Creating a Medical Home for Trans Older Adults: Challenges, education, and best practices

Background: LGBT individuals face multiple disparities and challenges navigating the healthcare system. Most attention on such issues has focused on LGBT youth, leaving older adults as an especially vulnerable population. LGBT older adults are more likely than their heterosexual counterparts to experience poverty, worse mental and physical health, and mistreatment under current care models. Trans older adults represent a particularly underserved group and often have specialized care needs, including hormone therapy and behavioral healthcare. Geriatricians can help improve access to care with increased sensitivity toward and knowledge of LGBTspecific issues. With the unique challenges faced by LGBT older adults in mind, Jefferson Geriatrics, an outpatient practice devoted to the care of older adults, launched an initiative to create more LGBT-inclusive and trans-friendly primary care services in the Philadelphia region. Objectives: After engaging with our poster, participants will: 1) Understand needs and challenges facing LGBT older adults, focusing on trans older adults 2) Identify best practices for providing trans-competent primary care 3) Explore concerns and challenges facing health care providers and staff in caring for a trans older adult population Methods: An online survey was administered to healthcare providers and staff in a geriatric primary care practice to assess knowledge and attitudes related to LGBT individuals. Providers underwent cultural competency training pertaining to the care of the LGBT aging community. They also participated in medical competency training in areas such as HIV management and hormone therapy for trans individuals. Finally, a survey was conducted within an LGBT aging community to help gain an understanding of attitudes, perceptions and needs of older LGBT adults. Conclusions/Impact: There remains much opportunity to improve upon the care of LGBT older adults, in particular trans older adults. In our poster, we describe a model for practice transformation to create a medical home for trans older adults.https://jdc.jefferson.edu/sexandgenderhealth/1005/thumbnail.jp

Task-Selective Memory Effects for Successfully Implemented Encoding Strategies

Previous behavioral evidence suggests that instructed strategy use benefits associative memory formation in paired associate tasks. Two such effective encoding strategies–visual imagery and sentence generation–facilitate memory through the production of different types of mediators (e.g., mental images and sentences). Neuroimaging evidence suggests that regions of the brain support memory reflecting the mental operations engaged at the time of study. That work, however, has not taken into account self-reported encoding task success (i.e., whether participants successfully generated a mediator). It is unknown, therefore, whether task-selective memory effects specific to each strategy might be found when encoding strategies are successfully implemented. In this experiment, participants studied pairs of abstract nouns under either visual imagery or sentence generation encoding instructions. At the time of study, participants reported their success at generating a mediator. Outside of the scanner, participants further reported the quality of the generated mediator (e.g., images, sentences) for each word pair. We observed task-selective memory effects for visual imagery in the left middle occipital gyrus, the left precuneus, and the lingual gyrus. No such task-selective effects were observed for sentence generation. Intriguingly, activity at the time of study in the left precuneus was modulated by the self-reported quality (vividness) of the generated mental images with greater activity for trials given higher ratings of quality. These data suggest that regions of the brain support memory in accord with the encoding operations engaged at the time of study

Control of the induction of type I interferon by Peste des petits ruminants virus.

Peste des petits ruminants virus (PPRV) is a morbillivirus that produces clinical disease in goats and sheep. We have studied the induction of interferon-β (IFN-β) following infection of cultured cells with wild-type and vaccine strains of PPRV, and the effects of such infection with PPRV on the induction of IFN-β through both MDA-5 and RIG-I mediated pathways. Using both reporter assays and direct measurement of IFN-β mRNA, we have found that PPRV infection induces IFN-β only weakly and transiently, and the virus can actively block the induction of IFN-β. We have also generated mutant PPRV that lack expression of either of the viral accessory proteins (V&C) to characterize the role of these proteins in IFN-β induction during virus infection. Both PPRV_ΔV and PPRV_ΔC were defective in growth in cell culture, although in different ways. While the PPRV V protein bound to MDA-5 and, to a lesser extent, RIG-I, and over-expression of the V protein inhibited both IFN-β induction pathways, PPRV lacking V protein expression can still block IFN-β induction. In contrast, PPRV C bound to neither MDA-5 nor RIG-I, but PPRV lacking C protein expression lost the ability to block both MDA-5 and RIG-I mediated activation of IFN-β. These results shed new light on the inhibition of the induction of IFN-β by PPRV

Biomechanical Analysis of a Semitendinosus Allograft versus Achilles Turndown for Reconstruction of Large Segmental Achilles Defects

Category: Sports. Introduction/Purpose: Large segmental Achilles tendon defects present a difficult problem to treating surgeons. Multiple procedures have been utilized to reconstruct these defects, but no studies have evaluated the comparative tensile strength of the various repair methods. Our institution has recently described the use of a dual semitendinosus allograft for Achilles reconstruction. Advantages of this procedure include eliminating donor site morbidity and providing an increased surface area for healing and tendon incorporation. Our study investigated the tensile strength of this novel technique as compared to a standard myofascial turndown procedure. We hypothesized that no differences in biomechanical properties would be found between dual semitendinosus reconstruction and Achilles myofascial turndown reconstruction. Methods: An 8-cm segmental Achilles defect was created in both specimens of nine matched pair, cadaveric lower extremities. The specimens in each pair were randomly assigned to undergo allograft or turndown reconstruction. The myofacial turndown was secured distally with modified Kessler sutures of 0 braided polyester sutures through bone tunnels in the calcaneus and proximally with multiple interrupted figure-of-8 polyester braid sutures. Semitendinosus grafts were anchored proximally with a Pulvertaft weave and then distally through two bone tunnels within the calcaneus and sutured together around the posterior heel with similar polyester sutures. The foot was disarticulated through the subtalar joint and the Achilles was dissected free of excess soft tissues. The constructs were mounted onto a load frame and differential variable reluctance transducers were applied to the construct. Specimens were preconditioned and then loaded axially. Tensile forces were recorded at 10 mm of displacement and at failure Results: Semitendinosus allograft failure occurred via calcaneal bone bridge fracture in 8 of 9 specimens, and all myofascial turndowns failed through suture pullout through the fascial tissue at its insertion. None of the specimens failed at the MTS grip sites or via de novo tendon substance rupture. Average ultimate tensile strength of the semitendinosus allograft reconstruction was 290.9± 83.2 N compared to that of the turndown repair which was 140.7± 43.5 N. At 10 mm of displacement, average tensile strength of the allograft repair was 156.9 ± 29.7 N versus the turndown repair at 101.2 ± 20.0 N. Strength differences between the two repairs were significant at both failure and 10 mm displacement (p < 0.001). Conclusion: Dual semitendinosus allograft reconstruction demonstrates superior tensile strength properties when compared to myofascial turndown in a cadaveric model of large Achilles tendon defects

Discordance Between Cobas BRAF V600 Testing and VE1 Immunohistochemistry in a Melanoma Patient With Bone Marrow Metastases.

False negative result remains an ongoing problem in direct gene sequencing of cancers. It is important to use the appropriate mutation detection method most appropriate to each circumstance and the available tissue. Here, we report a patient with melanoma of unknown primary with metastases to spleen and bone marrow, who was tested negative for Cobas BRAF V600E mutation, whose cancer progressed on antiprogrammed death 1 (PD1) receptor monoclonal antibody therapy. Subsequent VE1 immunohistochemistry was positive for BRAF V600E mutation, and the tumor responded dramatically to v-Raf murine sarcoma viral oncogene homolog B (BRAF)/Mitogen-activated protein kinase inhibitor combination therapy. This demonstrates how alternative BRAF testing methodology could produce results that can influence treatment choice and the outcome

Racial Differences in Patient Satisfaction With the Hospital Experience Undergoing Primary Unilateral Hip and Knee Arthroplasty: A Retrospective Study

Background: Press Ganey (PG) inpatient survey is widely used to track patient satisfaction with the hospital experience. Our aim was to use the PG survey to determine if there are racial differences in overall hospital experience and perception of nurses and surgeons following hip and knee arthroplasty. Methods: We retrospectively analyzed Black and White patients from hip and knee arthroplasty registries from a single institution between July 2010 and February 2012. The overall assessment score for the hospital experience and perception of the nurse and surgeon questions from the PG inpatient survey were dichotomized as “not completely satisfied” or “completely satisfied”. Multivariable logistic regression models were developed to determine the impact of race on the likelihood of being ‘completely satisfied’ in the hip and knee cohorts. Results: There were 2517 hip and 2114 knee patients who underwent surgery and completed the PG survey, of whom 3.9% were Black and 96.0% were White. Black patients were less likely to be completely satisfied with their hospital experience compared to White patients in the hip (odds ratio 0.62, confidence interval 0.39-1.00, P = .049) and knee (odds ratio 0.52, confidence interval 0.33-0.82, P = .005) cohorts. Black patients were also less likely to be completely satisfied with multiple aspects of care they received from the nurse and surgeon in both cohorts. Conclusions: We found that the PG Survey shows Black patients were less likely to be completely satisfied than White patients with the hospital experience, including their interactions with nurses and surgeons. More work is needed to understand this difference

Centers for Medicare and Medicaid services quality indicators do not correlate with risk-adjusted mortality at trauma centers.

OBJECTIVES: The Centers for Medicare and Medicaid Services (CMS) publicly reports hospital compliance with evidence-based processes of care as quality indicators. We hypothesized that compliance with CMS quality indicators would correlate with risk-adjusted mortality rates in trauma patients. METHODS: A previously validated risk-adjustment algorithm was used to measure observed-to-expected mortality ratios (O/E with 95% confidence interval) for Level I and II trauma centers using the National Trauma Data Bank data. Adult patients (\u3eor=16 years) with at least one severe injury (Abbreviated Injury Score \u3eor=3) were included (127,819 patients). Compliance with CMS quality indicators in four domains was obtained from Hospital Compare website: acute myocardial infarction (8 processes), congestive heart failure (4 processes), pneumonia (7 processes), surgical infections (3 processes). For each domain, a single composite score was calculated for each hospital. The relationship between O/E ratios and CMS quality indicators was explored using nonparametric tests. RESULTS: There was no relationship between compliance with CMS quality indicators and risk-adjusted outcomes of trauma patients. CONCLUSIONS: CMS quality indicators do not correlate with risk-adjusted mortality rates in trauma patients. Hence, there is a need to develop new trauma-specific process of care quality indicators to evaluate and improve quality of care in trauma centers