Dysphagia Screening for Pneumonia Prevention in a Cancer Hospital: Results of a Quality/Safety Initiative.

Objective Hospital-acquired aspiration pneumonia remains a rare but potentially devastating problem. The best means by which to prevent aspiration in a cancer hospital population has not been evaluated. The aim of this study was to evaluate the impact of dysphagia screening on aspiration pneumonia rates in an acute care oncology hospital. Methods A prospective single-institution quality-improvement dysphagia screening protocol at a comprehensive cancer center. Effect of dysphagia screening implemented in 2016 on hospital acquired aspiration pneumonia rates coded “aspiration pneumonitis due to food/vomitus” were compared with rates from 2014-15, prior to implementation. Screening compliance, screening outcomes, patient demographics, and medical data were reviewed as part of a post hoc analysis. Results Of 12,392 admissions in 2014-16, 97 patients developed aspiration pneumonia during their hospitalization. No significant change in aspiration pneumonia rate was seen during the dysphagia screening year when compared to prior years (baseline- 7.36 and screening year- 8.78 per 1000 discharges p=0.33). Sixty-eight of the cases (66%) were associated with emesis/gastrointestinal obstruction or perioperative aspiration and only 15 (15%) with oropharyngeal dysphagia. Multivariate analysis found that patients admitted to GI surgery had an aspiration risk equivalent to patients admitted to head and neck, thoracic and pulmonary services (OR 0.65, p= 0.2). Discussion: Nursing-initiated dysphagia screening did not decrease aspiration pneumonia rates. The causes of aspiration-associated pneumonia were heterogeneous. Aspiration of intestinal contents is a more common source of hospital-acquired pneumonia than oropharyngeal dysphagia

Rapamycin-coated expanded polytetrafluoroethylene bypass grafts exhibit decreased anastomotic neointimal hyperplasia in a porcine model

ObjectiveWe tested the hypothesis that rapamycin coated onto, and eluted from, expanded polytetrafluoroethylene (ePTFE) grafts would diminish neointimal hyperplasia in a porcine model.MethodsRapamycin (also called sirolimus) was coated onto the luminal surface of 6-mm-internal-diameter thin-walled ePTFE grafts by using an adhesive polymer that allows timed release of the drug. An adhesive polymer that allows timed release of rapamycin from ePTFE was developed with commercially available chemicals and applied on 6-mm ePTFE grafts. Graft integrity was characterized by scanning electron microscopy, and rapamycin levels were quantified by using high-performance liquid chromatography. Twenty-two mongrel pigs were randomized into three groups: untreated ePTFE (n = 6), adhesive-only coated ePTFE (n = 6), or adhesive- and rapamycin-coated ePTFE (n = 10). End-to-side unilateral aortoiliac bypasses were performed by using 6-mm-internal-diameter ePTFE grafts and standardized anastomotic lengths. Unilateral end-to-side aortoiliac ePTFE grafts (6-mm internal diameter) were inserted by using polypropylene sutures, 6-0 proximally and 7-0 distally; all anastomoses were 12 mm long. All animals received aspirin (325 mg orally) daily. All animals were given oral aspirin (325 mg) daily beginning on the day before surgery. At 28 days, the animals were killed, and the grafts were explanted in continuity with the adjacent aortic cuff and the outflow iliac artery. Variables compared between groups included graft patency, distal anastomotic length and cross-sectional narrowing, and intimal thickness at the arterial-graft junction indexed to the adjacent graft thickness. Microscopic analysis was performed with hematoxylin and eosin and Masson trichrome stains on paraffin sections. A pathologist blinded to experimental groups graded sections for collagen deposition, neointima formation, inflammatory cellular infiltrates, medial necrosis, and aneurysmal degeneration.ResultsAll animals survived until they were killed without clinical evidence of limb ischemia or graft infection. Preplanned t tests in the context of one-way analysis of variance showed no difference in outcome measures between the untreated ePTFE and adhesive-only coated ePTFE groups; therefore, they were combined in further comparisons with the adhesive- and rapamycin-coated ePTFE group. The Rapamycine eluting expanded polytetrafluoroethylene group had longer anastomoses (85.6% vs 60.6% of the initial anastomotic length maintained; P < .0001) and less cross-sectional narrowing in the outflow graft (16.2% vs 28.5%; P = .0007) when compared with the other two groups by using two-tailed Student t tests. There was no evidence of medial necrosis or aneurysmal degeneration. All patent grafts had complete endothelialization on hematoxylin and eosin sections. Rapamycin was detectable and quantifiable in the arterial wall at 28 days after implantation.ConclusionsRapamycin can be coated onto and eluted from ePTFE by using a nonionic polymer and a simple coating technique. At 4 weeks after implantation, the rapamycin-eluting ePTFE grafts demonstrate gross, pathologic, and morphometric features of diminished neointimal hyperplasia when compared with non–drug-eluting ePTFE. Four weeks after implantation in a porcine model, rapamycin-eluting ePTFE grafts demonstrated gross, pathologic, and morphometric features of diminished neointimal hyperplasia when compared with untreated and adhesive-only coated ePTFE grafts.Clinical RelevanceRapamycin-eluting ePTFE grafts decrease neointimal hyperplasia in a porcine model. Further studies are needed to evaluate whether patency will be improved. Rapamycin-eluting ePTFE grafts may allow the use of prosthetic grafts in situations in which autologous vein is unavailable and in which neointimal hyperplasia is pronounced, such as in small-diameter (<6-mm) vessels typical of infrapopliteal interventions

The effect of neighborhood social environment on prostate cancer development in black and white men at high risk for prostate cancer

INTRODUCTION: Neighborhood socioeconomic (nSES) factors have been implicated in prostate cancer (PCa) disparities. In line with the Precision Medicine Initiative that suggests clinical and socioenvironmental factors can impact PCa outcomes, we determined whether nSES variables are associated with time to PCa diagnosis and could inform PCa clinical risk assessment. MATERIALS AND METHODS: The study sample included 358 high risk men (PCa family history and/or Black race), aged 35-69 years, enrolled in an early detection program. Patient variables were linked to 78 nSES variables (employment, income, etc.) from previous literature via geocoding. Patient-level models, including baseline age, prostate specific antigen (PSA), digital rectal exam, as well as combined models (patient plus nSES variables) by race/PCa family history subgroups were built after variable reduction methods using Cox regression and LASSO machine-learning. Model fit of patient and combined models (AIC) were compared; p-values RESULTS: In combined models, nSES variables were significantly associated with time to PCa diagnosis. Workers mode of transportation and low income were significant in White men with a PCa family history. Homeownership (%owner-occupied houses with \u3e3 bedrooms) and unemployment were significant in Black men with and without a PCa family history, respectively. The 5-year predicted probability of PCa was higher in men with a high neighborhood score (weighted combination of significant nSES variables) compared to a low score (e.g., Baseline PSA level of 4ng/mL for men with PCa family history: White-26.7% vs 7.7%; Black-56.2% vs 29.7%). DISCUSSION: Utilizing neighborhood data during patient risk assessment may be useful for high risk men affected by disparities. However, future studies with larger samples and validation/replication steps are needed

A Telephone-Adapted Mindfulness-Based Stress Reduction Program: Preliminary Effects among Healthcare Employees

Healthcare employees often experience high stress and may benefit from accessible psychosocial interventions. In this pilot study, we explored preliminary feasibility, acceptability, and psychological effects of a telephone-based adaption of mindfulness-based stress reduction (MBSR) for healthcare employees. Eleven participants (M age = 49.9; 27.3% ethnic/racial minority) were enrolled in an eight-session group-based MBSR program adapted for telephone delivery. Feasibility was assessed using rates of program attrition and session completion; acceptability was explored qualitatively via participants\u27 responses to an open-ended item about their program experience. Participants also completed pre-and post-program assessments on psychosocial outcomes (distress (overall distress, depression, anxiety, somatization), mindfulness, and self-compassion). We characterized mean change scores, 95% confidence intervals, and effect sizes to explore preliminary program effects. With regard to preliminary feasibility, one participant dropped out prior to the intervention; of the remaining 10 participants, 90% completed at least half (≥4) of the sessions; 70% completed at least three-quarters (≥6 sessions). Feedback reflected positive experiences and included suggestions for program delivery. Participants reported reductions in distress post-program (M difference range = -5.0 to -9.4), showing medium to large effect sizes (d range = 0.68 to 1.11). Mindfulness scores increased from pre- to post-intervention (M difference range = 1.0 to 10.4), with small-to-medium effects (d range = 0.18 to 0.55). Almost all aspects of self-compassion remained stable over time, with the exception of common humanity, which increased post-program (M difference = 2.9, CI 95% 0.5 to 5.4, d = 0.91). Preliminary findings from our small pilot trial suggest that telephone-based adaptations of MBSR may be a useful mode of delivery for healthcare employees; however, larger studies are needed to provide further evidence of feasibility, acceptability, and program effects

Improving Long-Term Adherence to Monitoring/Treatment in Underserved Asian Americans with Chronic Hepatitis B (CHB) through a Multicomponent Culturally Tailored Intervention: A Randomized Controlled Trial

Background: Although Asian Americans make up 6% of the U.S. population, they account for 58% of Americans with chronic hepatitis B (CHB). Yet, adherence to monitoring and antiviral treatment guidelines among Asian American CHB patients remains suboptimal. Methods: The purpose of this study was to evaluate the efficacy of a multicomponent intervention on adherence to CHB monitoring among Asian Americans with CHB. The intervention components included virtual patient education, patient navigation, and mobile health reminders delivered by bilingual community health educators. Chi-square test and t -test were used to compare demographic characteristics and two CHB measures: CHB clinical follow-up and CHB laboratory monitoring by the time of the 12-month follow-up assessment. A generalized linear mixed-effects model (GLMM) was fitted to assess the effectiveness of the intervention. Results: The study sample consisted of 358 Chinese and Vietnamese Americans living with CHB, including 181 in the intervention group and 177 in the control group. The intervention group had a significantly higher rate of CHB clinical follow- up (86.2%) and CHB laboratory monitoring (79.0%) than did the control group (54.2% and 45.2%, respectively). Results of the GLMM showed significant intervention effects on CHB clinical follow-up (odds ratio = 7.35, 95% confidence interval = 4.06–13.33) and CHB laboratory monitoring (odds ratio = 6.60, 95% confidence interval = 3.77–11.56) at the 12-month follow-up assessment. Conclusion: The multicomponent intervention was effective in improving adherence to CHB monitoring among Asian Americans. Additional implementation research is needed to better understand and apply effective interventions to other underserved populations

Factors Associated with Hepatitis B Medication Adherence and Persistence among Underserved Chinese and Vietnamese Americans

Background: Hepatitis B virus (HBV) infection disproportionately affects Asian Amer- icans in the United States, while this population faces low adherence to HBV treatment. Using the information–motivation–behavioral skills model (IMB), the study aims to examine medication adherence and persistence among Chinese and Vietnamese people with HBV. Methodology: Study participants were recruited between March 2019 and March 2020 and were enrolled through multiple recruitment approaches in the Greater Philadelphia Area and New York City. The study is an assess- ment of the baseline data on medication adherence, HBV-related knowledge, motivation of HBV med- ication treatment, self-efficacy about HBV medication treatment, and socioeconomic status. Results: Among 165 participants, 77.6% were Chinese and 22.4% were Vietnamese Americans. HBV-related knowledge/information, motivation, and self-efficacy were all positively associated with having medium/high medication adherence. Multilevel mixed-effects generalized linear regression revealed that living more than 10 years in the U.S. (OR = 4.24; p = 0.028) and greater information–knowledge about HBV (OR = 1.46; p = 0.004) were statistically associated with higher odds of medium/high medication adherence. Moreover, greater HBV-related knowledge/information ( OR = 1.49; p = 0.023) and greater motivation towards HBV treatment adherence (OR = 1.10; p = 0.036) were both associated with a higher likelihood of medication persistence. Conclusion: Our findings provided significant im- plications in designing behavioral interventions focused on self-efficacy, information, and motivation to promote better medication adherence among Asian Americans living with HBV

Genetic Risk Factors for Hepatopulmonary Syndrome in Patients With Advanced Liver Disease

Hepatopulmonary syndrome (HPS) affects 10%–30% of patients with cirrhosis and portal hypertension and significantly increases mortality. Studies in experimental models indicate that pulmonary angiogenesis contributes to the development of HPS, but pathogenesis in humans is poorly understood. We investigated genetic risk factors for HPS in patients with advanced liver disease