Development And Validation Of A Predictive Model For Oncology Hospital-At-Home

Background: Hospital-at-Home (HaH) is a unique care model that allows for the provision of inpatient level care in the patient’s home. HaH has been used to facilitate early discharge from inpatient care or to substitute entirely for an inpatient admission. Hospital-at-Home has been shown to have similar clinical outcomes to inpatient care, while reducing cost and complications associated with inpatient admission. Application of the HaH model to patients with oncologic disease is a promising avenue to reduce healthcare costs while improving patients’ quality of life by increasing time spent at home. A major challenge to implementing a Hospital-at-Home program for cancer patients is the lack of validated criteria to inform the selection of admissions most suitable for home-based hospital level care. Methods and Results: Admissions to the Yale New Haven Smilow Cancer Hospital’s medical oncology floor in New Haven from Jan 2015- Jun 2019 were included in the analysis (N=3,322). The analysis focused entirely on patients with solid tumors hospitalized for unplanned admissions. The definition of suitability for HaH was based on a substitutive model and identified admissions that did not receive any services that would be difficult to deliver or were inconsistent with safe care in the home. Twenty-seven-point-three percent of admissions were identified as suitable for HaH, accounting for 908 admissions during the study period. Admissions that were suitable for HaH were shorter in duration (2.79 vs 6.41 days), more likely to result in discharge home rather than to other healthcare facility (87.5% vs 69.5%), and less likely to be readmitted in the following 30 days (25.3% vs 31.5%). A predictive logistic model constructed using a purposeful selection process identified 13 statistically significant predictors for suitability for HaH: Black/African American race (vs all other), observation status, patient evaluated in the emergency department (ED) or oncology extended care center (vs admitted directly from clinic), primary admission diagnosis of secondary malignancy, primary admission diagnosis of fever, primary admission diagnosis of digestive diseases, oncology diagnosis of secondary or unknown malignancy, initial pre-admission respiratory rate \u3e20 breaths/min, final pre-admission systolic blood pressure \u3c100 mmHg, final pre-admission temperature \u3e100o F, Sodium \u3c 135 mmol/L, hemoglobin \u3c10 g/dL and ED visit in the previous 90 days. The predictive model had moderate discrimination (c-statistic 0.686) and was well calibrated in the validation cohort (Hosmer-Lemeshow P-value \u3e0.05). Conclusion: We describe the first predictive model of suitability for Hospital-at-Home in oncology patients. This model serves as a starting point to creating selection criteria and can be further refined and tested in prospective validation and pilot studies. The modest discrimination of the model indicates that much of the variability that allows for accurate prediction is still unaccounted for and would benefit from larger studies and inclusion of clinician judgement

Homeostatic Plasticity and STDP: Keeping a Neuron's Cool in a Fluctuating World

Spike-timing-dependent plasticity (STDP) offers a powerful means of forming and modifying neural circuits. Experimental and theoretical studies have demonstrated its potential usefulness for functions as varied as cortical map development, sharpening of sensory receptive fields, working memory, and associative learning. Even so, it is unlikely that STDP works alone. Unless changes in synaptic strength are coordinated across multiple synapses and with other neuronal properties, it is difficult to maintain the stability and functionality of neural circuits. Moreover, there are certain features of early postnatal development (e.g., rapid changes in sensory input) that threaten neural circuit stability in ways that STDP may not be well placed to counter. These considerations have led researchers to investigate additional types of plasticity, complementary to STDP, that may serve to constrain synaptic weights and/or neuronal firing. These are collectively known as “homeostatic plasticity” and include schemes that control the total synaptic strength of a neuron, that modulate its intrinsic excitability as a function of average activity, or that make the ability of synapses to undergo Hebbian modification depend upon their history of use. In this article, we will review the experimental evidence for homeostatic forms of plasticity and consider how they might interact with STDP during development, and learning and memory

Depressive symptoms, frailty, and adverse outcomes among kidney transplant recipients

Depressive symptoms and frailty are each independently associated with morbidity and mortality in kidney transplant (KT) recipients. We hypothesized that having both depressive symptoms and frailty would be synergistic and worse than the independent effect of each. In a multicenter cohort study of 773 KT recipients, we measured the Fried frailty phenotype and the modified 18â question Center for Epidemiologic Studiesâ Depression Scale (CESâ D). Using adjusted Poisson regression and survival analysis, we tested whether depressive symptoms (CESâ D score > 14) and frailty were associated with KT length of stay (LOS), deathâ censored graft failure (DCGF), and mortality. At KT admission, 10.0% of patients exhibited depressive symptoms, 16.3% were frail, and 3.6% had both. Recipients with depressive symptoms were more likely to be frail (aOR = 3.97, 95% CI: 2.28â 6.91, P < 0.001). Recipients with both depressive symptoms and frailty had a 1.88 times (95% CI: 1.70â 2.08, P < 0.001) longer LOS, 6.20â fold (95% CI:1.67â 22.95, P < 0.01) increased risk of DCGF, and 2.62â fold (95% CI:1.03â 6.70, P = 0.04) increased risk of mortality, compared to those who were nonfrail and without depressive symptoms. There was only evidence of synergistic effect of frailty and depressive symptoms on length of stay (P for interaction < 0.001). Interventions aimed at reducing preâ KT depressive symptoms and frailty should be explored for their impact on postâ KT outcomes.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146305/1/ctr13391_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146305/2/ctr13391.pd

Reporting trends, practices, and resource utilization in neuroendocrine tumors of the prostate gland: a survey among thirty-nine genitourinary pathologists

Background: Neuroendocrine differentiation in the prostate gland ranges from clinically insignificant neuroendocrine differentiation detected with markers in an otherwise conventional prostatic adenocarcinoma to a lethal high-grade small/large cell neuroendocrine carcinoma. The concept of neuroendocrine differentiation in prostatic adenocarcinoma has gained considerable importance due to its prognostic and therapeutic ramifications and pathologists play a pivotal role in its recognition. However, its awareness, reporting, and resource utilization practice patterns among pathologists are largely unknown. Methods: Representative examples of different spectrums of neuroendocrine differentiation along with a detailed questionnaire were shared among 39 urologic pathologists using the survey monkey software. Participants were specifically questioned about the use and awareness of the 2016 WHO classification of neuroendocrine tumors of the prostate, understanding of the clinical significance of each entity, and use of different immunohistochemical (IHC) markers. De-identified respondent data were analyzed. Results: A vast majority (90%) of the participants utilize IHC markers to confirm the diagnosis of small cell neuroendocrine carcinoma. A majority (87%) of the respondents were in agreement regarding the utilization of type of IHC markers for small cell neuroendocrine carcinoma for which 85% of the pathologists agreed that determination of the site of origin of a high-grade neuroendocrine carcinoma is not critical, as these are treated similarly. In the setting of mixed carcinomas, 62% of respondents indicated that they provide quantification and grading of the acinar component. There were varied responses regarding the prognostic implication of focal neuroendocrine cells in an otherwise conventional acinar adenocarcinoma and for Paneth cell-like differentiation. The classification of large cell neuroendocrine carcinoma was highly varied, with only 38% agreement in the illustrated case. Finally, despite the recommendation not to perform neuroendocrine markers in the absence of morphologic evidence of neuroendocrine differentiation, 62% would routinely utilize IHC in the work-up of a Gleason score 5 + 5 = 10 acinar adenocarcinoma and its differentiation from high-grade neuroendocrine carcinoma. Conclusion: There is a disparity in the practice utilization patterns among the urologic pathologists with regard to diagnosing high-grade neuroendocrine carcinoma and in understanding the clinical significance of focal neuroendocrine cells in an otherwise conventional acinar adenocarcinoma and Paneth cell-like neuroendocrine differentiation. There seems to have a trend towards overutilization of IHC to determine neuroendocrine differentiation in the absence of neuroendocrine features on morphology. The survey results suggest a need for further refinement and development of standardized guidelines for the classification and reporting of neuroendocrine differentiation in the prostate gland

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

PRIORITY MECHANISM DESIGN FOR INCOMING TRAFFIC IN 4G LTE NETWORK

Long Term Evolution (LTE) is currently being used for commercial networks and the same technology will also be used for Public Safety (PS) applications. As a way to maximize network usage and also to allow PS users to share the commercial networks especially during emergency or disaster situations, PS users need to co-exist with commercial users in a shared network environment. To ensure proper assignment of resources in a network originated call scenario, priority mechanisms have been proposed in this report. Priority mechanism in terms of assignment of resources for the user plane, for scheduling of resources in the control plane, and for meeting Quality of Service (QoS) requirements have been discussed. To provide priority treatment, the use of a new parameter named Call Priority Number (CPN) generated by the Policy control and Charging Rules Function (PCRF) is proposed. This parameter signifies the priority of a call in terms of the caller priority, the callee priority and the priority of the application. For incoming calls, the functionality of providing priority mechanism for resource assignment using CPN is proposed to be in the Mobility Management Entity (MME). The functionality for scheduling resources in the control plane, for performing paging, for priority mechanism functionality that uses CPN and the implementation of using different paging cycles for the users based on their priority resides in the evolved NodeB (eNodeB). For managing the priority based on QoS, a mapping of the priority of applications served by LTE networks to the Differentiated Services has been proposed. The mapping can be implemented in the Packet data network Gate Way (PGW). The proposals are verified by simulation. The results show that the PS users are assigned the x required resources for the user plane, they get prioritized QoS treatment within the LTE network, and the PS users are given higher priority over the commercial users. As a result of the techniques proposed in this report, the time it takes to set up a call between PS users is reduced, the number of dropped calls for the PS user decrease, and the PS users have a faster access to network resources.M.S. in Electrical Engineering, December 201

CAD Modeling Based Thermal Analysis of 60-kW Universal Battery Supercharger (UBS)

Power electronics devices when operating at high power sometimes face performance issues due to poor thermal handling. The main goal of this work is to get an effective design for a cold plate to manage the thermal load for effective performance. The cold-plate design should be done such a way that it can deliver the required amount of power, reduces the semiconductor losses and keeps the junction temperature in the acceptable limit. The work started with designing the CAD model for the 60-kW Universal Battery Supercharger (UBS). Initially, two designs ‘V1.0 and V2.0’ were made. The first version V1.0 did not match the power density and hence, the final version V2.0 with both the factor satisfying was made. Hence, thermal analysis was done based on the second version V2.0. The thermal analysis was done initially using thermal and subsequently, using fluent packages of ANSYS. Once the modeling part was completed, for localized cooling of SiC module, the fin-based cold-plate design was made. With this fin-based cold-plate design, initial results were taken and based on the required performance, minor changes in the cold plate were made. After testing a total of six cold-plate designs with minor changes in it, the one with the most effective cooling was selected

An update on the diagnosis and management of tic disorders

Tic disorders (TDs) are a group of common neuropsychiatric disorders of childhood and adolescence. TDs may impact the physical, emotional, and social well-being of the affected person. In this review, we present an update on the clinical manifestations, pathophysiology, diagnosis, and treatment of TDs. We searched the PubMed database for articles on tics and Tourette syndrome. More than 400 articles were reviewed, of which 141 are included in this review. TDs are more prevalent in children than in adults and in males than in females. It may result from a complex interaction between various genetic, environmental, and immunological factors. Dysregulation in the cortico-striato-pallido-thalamo-cortical network is the most plausible pathophysiology resulting in tics. TD is a clinical diagnosis based on clinical features and findings on neurological examination, especially the identification of tic phenomenology. In addition to tics, TD patients may have sensory features, including premonitory urge; enhanced and persistent sensitivity to non-noxious external or internal stimuli; and behavioral manifestations, including attention deficit hyperactivity disorders, obsessive-compulsive disorders, and autism spectrum disorders. Clinical findings of hyperkinetic movements that usually mimic tics have been compared and contrasted with those of TD. Patients with TD may not require specific treatment if tics are not distressing. Psychoeducation and supportive therapy can help reduce tics when combined with medication. Dispelling myths and promoting acceptance are important to improve patient outcomes. Using European, Canadian, and American guidelines, the treatment of TD, including behavioral therapy, medical therapy, and emerging/experimental therapy, has been discussed