An integrated electronic health record-based workflow to improve management of colonoscopy-generated pathology results

Purpose: Managing and communicating colonoscopy-generated pathology results and appropriate follow-up recommendations can be challenging. To improve this process, we developed and implemented a standardized electronic health record-based intervention with built-in decision support. Methods: Fourteen attending endoscopists performed enough colonoscopies to qualify for the study. For each, we randomly sampled and abstracted data from 35 colonoscopies that met prespecified inclusion criteria during both the pre-intervention and also post-intervention periods. Follow-up recommendations were compared to guidelines. We used the Wilcoxon Signed Rank Test to assess the change in the proportion of cases with guideline-concordant results, the proportion with a documented follow-up result letter, and the median time to letter completion. A brief survey assessed endoscopists’ satisfaction with the intervention. Results: In total, 1,947 colonoscopies were extracted, of which 968 met inclusion criteria. The proportion of follow-up recommendations that were guideline concordant increased from a median of 82.9% pre-intervention to 85.7% post-intervention (P=0.72). The proportion of observations with a documented follow-up result letter increased from a median of 88.9% pre-intervention to 97.1% post-intervention (P=0.07). The number of calendar days between the date of the colonoscopy and the date the letter was sent decreased from a median of 7.7 days pre-intervention to 6.8 days post-intervention (P=0.79). Eighty-six percentage of endoscopists were either “very satisfied” or “satisfied” with the overall process. Conclusion: The intervention was not associated with a statistically significant increase in guideline-concordant recommendations or efficiency measures, perhaps due to high baseline performance. The intervention was well received by endoscopists and captured data necessary for important downstream processes

Modifiable Risk Factors for Hospital Readmission among Patients with Inflammatory Bowel Disease in a Nationwide Database

Background: Previous studies suggest that disease activity alone does not reliably predict hospital readmission among patients with inflammatory bowel diseases (IBDs). Using a national database, we aimed to further describe the burden of readmissions for IBD and identify modifiable risk factors. Methods: We performed a retrospective cohort study using 2013 data from the Nationwide Readmission Database (NRD). Using International Classification of Diseases, ninth Revision, Clinical Modification (ICD-9-CM) codes, we identified adult patients with discharge diagnoses of ulcerative colitis or Crohn's disease and ascertained diagnoses of anxiety, depression, chronic pain, tobacco use, and other comorbidities during index admission. Logistic regression was used to estimate factors associated with hospital readmission. Results: Among 52,498 hospitalizations of patients with IBD (63% Crohn's disease and 37% ulcerative colitis), 12,407 (24%) were readmitted within 90 days of the index hospitalization, resulting in roughly $576 million in excess charges. In multivariable analysis of patients with Crohn's disease, anxiety (odds ratio [OR] 1.31, 95% confidence interval [CI], 1.21-1.43), depression (OR 1.27, 95% CI, 1.07-1.50), chronic pain (OR 1.31, 95% CI, 1.18-1.46), and tobacco abuse (OR 1.13, 95% CI, 1.06-1.22) were associated with a significant increase in odds of readmission. Among patients with ulcerative colitis, anxiety (OR 1.28, 95% CI, 1.14-1.45), depression (OR 1.35, 95% CI, 1.07-1.70), and chronic pain (OR 1.44, 95% CI, 1.21-1.73) were associated with a significant increase in odds of readmission. Conclusions: Readmission occurs frequently in patients with IBD and is costly. Anxiety, depression, and chronic pain may represent targets for interventions to prevent 90-day hospital readmission in this population

The Burden of Hospital Readmissions among Pediatric Patients with Inflammatory Bowel Disease

Objective To evaluate the burden and predictors of hospital readmissions among pediatric patients with inflammatory bowel disease using the Nationwide Readmissions Database. Study design We performed a retrospective cohort study using 2013 Nationwide Readmissions Database. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients 7 days was associated with increased readmissions (aOR 1.69, 95% CI 1.09-2.62). Conclusions Readmission occurs frequently in children with inflammatory bowel disease and is associated with significant cost and resource burdens. Among patients with CD, psychiatric comorbidities such as anxiety and depression are apparent drivers of readmission

On the Progenitors of Core-Collapse Supernovae

Theory holds that a star born with an initial mass between about 8 and 140 times the mass of the Sun will end its life through the catastrophic gravitational collapse of its iron core to a neutron star or black hole. This core collapse process is thought to usually be accompanied by the ejection of the star's envelope as a supernova. This established theory is now being tested observationally, with over three dozen core-collapse supernovae having had the properties of their progenitor stars directly measured through the examination of high-resolution images taken prior to the explosion. Here I review what has been learned from these studies and briefly examine the potential impact on stellar evolution theory, the existence of "failed supernovae", and our understanding of the core-collapse explosion mechanism.Comment: 7 Pages, invited review accepted for publication by Astrophysics and Space Science (special HEDLA 2010 issue

Internalized HIV Stigma and Pain among Women with HIV in the United States: The Mediating Role of Depressive Symptoms

Pain is common in women with HIV, though little research has focused on psychosocial experiences contributing to pain in this population. In the present study we examined whether internalized HIV stigma predicts pain, and whether depressive symptoms mediate this relationship among women with HIV. Data were drawn from the Women’s Interagency HIV Study (WIHS), for 1,364 women with HIV who completed three study visits between 2015 and 2016. We used a sequential longitudinal design to assess the relationship between internalized HIV stigma at time 1 on pain at time 3 through depressive symptoms at time 2. Analyses revealed internalized HIV stigma was prospectively associated with greater pain, B = 5.30, 95% CI [2.84, 7.60]. The indirect effect through depressive symptoms supported mediation, B = 3.68, 95% CI [2.69, 4.79]. Depression is a modifiable risk factor that can be addressed to improve pain prevention and intervention for women with HIV

Neighborhood Racial Diversity, Socioeconomic Status, and Perceptions of HIV-Related Discrimination and Internalized HIV Stigma among Women Living with HIV in the United States

Relationships that traverse sociodemographic categories may improve community attitudes toward marginalized groups and potentially protect members of those groups from stigma and discrimination. The present study evaluated whether internalized HIV stigma and perceived HIV-related discrimination in health care settings differ based on individual-and neighborhood-level characteristics of women living with HIV (WLHIV). We also sought to extend previous conceptual and empirical work to explore whether perceived HIV-related discrimination mediated the association between neighborhood racial diversity and internalized HIV stigma. A total of 1256 WLHIV in the Women's Interagency HIV Study (WIHS) attending 10 sites in metropolitan areas across the United States completed measures of internalized HIV stigma and perceived HIV-related discrimination in health care settings. Participants also provided residential information that was geocoded into Federal Information Processing Standard (FIPS) codes and linked with census-tract level indicators. In cross-sectional analyses, greater neighborhood racial diversity was associated with less internalized HIV stigma and less perceived HIV-related discrimination regardless of individual race. Neighborhood median income was positively associated with internalized HIV stigma and perceived discrimination, while individual income was negatively associated with perceptions of stigma and discrimination. In an exploratory mediation analysis, neighborhood racial diversity had a significant indirect effect on internalized HIV stigma through perceived HIV-related discrimination. An indirect effect between neighborhood income and internalized stigma was not supported. These findings suggest that greater neighborhood racial diversity may lessen HIV stigma processes at the individual level and that HIV stigma-reduction interventions may be most needed in communities that lack racial diversity

Herschel observations of EXtra-Ordinary Sources (HEXOS): Observations of H2O and its isotopologues towards Orion KL

We report the detection of more than 48 velocity-resolved ground rotational state transitions of H 16 2 O, H 18 2 O, and H 17 2 O – most for the first time – in both emission and absorption toward Orion KL using Herschel/HIFI. We show that a simple fit, constrained to match the known emission and absorption components along the line of sight, is in excellent agreement with the spectral profiles of all the water lines. Using the measured H 18 2 O line fluxes, which are less affected by line opacity than their H 16 2 O counterparts, and an escape probability method, the column densities of H 18 2 O associated with each emission component are derived. We infer total water abundances of 7.4 × 10−5, 1.0× 10−5, and 1.6 × 10−5 for the plateau, hot core, and extended warm gas, respectively. In the case of the plateau, this value is consistent with previous measures of the Orion-KL water abundance as well as those of other molecular outflows. In the case of the hot core and extended warm gas, these values are somewhat higher than water abundances derived for other quiescent clouds, suggesting that these regions are likely experiencing enhanced water-ice sublimation from (and reduced freeze-out onto) grain surfaces due to the warmer dust in these sources

Herschel observations of EXtra-Ordinary Sources (HEXOS): Detection of hydrogen fluoride in absorption towards Orion KL

We report a detection of the fundamental rotational transition of hydrogen fluoride in absorption towards Orion KL using Herschel/HIFI. After the removal of contaminating features associated with common molecules (“weeds”), the HF spectrum shows a P-Cygni profile, with weak redshifted emission and strong blue-shifted absorption, associated with the low-velocity molecular outflow. We derive an estimate of 2.9 × 1013 cm−2 for the HF column density responsible for the broad absorption component. Using our best estimate of the H2 column density within the low-velocity molecular outflow, we obtain a lower limit of ∼1.6 × 10−10 for the HF abundance relative to hydrogen nuclei, corresponding to ∼0.6% of the solar abundance of fluorine. This value is close to that inferred from previous ISO observations of HF J = 2−1 absorption towards Sgr B2, but is in sharp contrast to the lower limit of 6 × 10−9 derived by Neufeld et al. for cold, foreground clouds on the line of sight towards G10.6-0.4

Herschel observations of deuterated water towards Sgr B2(M)

Observations of HDO are an important complement for studies of water, because they give strong constraints on the formation processes – grain surfaces versus energetic process in the gas phase, e.g. in shocks. The HIFI observations of multiple transitions of HDO in Sgr B2(M) presented here allow the determination of the HDO abundance throughout the envelope, which has not been possible before with ground-based observations only. The abundance structure has been modeled with the spherical Monte Carlo radiative transfer code RATRAN, which also takes radiative pumping by continuum emission from dust into account. The modeling reveals that the abundance of HDO rises steeply with temperature from a low abundance (2.5 × 10−11) in the outer envelope at temperatures below 100 K through a medium abundance (1.5 × 10−9) in the inner envelope/outer core at temperatures between 100 and 200 K, and finally a high abundance ( 3.5 × 10−9) at temperatures above 200 K in the hot core