at increased risk of a return visit remains underexplored.Methods: This was a population-based, retrospective, cohort study using administrative data from a large physician partnership. We included patients discharged from EDs from 80 hospitals in seven states from July 2014 – June 2016. We performed multivariable logistic regression of short-term return visits on patient, visit, hospital, and community characteristics. The primary outcome was the proportion of patients who had a return visit within 14 days of an index ED visit.Results: Among 6,699,717 index visits, the overall risk of 14-day revisit was 12.6%. Frequent visitors accounted for 18.7% of all visits and 40.2% of all 14-day revisits. Frequent visitor status was associated with the highest odds of a revisit (odds ratio [OR] 3.06; 95% confidence interval [CI], 3.041 – 3.073). Other predictors of revisits were cellulitis (OR 2.131; 95% CI, 2.106 – 2.156), alcohol-related disorders (OR 1.579; 95%CI, 1.548 – 1.610), congestive heart failure (OR 1.175; 95% CI, 1.126 – 1.226), and public insurance (Medicaid OR 1.514; 95% CI, 1.501 – 1.528; Medicare OR 1.601; 95% CI, 1.583 – 1.620).Conclusion: Previous ED use – even a single previous visit – was a stronger predictor of a return visit than any other patient, hospital, or community characteristic. Clinicians should consider previous ED use when considering treatment decisions and risk of return visit, as should stakeholders targeting patients at risk of a return visit

The Design, Construction, and Some Uses of an Automatic Recording Balance

Many chemical and physical reactions are accompanied by changes in weight of the reactants due to evaporation of liquids, evolution of gases, or adsorption of gases. Studies are made using data which show the manner in which the weight changes with time. Kinetic studies are made from a knowledge of the rate of loss or gain of a component. The drying of a precipitate to constant weight involves a loss in weight. Rates of evaporation of liquids from different types of surfaces involve changes of weight as a function of time. Several instruments and methods are used to follow weight changes. Gas buret systems are used to measure the volume of a gaseous component which is adding to or subtracting from the weight of a reactant. The ordinary analytical balance is used to follow weight changes by making intermittent weighings. This latter method involves tedious operations and interruptions of the treatment of the reactants. Effort has been put forth to devise instruments which will automatically weigh substances and record these weighings on some type of graph. Gregg and Wintle (1) devised a glass automatic electrical sorption balance. Gregg (2) later described a recording system for this type balance. Eyrand (3) reported a glass sorption balance of a somewhat different type. Duval (4) described a thermal balance that automatically records changes in weight on film. Described in this paper is an instrument attached to a modified ordinary analytical balance which automatically records on graph paper changes in weight as a function of time

Understanding the Use of Prostate Biopsy Among Men with Limited Life Expectancy in a Statewide Quality Improvement Collaborative

BACKGROUND: The potential harms of a prostate cancer (PCa) diagnosis may outweigh its benefits in elderly men. OBJECTIVE: To assess the use of prostate biopsy in men with limited life expectancy (LE) within the practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). DESIGN, SETTING, AND PARTICIPANTS: MUSIC is a consortium of 42 practices and nearly 85% of the urologists in Michigan. From July 2013 to October 2014, clinical data were collected prospectively for all men undergoing prostate biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We calculated comorbidity-adjusted LE in men aged ≥66 yr and identified men with(limited LE) undergoing a first biopsy. Our LE calculator was not designed for men agedyr; thus these men were excluded. Multivariable models estimated the proportion of all biopsies performed for men with limited LE in each MUSIC practice, adjusting for differences in patient characteristics. We also evaluated what treatments, if any, these patients received. RESULTS AND LIMITATIONS: Among 3035 men aged ≥66 yr undergoing initial prostate biopsy, 60% had none of the measured comorbidities. Overall, 547 men (18%) had limited LE. Compared with men with a longer LE, these men had significantly higher prostate-specific antigen levels and abnormal digital rectal examination findings. The adjusted proportion of biopsies performed for men with limited LE ranged from 3.8% to 39% across MUSIC practices (p \u3c 0.001). PCa was diagnosed in 69% of men with limited LE; among this group, 74% received any active treatment. Of these men, 46% had high-grade cancer (Gleason score 8-10). CONCLUSIONS: Among a large and diverse group of urology practices, nearly 20% of prostate biopsies are performed in men with limited LE. These data provide useful context for quality improvement efforts aimed at optimizing patient selection for prostate biopsy. PATIENT SUMMARY: In this report, nearly 2 of every 10 men undergoing prostate biopsy had a life expectancy (LE)biopsy

The targeted delivery of multicomponent cargos to cancer cells by nanoporous particle-supported lipid bilayers.

Encapsulation of drugs within nanocarriers that selectively target malignant cells promises to mitigate side effects of conventional chemotherapy and to enable delivery of the unique drug combinations needed for personalized medicine. To realize this potential, however, targeted nanocarriers must simultaneously overcome multiple challenges, including specificity, stability and a high capacity for disparate cargos. Here we report porous nanoparticle-supported lipid bilayers (protocells) that synergistically combine properties of liposomes and nanoporous particles. Protocells modified with a targeting peptide that binds to human hepatocellular carcinoma exhibit a 10,000-fold greater affinity for human hepatocellular carcinoma than for hepatocytes, endothelial cells or immune cells. Furthermore, protocells can be loaded with combinations of therapeutic (drugs, small interfering RNA and toxins) and diagnostic (quantum dots) agents and modified to promote endosomal escape and nuclear accumulation of selected cargos. The enormous capacity of the high-surface-area nanoporous core combined with the enhanced targeting efficacy enabled by the fluid supported lipid bilayer enable a single protocell loaded with a drug cocktail to kill a drug-resistant human hepatocellular carcinoma cell, representing a 10(6)-fold improvement over comparable liposomes

Predictive Modeling Techniques in Prostate Cancer

A number of new predictive modeling techniques have emerged in the past several years. These methods can be used independently or in combination with traditional modeling techniques to produce useful tools for the management of prostate cancer. Investigators should be aware of these techniques and avail themselves of their potentially useful properties. This review outlines selected predictive methods that can be used to develop models that may be useful to patients and clinicians for prostate cancer management.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63147/1/10915360152745812.pd

Increases in sampling support the southern Gondwanan hypothesis for the origin of dinosaurs

Dinosaurs were ubiquitous in terrestrial ecosystems through most of the Mesozoic and are still diversely represented in the modern fauna in the form of birds. Recent efforts to better understand the origins of the group have resulted in the discovery of many new species of early dinosaurs and their closest relatives (dinosauromorphs). In addition, recent re-examinations of early dinosaur phylogeny have highlighted uncertainties regarding the interrelationships of the main dinosaur lineages (Sauropodomorpha, Theropoda and Ornithischia), and questioned the traditional hypothesis that the group originated in South Gondwana and gradually dispersed over Pangaea. Here, we use a historical approach to examine the impact of new fossil discoveries and changing phylogenetic hypotheses on biogeographic scenarios for dinosaur origins over 20 years of research time, and analyse the results in the light of different fossil record sampling regimes. Our results consistently optimize South Gondwana as the ancestral area for Dinosauria, as well as for more inclusive clades including Dinosauromorpha, and show that this hypothesis is robust to increased taxonomic and geographic sampling and divergent phylogenetic results. Our results do not find any support for the recently proposed Laurasian origin of dinosaurs and suggest that a southern Gondwanan origin is by far the most plausible given our current knowledge of the diversity of early dinosaurs and non-dinosaurian dinosauromorphs

BMQ

BMQ: Boston Medical Quarterly was published from 1950-1966 by the Boston University School of Medicine and the Massachusetts Memorial Hospitals

Performance-based financing as a health system reform : mapping the key dimensions for monitoring and evaluation

Peer reviewedPublisher PD

Use of the Behavior Assessment Tool in 18 Pilot Residency Programs

Background: The purpose of this study was to determine the feasibility and evaluate the effectiveness of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) for measuring professionalism. Methods: Through collaboration between the American Board of Orthopaedic Surgery and American Orthopaedic Association\u27s Council of Residency Directors, 18 residency programs piloted the use of the ABOSBT. Residents requested assessments from faculty at the end of their clinical rotations, and a 360° request was performed near the end of the academic year. Program Directors (PDs) rated individual resident professionalism (based on historical observation) at the outset of the study, for comparison to the ABOSBT results. Results: Nine thousand eight hundred ninety-two evaluations were completed using the ABOSBT for 449 different residents by 1,012 evaluators. 97.6% of all evaluations were scored level 4 or 5 (high levels of professional behavior) across all of the 5 domains. In total, 2.4% of all evaluations scored level 3 or below reflecting poorer performance. Of 431 residents, the ABOSBT identified 26 of 32 residents who were low performers (2 or more \u3c level 3 scores in a domain) and who also scored below expectations by the PD at the start of the pilot project (81% sensitivity and 57% specificity), including 13 of these residents scoring poorly in all 5 domains. Evaluators found the ABOSBT was easy to use (96%) and that it was an effective tool to assess resident professional behavior (81%). Conclusions: The ABOSBT was able to identify 2.4% low score evaluations ( Level of Evidence: Level II