Doctor of Philosophy

dissertationClinical practice guidelines and accrediting agencies emphasize the need for palliative care in nursing homes and care coordination between the hospital and nursing home. However, it is unclear how care is managed for patients discharged to nursing homes after a hospital-based palliative care consult. The purpose of this study was to describe the continuity of care, experiences, and outcomes of residents in a nursing home after palliative care consult during hospitalization. A qualitative descriptive approach was used to enroll a sample of 12 adults, 60 years or older, with a life expectancy of at least 7 days, who received a palliative care consult during hospitalization, and who were discharged to a nursing home without hospice support. Participants' charts were reviewed for clinical information at five time points from hospital discharge to 100 days after nursing home admission. Face-to-face semistructured interviews were conducted, individual chart data were extracted, and care trajectories were mapped. Audio recordings of the interviews were transcribed, and transcripts were imported into a qualitative data analysis software program that was used to organize and manage all data. Content analysis was employed to identify codes, categories, and themes. The mean age of this sample was 80 years (range 62-95). All participants were seriously ill and received goals-of-care conversations facilitated by a palliative care team in the hospital; care preferences ranged from comfort care only to aggressive life-prolonging treatments. However, all participants accessed the Medicare skilled nursing facility benefit upon nursing home iv admission, which indicated a need for rehabilitative or restorative care. None of the participants accessed hospice services in the nursing home. Study findings indicate that despite receiving a palliative care consultation, continuity in care was largely insufficient, and palliative care follow-up was episodic. Three influences on care discontinuity for this complex group of patients are care-setting transitions, individual patient- and family-level factors, and system-level interference. To improve palliative care throughout illness trajectory, older adults need better access to ongoing community and primary palliative care

A Complex Interaction Between Reduced Reelin Expression and Prenatal Organophosphate Exposure Alters Neuronal Cell Morphology.

Genetic and environmental factors are both likely to contribute to neurodevelopmental disorders including schizophrenia, autism spectrum disorders, and major depressive disorders. Prior studies from our laboratory and others have demonstrated that the combinatorial effect of two factors-reduced expression of reelin protein and prenatal exposure to the organophosphate pesticide chlorpyrifos oxon-gives rise to acute biochemical effects and to morphological and behavioral phenotypes in adolescent and young adult mice. In the current study, we examine the consequences of these factors on reelin protein expression and neuronal cell morphology in adult mice. While the cell populations that express reelin in the adult brain appear unchanged in location and distribution, the levels of full length and cleaved reelin protein show persistent reductions following prenatal exposure to chlorpyrifos oxon. Cell positioning and organization in the hippocampus and cerebellum are largely normal in animals with either reduced reelin expression or prenatal exposure to chlorpyrifos oxon, but cellular complexity and dendritic spine organization is altered, with a skewed distribution of immature dendritic spines in adult animals. Paradoxically, combinatorial exposure to both factors appears to generate a rescue of the dendritic spine phenotypes, similar to the mitigation of behavioral and morphological changes observed in our prior study. Together, our observations support an interaction between reelin expression and chlorpyrifos oxon exposure that is not simply additive, suggesting a complex interplay between genetic and environmental factors in regulating brain morphology

Care coordination for children with medical complexity: a mixed-methods evaluation

In the US and the world, the number of children living with chronic and complex medical conditions is growing. Many also have unmet health needs. While these children are frequent users of high-cost health services, their care is often received in home- and community-based settings, with families assuming responsibility for care management and direct care. Care coordination is part of the recommended standard of care to improve patient outcomes and ensure patient-/family-focused, comprehensive care across service settings for children who have special health care needs. Living with a child with medical complexity can place psychological, social, and financial strains on a family. It is hypothesized that families at risk of poor outcomes stand to benefit from care coordination, and that care coordination could lead to cost-savings for the health system. Despite growth in the research on care coordination and some evidence of its benefits on health outcomes and costs, substantial variation in definition, implementation, and evaluation remains. This issue has public health significance because care coordination may be an effective strategy to reduce high-cost health services use, prevent unnecessary care, improve the patient/family experience, and ultimately improve patient outcomes. The goals of this dissertation were to review the literature on key aspects of care coordination for children with special health care needs and their associations with empowerment, assess the implementation of a pilot care coordination program, and use interviews and surveys to explore families’ experiences of care coordination. As per agency policy, the pilot care coordination program provided tiered support based on medical and psychosocial acuity. Higher-acuity families received more staff contacts and longer contact time. Trends show the majority of families reduced acuity from enrollment to the end of the study period. Higher-acuity families and families enrolled for a longer period rated the family-centeredness of the care coordination they received higher than those at lower acuity and those in the program for less time. Higher-acuity families self-reported a reduction in emergency department use and hospitalization since enrolling. While there were no significant results on empowerment, families described numerous benefits of care coordination, including: efficiency, legitimacy, support, and stress reduction

The phylogeny of the social wasp subfamily Polistinae: evidence from microsatellite flanking sequences, mitochondrial COI sequence, and morphological characters

BACKGROUND: Social wasps in the subfamily Polistinae (Hymenoptera: Vespidae) have been important in studies of the evolution of sociality, kin selection, and within colony conflicts of interest. These studies have generally been conducted within species, because a resolved phylogeny among species is lacking. We used nuclear DNA microsatellite flanking sequences, mitochondrial COI sequence, and morphological characters to generate a phylogeny for the Polistinae (Hymenoptera) using 69 species. RESULTS: Our phylogeny is largely concordant with previous phylogenies at higher levels, and is more resolved at the species level. Our results support the monophyly of the New World subgenera of Polistini, while the Old World subgenera are a paraphyletic group. All genera for which we had more than one exemplar were supported as monophyletic except Polybia which is not resolved, and may be paraphyletic. CONCLUSION: The combination of DNA sequences from flanks of microsatellite repeats with mtCOI sequences and morphological characters proved to be useful characters establishing relationships among the different subgenera and species of the Polistini. This is the first detailed hypothesis for the species of this important group

Understanding Treatment Burden and Quality of Life Impact of Participating in an Early-Phase Pediatric Oncology Clinical Trial: A Pilot Study

PURPOSE: Early-phase clinical trials (EPTs) have led to new, more effective treatment options for children with cancer. Despite the extensive use of EPTs in pediatric oncology, little is known about parent and child experiences during EPT participation. The purposes of this pilot study were to assess the feasibility and preliminary results of having children with cancer and their parents complete measures of treatment burden and quality of life (QOL) concurrent with EPT participation. METHODS: In this descriptive, longitudinal, pilot study, parents and children were followed for the first 60 days of an EPT. Feasibility was assessed by participant enrollment and retention and completion of measures. Measures completed included the following: demographic form (completed at baseline); Diary of Trial Experiences to capture treatment burden (completed ongoing); and PedsQL™ Quality of Life Inventories, Cancer Modules, and Family Impact Module (completed at baseline, post-first disease evaluation, and off-study). Data were analyzed using descriptive statistics. RESULTS: Feasibility goals of enrollment, retention, and measure completion were partially met. Preliminary treatment burden and QOL results are provided. CONCLUSIONS: While QOL assessments may provide insight into EPT experiences, future studies need to be conducted at multiple sites and enrollment goals must account for participant attrition

Patient Perceptions of Provider and Hospital Factors Associated With New Medication Communication

This research examined provider and hospital factors associated with patients’ perceptions of how often explanations of new medications were “always” given to them, using Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. HCAHPS results were obtained for October 2012 to September 2013, from 3,420 hospitals and combined with a Magnet-designated hospital listing. Multiple regression examined correlates of new medication communication, including health care provider factors (perceptions of nurse and physician communication) and health care system factors (magnet designation, hospital ownership, hospital type, availability of emergency services, and survey numbers). Nurse and physician communication was strongly associated with new medication communication (r = .819, p < .001; r = .722, p < .001, respectively). Multivariable correlates included nurse communication (p < .001), physician communication (p < .001), hospital ownership, availability of emergency services, and survey numbers. There was a significant relationship between patients’ perceptions of nurse and physician communication and the explanations they had received about their new medications during hospitalization

The dust, planetesimals and planets of HD 38529

HD 38529 is a post-main sequence G8III/IV star (3.5 Gyr old) with a planetary system consisting of at least two planets having Msin(i) of 0.8 MJup and 12.2 MJup, semimajor axes of 0.13 AU and 3.74 AU, and eccentricities of 0.25 and 0.35, respectively. Spitzer observations show that HD 38529 has an excess emission above the stellar photosphere, with a signal-to-noise ratio (S/N) at 70 micron of 4.7, a small excess at 33 micron (S/N=2.6) and no excess <30 micron. We discuss the distribution of the potential dust-producing planetesimals from the study of the dynamical perturbations of the two known planets, considering in particular the effect of secular resonances. We identify three dynamically stable niches at 0.4-0.8 AU, 20-50 AU and beyond 60 AU. We model the spectral energy distribution of HD 38529 to find out which of these niches show signs of harboring dust-producing plantesimals. The secular analysis, together with the SED modeling resuls, suggest that the planetesimals responsible for most of the dust emission are likely located within 20-50 AU, a configuration that resembles that of the Jovian planets + Kuiper Belt in our Solar System. Finally, we place upper limits (8E-6 lunar masses of 10 micron particles) to the amount of dust that could be located in the dynamically stable region that exists between the two planets (0.25--0.75 AU).Comment: 23 pages, including 1 table and 5 figures. Accepted for publication in Ap

Factors Associated with Neutralizing Antibody Response in Piglets Experimentally Infected with Porcine Reproductive and Respiratory Virus

Host genetic differences and other factors associated with neutralizing antibody (NAb) response were examined in 464 Large White-Landrace piglets that were experimentally challenged with porcine reproductive and respiratory virus (PRRSv) isolate NVSL-97-7895. Serum samples and viremia data were collected on piglets periodically for 42 days post infection (dpi). NAb response was defined as the inverse of the highest 1:2 serial dilution of serum without cytopathic effects. Heritability and other factors associated with NAb response were estimated using an animal model in ASReml. These analyses identified two aspects of viremia that were associated with NAb response: viral load (area under the curve from 0-21 dpi) and virus rebound (a two Log increase in viremia after the virus had started to clear). These results also suggested that NAb response may be lowly heritable and provided the groundwork for further characterization of NAb response

Predicting Outcomes Among Adolescents With Disruptive Disorders Being Treated in a System of Care Program

BACKGROUND: “Systems of care” are strengths-based approaches to treating adolescents and others with disruptive disorders. However, little is known about why some adolescents improve and others do not. OBJECTIVE: To examine changes in personal strengths and family functioning as predictors of behavioral and social functioning among adolescents with disruptive disorders who participated in a system of care program. DESIGN: Secondary analyses of data from 114 adolescents (12-17 years of age) with disruptive disorders and their caregivers who participated in the Dawn Project Evaluation Study. Caregivers completed in-depth interviews conducted by trained data collectors using standardized questionnaires. Baseline and 12- month data are reported here. RESULTS: Improvement in personal strengths was a significant predictor of improvement in adolescent behavioral and social functioning, controlling for demographics (p < .001). CONCLUSION: In adolescents with disruptive disorders, psychiatric nurses should focus on enhancing adolescents’ personal strengths to improve behavioral and social functioning

The state of the art in clinical knowledge management: An inventory of tools and techniques

Purpose To explore the need for, and use of, high-quality, collaborative, clinical knowledge management (CKM) tools and techniques to manage clinical decision support (CDS) content. Methods In order to better understand the current state of the art in CKM, we developed a survey of potential CKM tools and techniques. We conducted an exploratory study by querying a convenience sample of respondents about their use of specific practices in CKM. Results The following tools and techniques should be priorities in organizations interested in developing successful computer-based provider order entry (CPOE) and CDS implementations: (1) a multidisciplinary team responsible for creating and maintaining the clinical content; (2) an external organizational repository of clinical content with web-based viewer that allows anyone in the organization to review it; (3) an online, collaborative, interactive, Internet-based tool to facilitate content development; (4) an enterprise-wide tool to maintain the controlled clinical terminology concepts. Even organizations that have been successfully using computer-based provider order entry with advanced clinical decision support features for well over 15 years are not using all of the CKM tools or practices that we identified. Conclusions If we are to further stimulate progress in the area of clinical decision support, we must continue to develop and refine our understanding and use of advanced CKM capabilities