Primary Care Patient Experience in Pneumonia Patient and the Effects of Readmissions

Patient primary care experience is an essential component of patient care. Research has consistently demonstrated that patient experience correlates with clinical processes of care for prevention and disease management and with better health outcomes. Patients who are admitted to the hospital face numerous challenges upon discharge, including high readmission rates. In fact, one-fifth of Medicare patients admitted to the hospital will be readmitted within 30 days of discharge. With the Affordable Care Act’s creation of the Hospital Readmission Reduction Program (HRRP), hospitals are now penalized for excess readmission rates for common admitting diagnoses such as pneumonia. The purpose of this study was to examine how patients’ baseline primary care experiences relate to the likelihood of readmission. Patients diagnosed with pneumonia were identified during their initial hospitalization and administered the CG-CAHPS 3.0 and Supplementary CAHPS PCMH. The results of these surveys were compared between readmitted and non-readmitted patients. Also, the differences between the primary care experiences of the pneumonia patient cohort and patients at the hospital system’s primary care sites were examined. Results showed that 5 patients out of the 33 patients surveyed were readmitted with non-pneumonia related causes. Patients across 18 primary care sites report higher levels of satisfaction with their PCP (88.7%) compared to patients hospitalized for Pneumonia (66.7%; X2 =14.9,

Pseudo-Separation for Assessment of Structural Vulnerability of a Network

Based upon the idea that network functionality is impaired if two nodes in a network are sufficiently separated in terms of a given metric, we introduce two combinatorial \emph{pseudocut} problems generalizing the classical min-cut and multi-cut problems. We expect the pseudocut problems will find broad relevance to the study of network reliability. We comprehensively analyze the computational complexity of the pseudocut problems and provide three approximation algorithms for these problems. Motivated by applications in communication networks with strict Quality-of-Service (QoS) requirements, we demonstrate the utility of the pseudocut problems by proposing a targeted vulnerability assessment for the structure of communication networks using QoS metrics; we perform experimental evaluations of our proposed approximation algorithms in this context

A panel model for predicting the diversity of internal temperatures from English dwellings

Using panel methods, a model for predicting daily mean internal temperature demand across a heterogeneous domestic building stock is developed. The model offers an important link that connects building stock models to human behaviour. It represents the first time a panel model has been used to estimate the dynamics of internal temperature demand from the natural daily fluctuations of external temperature combined with important behavioural, socio-demographic and building efficiency variables. The model is able to predict internal temperatures across a heterogeneous building stock to within ~0.71°C at 95% confidence and explain 45% of the variance of internal temperature between dwellings. The model confirms hypothesis from sociology and psychology that habitual behaviours are important drivers of home energy consumption. In addition, the model offers the possibility to quantify take-back (direct rebound effect) owing to increased internal temperatures from the installation of energy efficiency measures. The presence of thermostats or thermostatic radiator valves (TRV) are shown to reduce average internal temperatures, however, the use of an automatic timer is statistically insignificant. The number of occupants, household income and occupant age are all important factors that explain a proportion of internal temperature demand. Households with children or retired occupants are shown to have higher average internal temperatures than households who do not. As expected, building typology, building age, roof insulation thickness, wall U-value and the proportion of double glazing all have positive and statistically significant effects on daily mean internal temperature. In summary, the model can be used as a tool to predict internal temperatures or for making statistical inferences. However, its primary contribution offers the ability to calibrate existing building stock models to account for behaviour and socio-demographic effects making it possible to back-out more accurate predictions of domestic energy demand

Ventral Hernia Repairs: 10 year Single Institution Review at Thomas Jefferson University Hospital

Abstract Background Definitive repair of recurrent ventral hernias using abdominal wall reconstruction techniques is an essential tool in the armentarium for general and plastic surgeons. Ramirez 1 et al describes the “component separation” technique to mobilize the rectus-abdominus internal oblique and external oblique flap to correct the defect. The recurrence rate of incisional hernias increases to 20% after gastric bypass or extensive weight loss.2 The incidence of ventral hernias after failed recurrent hernia repair increases to 40%.3 It has been reported that utilizing the sliding myofascial flap repair technique, the recurrence rate was reduced to 8.5%.4 Materials and Methods This retrospective institutional study reviews 10 years of myofascial flap reconstruction 1996-2006 at TJUH. Several techniques and prosthetic materials (alloderm, permacol, vicryl, composix) were used in our institutional review by multiple surgeons in this time period. Our goal is to identify risk factors (i.e. smoking, diabetes, obesity, size of defect, peripheral vascular disease, enterocutaneous fistula, infection) that predict or categorize patients that are at increased risk for failure of primary repair, measure the complication rates (i.e. infection, recurrence, seroma, hematoma) and evaluate the techniques and long term effectiveness of several prosthetic materials. Results Three thousand twenty ventral hernia repairs were performed at TJUH between 1996 and 2006. Two thousand three hundred eighty three approximated the rectus abdominus primarily and of these 645 utilized a component separation technique. The recurrence rate for component separations was 18.5% and 83% for primary repairs. The average follow up was 5.49 years. Statistically significant risk factors (p\u3c0.05) for recurrence were obesity (BMI\u3e30 kg/m2), age\u3e65 years, male gender, preoperative infection and postoperative seroma. Conclusion Myofascial flaps are a safe, reliable therapy for recurrent ventral hernias that addresses the population of patients that have failed conventional primary closure and reduce the recurrence rates greater than 40 percent to 18.5 percent in the carefully selected patient population

Evaluation of predicted loss of different land use and land cover (LULC) due to coastal erosion in Bangladesh

Coastal erosion is one of the most significant environmental threats to coastal communities globally. In Bangladesh, coastal erosion is a regularly occurring and major destructive process, impacting both human and ecological systems at sea level. The Lower Meghna estuary, located in southern Bangladesh, is among the most vulnerable landscapes in the world to the impacts of coastal erosion. Erosion causes population displacement, loss of productive land area, loss of infrastructure and communication systems, and, most importantly, household livelihoods. With an aim to assess the impacts of historical and predicted shoreline change on different land use and land cover, this study estimated historical shoreline movement, predicted shoreline positions based on historical data, and quantified and assessed past land use and land cover change. Multi-temporal Landsat images from 1988–2021 were used to quantify historical shoreline movement and past land use and land cover. A time-series classification of historical land use and land cover (LULC) were produced to both quantify LULC change and to evaluate the utility of the future shoreline predictions for calculating amounts of lost or newly added land resources by LULC type. Our results suggest that the agricultural land is the most dominant land cover/use (76.04% of the total land loss) lost over the studied period. Our results concluded that the best performed model for predicting land loss was the 10-year time depth and 20-year time horizon model. The 10-year time depth and 20-year time horizon model was also most accurate for agricultural, forested, and inland waterbody land use/covers loss prediction. We strongly believe that our results will build a foundation for future research studying the dynamics of coastal and deltaic environments

Circulating Inflammatory and Oxidative Stress Responses to Steady-State Moderate-Intensity and High-Intensity Interval Exercise in Mid-Spectrum Chronic Kidney Disease

Inflammation and oxidative stress can be potent modulators of vascular function. These factors may transiently respond to moderate-intensity steady state exercise (SSE) in a manner that improves post-exercise vascular function in healthy adults. Whether exercise imparts similar effects in adults with Stage 3 or 4 chronic kidney disease (CKD) remains understudied. Moreover, a comparison of SSE and high-intensity interval exercise (HIIE) may add to clinically-relevant findings for improving vascular function in mid-spectrum CKD. PURPOSE: To determine the influence of SSE and a comparable amount of HIIE on post-exercise inflammation and oxidative stress in patients diagnosed with secondary Stage 3 or 4 CKD. METHODS: Twenty participants (n = 6 men; n = 14 women; age 62.0 + 9.9 yr; weight 80.9 + 16.2 kg; body fat 37.3 + 8.5% of weight; VO2max 19.4 + 4.7 ml/kg/min) completed 30 min of SSE at 65% VO2reserve or HIIE by treadmill walking (90% and 20% of VO2reserve in 3:2 min ratio) in a randomized crossover design. Both exercise conditions averaged ~ 65% VO2reserve. Blood samples were obtained by the same technician under standardized conditions just before, 1hr and 24hrs after exercise. Total antioxidant capacity (TAC), paraoxonase1 (PON1), asymmetric dimethylarginine (ADMA), 3nitrotyrosine (3NT) and interleukin-6 (IL6) responses were analyzed using 2 (condition) by 3 (sample point) repeated measures ANOVAs. RESULTS: Relative to pre-exercise measures: TAC increased by 4.3% 24hr after exercise (p = 0.012). PON1 was maintained 1hr and elevated by 6.1% 24hr after SSE, but not HIIE (p = 0.035). When corrected for plasma volume shifts, ADMA increased 30 ng/ml at 1hr but was 58 ng/ml lower 24hrs after exercise (p = 0.0006). 3NT and IL6 remained stable in the hours after exercise (p \u3e 0.05). CONCLUSION: Modest inflammatory and oxidative stress marker responses to either SSE and HIIE may contribute to improved vascular function in mid-spectrum CKD

Differential Expressed Genes Identified Between African American and European American Keloid Fibroblasts

Keloids are benign fibroproliferative tumors due to dysregulation of collagen remodeling and abnormal wound healing. Although worldwide, there is a higher incidence of keloid disease (KD) in skin of color, little is known about this predisposition. In this study, we used one tissue micro array slide comprised of six AA and 6 EA punch biopsies of primary untreated keloid tissue from the head and neck area was created, following the NanoString® DSP Technology Access Program protocol. The GeoMx Human Whole Transcriptome Atlas Assay was performed, using morphology marker FAP. Polygonal region of interests selection strategy for Fibroblast Activation Protein (FAP) positive cells was conducted. Univariate analysis was performed, using linear regression models to identify differentially expressed genes (DEG) at a false discovery rate (FDR) of 0.05. Ingenuity pathway analysis (IPA) software was used to determine DEG pathway enrichment. 1,450 DEG were identified (p-va

Unbiased Metagenomic Sequencing for Pediatric Meningitis in Bangladesh Reveals Neuroinvasive Chikungunya Virus Outbreak and Other Unrealized Pathogens.

The burden of meningitis in low-and-middle-income countries remains significant, but the infectious causes remain largely unknown, impeding institution of evidence-based treatment and prevention decisions. We conducted a validation and application study of unbiased metagenomic next-generation sequencing (mNGS) to elucidate etiologies of meningitis in Bangladesh. This RNA mNGS study was performed on cerebrospinal fluid (CSF) specimens from patients admitted in the largest pediatric hospital, a World Health Organization sentinel site, with known neurologic infections (n = 36), with idiopathic meningitis (n = 25), and with no infection (n = 30), and six environmental samples, collected between 2012 and 2018. We used the IDseq bioinformatics pipeline and machine learning to identify potentially pathogenic microbes, which we then confirmed orthogonally and followed up through phone/home visits. In samples with known etiology and without infections, there was 83% concordance between mNGS and conventional testing. In idiopathic cases, mNGS identified a potential bacterial or viral etiology in 40%. There were three instances of neuroinvasive Chikungunya virus (CHIKV), whose genomes were >99% identical to each other and to a Bangladeshi strain only previously recognized to cause febrile illness in 2017. CHIKV-specific qPCR of all remaining stored CSF samples from children who presented with idiopathic meningitis in 2017 (n = 472) revealed 17 additional CHIKV meningitis cases, exposing an unrecognized meningitis outbreak. Orthogonal molecular confirmation, case-based clinical data, and patient follow-up substantiated the findings. Case-control CSF mNGS surveys can complement conventional diagnostic methods to identify etiologies of meningitis, conduct surveillance, and predict outbreaks. The improved patient- and population-level data can inform evidence-based policy decisions.IMPORTANCE Globally, there are an estimated 10.6 million cases of meningitis and 288,000 deaths every year, with the vast majority occurring in low- and middle-income countries. In addition, many survivors suffer from long-term neurological sequelae. Most laboratories assay only for common bacterial etiologies using culture and directed PCR, and the majority of meningitis cases lack microbiological diagnoses, impeding institution of evidence-based treatment and prevention strategies. We report here the results of a validation and application study of using unbiased metagenomic sequencing to determine etiologies of idiopathic (of unknown cause) cases. This included CSF from patients with known neurologic infections, with idiopathic meningitis, and without infection admitted in the largest children's hospital of Bangladesh and environmental samples. Using mNGS and machine learning, we identified and confirmed an etiology (viral or bacterial) in 40% of idiopathic cases. We detected three instances of Chikungunya virus (CHIKV) that were >99% identical to each other and to a strain previously recognized to cause systemic illness only in 2017. CHIKV qPCR of all remaining stored 472 CSF samples from children who presented with idiopathic meningitis in 2017 at the same hospital uncovered an unrecognized CHIKV meningitis outbreak. CSF mNGS can complement conventional diagnostic methods to identify etiologies of meningitis, and the improved patient- and population-level data can inform better policy decisions

Genetic variation in the HLA region is associated with susceptibility to herpes zoster.

Herpes zoster, commonly referred to as shingles, is caused by the varicella zoster virus (VZV). VZV initially manifests as chicken pox, most commonly in childhood, can remain asymptomatically latent in nerve tissues for many years and often re-emerges as shingles. Although reactivation may be related to immune suppression, aging and female sex, most inter-individual variability in re-emergence risk has not been explained to date. We performed a genome-wide association analyses in 22,981 participants (2280 shingles cases) from the electronic Medical Records and Genomics Network. Using Cox survival and logistic regression, we identified a genomic region in the combined and European ancestry groups that has an age of onset effect reaching genome-wide significance (P>1.0 × 10(-8)). This region tags the non-coding gene HCP5 (HLA Complex P5) in the major histocompatibility complex. This gene is an endogenous retrovirus and likely influences viral activity through regulatory functions. Variants in this genetic region are known to be associated with delay in development of AIDS in people infected by HIV. Our study provides further suggestion that this region may have a critical role in viral suppression and could potentially harbor a clinically actionable variant for the shingles vaccine