Lessons for non-VA care delivery systems from the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative: QUERI Series

The U.S. Veterans Health Administration (VHA) may have a very different structure and function from the organizations and practices that provide medical care to most Americans, but those organizations and practices could learn a lot from the VHA's Quality Enhancement Research Initiative (QUERI). There are at least six topics of increasing importance for implementation research where QUERI experience should be of value to other non-VHA organizations, both within and external to the United States: 1) Researcher-clinical leader partnerships for care improvement; 2) Attention to culture, capacity, leadership, and a supportive infrastructure; 3) Practical economic evaluation of quality implementation efforts; 4) Human subject protection problems; 5) Sustainability of improvements; and 6) Scale-up and spread of improvements

Documentation of best interest by intensivists: a retrospective study in an Ontario critical care unit

<p>Abstract</p> <p>Background</p> <p>Intensive care physicians often must rely on substitute decision makers to address all dimensions of the construct of "best interest" for incapable, critically ill patients. This task involves identifying prior wishes and to facilitate the substitute decision maker's understanding of the incapable patient's condition and their likely response to treatment. We sought to determine how well such discussions are documented in a typical intensive care unit.</p> <p>Methods</p> <p>Using a quality of communication instrument developed from a literature search and expert opinion, 2 investigators transcribed and analyzed 260 handwritten communications for 105 critically ill patients who died in the intensive care unit between January and June 2006. Cohen's kappa was calculated before analysis and then disagreements were resolved by consensus. We report results on a per-patient basis to represent documented communication as a process leading up to the time of death in the ICU. We report frequencies and percentages for discrete data, median (m) and interquartile range (IQR) for continuous data.</p> <p>Results</p> <p>Our cohort was elderly (m 72, IQR 58-81 years) and had high APACHE II scores predictive of a high probability of death (m 28, IQR 23-36). Length of stay in the intensive care unit prior to death was short (m 2, IQR 1-5 days), and withdrawal of life support preceded death for more than half (n 57, 54%). Brain death criteria were present for 18 patients (17%). Although intensivists' communications were timely (median 17 h from admission to critical care), the person consenting on behalf of the incapable patient was explicitly documented for only 10% of patients. Life support strategies at the time of communication were noted in 45% of charts, and options for their future use were presented in 88%. Considerations relevant to determining the patient's best interest in relation to the treatment plan were not well documented. While explicit survival estimates were noted in 50% of charts, physicians infrequently documented their own predictions of the patient's functional status (20%), anticipated need for chronic care (0%), or post ICU quality of life (3%). Similarly, documentation of the patient's own perspectives on these ranged from 2-18%.</p> <p>Conclusions</p> <p>Intensivists' documentation of their communication with substitute decision makers frequently outlined the proposed plan of treatment, but often lacked evidence of discussion relevant to whether the treatment plan was expected to improve the patient's condition. Legislative standards for determination of best interest, such as the Health Care Consent Act in Ontario, Canada, may provide guidance for intensivists to optimally document the rationales for proposed treatment plans.</p

Mapping the categories of the Swedish primary health care version of ICD-10 to SNOMED CT concepts: Rule development and intercoder reliability in a mapping trial

<p>Abstract</p> <p>Background</p> <p>Terminologies and classifications are used for different purposes and have different structures and content. Linking or mapping terminologies and classifications has been pointed out as a possible way to achieve various aims as well as to attain additional advantages in describing and documenting health care data.</p> <p>The objectives of this study were:</p> <p>• to explore and develop rules to be used in a mapping process</p> <p>• to evaluate intercoder reliability and the assessed degree of concordance when the 'Swedish primary health care version of the International Classification of Diseases version 10' (ICD-10) is matched to the Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT)</p> <p>• to describe characteristics in the coding systems that are related to obstacles to high quality mapping.</p> <p>Methods</p> <p>Mapping (interpretation, matching, assessment and rule development) was done by two coders. The Swedish primary health care version of ICD-10 with 972 codes was randomly divided into an allotment of three sets of categories, used in three mapping sequences, A, B and C. Mapping was done independently by the coders and new rules were developed between the sequences. Intercoder reliability was measured by comparing the results after each set. The extent of matching was assessed as either 'partly' or 'completely concordant'</p> <p>Results</p> <p>General principles for mapping were outlined before the first sequence, A. New mapping rules had significant impact on the results between sequences A - B (p < 0.01) and A - C (p < 0.001). The intercoder reliability in our study reached 83%. Obstacles to high quality mapping were mainly a lack of agreement by the coders due to structural and content factors in SNOMED CT and in the current ICD-10 version. The predominant reasons for this were difficulties in interpreting the meaning of the categories in the current ICD-10 version, and the presence of many related concepts in SNOMED CT.</p> <p>Conclusion</p> <p>Mapping from ICD-10-categories to SNOMED CT needs clear and extensive rules. It is possible to reach high intercoder reliability in mapping from ICD-10-categories to SNOMED CT. However, several obstacles to high quality mapping remain due to structure and content characteristics in both coding systems.</p

Quality end-of-life care: A global perspective

BACKGROUND: Quality end-of-life care has emerged as an important concept in industrialized countries. DISCUSSION: We argue quality end-of-life care should be seen as a global public health and health systems problem. It is a global problem because 85 % of the 56 million deaths worldwide that occur annually are in developing countries. It is a public health problem because of the number of people it affects, directly and indirectly, in terms of the well being of loved ones, and the large-scale, population based nature of some possible interventions. It is a health systems problem because one of its main features is the need for better information on quality end-of-life care. We examine the context of end-of-life care, including the epidemiology of death and cross-cultural considerations. Although there are examples of success, we could not identify systematic data on capacity for delivering quality end-of-life care in developing countries. We also address a possible objection to improving end-of-life care in developing countries; many deaths are preventable and reduction of avoidable deaths should be the focus of attention. CONCLUSIONS: We make three recommendations: (1) reinforce the recasting of quality end-of-life care as a global public health and health systems problem; (2) strengthen capacity to deliver quality end-of-life care; and (3) develop improved strategies to acquire information about the quality of end-of-life care

Functional Characterization of an Aspergillus fumigatus Calcium Transporter (PmcA) that Is Essential for Fungal Infection

Aspergillus fumigatus is a primary and opportunistic pathogen, as well as a major allergen, of mammals. The Ca+2-calcineurin pathway affects virulence, morphogenesis and antifungal drug action in A. fumigatus. Here, we investigated three components of the A. fumigatus Ca+2-calcineurin pathway, pmcA,-B, and -C, which encode calcium transporters. We demonstrated that CrzA can directly control the mRNA accumulation of the pmcA-C genes by binding to their promoter regions. CrzA-binding experiments suggested that the 5′-CACAGCCAC-3′ and 5′-CCCTGCCCC-3′ sequences upstream of pmcA and pmcC genes, respectively, are possible calcineurin-dependent response elements (CDREs)-like consensus motifs. Null mutants were constructed for pmcA and -B and a conditional mutant for pmcC demonstrating pmcC is an essential gene. The ΔpmcA and ΔpmcB mutants were more sensitive to calcium and resistant to manganese and cyclosporin was able to modulate the sensitivity or resistance of these mutants to these salts, supporting the interaction between calcineurin and the function of these transporters. The pmcA-C genes have decreased mRNA abundance into the alveoli in the ΔcalA and ΔcrzA mutant strains. However, only the A. fumigatus ΔpmcA was avirulent in the murine model of invasive pulmonary aspergillosis

The acute effects of cocoa flavanols on temporal and spatial attention

In this study, we investigated how the acute physiological effects of cocoa flavanols might result in specific cognitive changes, in particular in temporal and spatial attention. To this end, we pre-registered and implemented a randomized, double-blind, placebo- and baseline-controlled crossover design. A sample of 48 university students participated in the study and each of them completed the experimental tasks in four conditions (baseline, placebo, low dose, and high-dose flavanol), administered in separate sessions with a 1-week washout interval. A rapid serial visual presentation task was used to test flavanol effects on temporal attention and integration, and a visual search task was similarly employed to investigate spatial attention. Results indicated that cocoa flavanols improved visual search efficiency, reflected by reduced reaction time. However, cocoa flavanols did not facilitate temporal attention nor integration, suggesting Potential underlying mechanisms are discussed

Routine pattern discovery and anomaly detection in individual travel behavior

Discovering patterns and detecting anomalies in individual travel behavior is a crucial problem in both research and practice. In this paper, we address this problem by building a probabilistic framework to model individual spatiotemporal travel behavior data (e.g., trip records and trajectory data). We develop a two-dimensional latent Dirichlet allocation (LDA) model to characterize the generative mechanism of spatiotemporal trip records of each traveler. This model introduces two separate factor matrices for the spatial dimension and the temporal dimension, respectively, and use a two-dimensional core structure at the individual level to effectively model the joint interactions and complex dependencies. This model can efficiently summarize travel behavior patterns on both spatial and temporal dimensions from very sparse trip sequences in an unsupervised way. In this way, complex travel behavior can be modeled as a mixture of representative and interpretable spatiotemporal patterns. By applying the trained model on future/unseen spatiotemporal records of a traveler, we can detect her behavior anomalies by scoring those observations using perplexity. We demonstrate the effectiveness of the proposed modeling framework on a real-world license plate recognition (LPR) data set. The results confirm the advantage of statistical learning methods in modeling sparse individual travel behavior data. This type of pattern discovery and anomaly detection applications can provide useful insights for traffic monitoring, law enforcement, and individual travel behavior profiling

Bafilomycin A1 activates respiration of neuronal cells via uncoupling associated with flickering depolarization of mitochondria

Bafilomycin A1 (Baf) induces an elevation of cytosolic Ca2+ and acidification in neuronal cells via inhibition of the V-ATPase. Also, Baf uncouples mitochondria in differentiated PC12 (dPC12), dSH-SY5Y cells and cerebellar granule neurons, and markedly elevates their respiration. This respiratory response in dPC12 is accompanied by morphological changes in the mitochondria and decreases the mitochondrial pH, Ca2+ and ΔΨm. The response to Baf is regulated by cytosolic Ca2+ fluxes from the endoplasmic reticulum. Inhibition of permeability transition pore opening increases the depolarizing effect of Baf on the ΔΨm. Baf induces stochastic flickering of the ΔΨm with a period of 20 ± 10 s. Under conditions of suppressed ATP production by glycolysis, oxidative phosphorylation impaired by Baf does not provide cells with sufficient ATP levels. Cells treated with Baf become more susceptible to excitation with KCl. Such mitochondrial uncoupling may play a role in a number of (patho)physiological conditions induced by Baf