Emergency Department Operations in Top-Performing Safety-Net Hospitals

This report profiles five safety-net hospitals—Boston Medical Center, Denver Health, Memorial Regional Hospital, Memorial Hospital West, and Virginia Commonwealth University Health System—that made improvements to curb emergency department (ED) crowding, reduce long waits, and lower the number of hours spent on ambulance diversion. Hospitals used a combination of interventions, including: reconfiguring the ED to maximize efficiency; devising a pre-diversion system to alert staff of ED crowding; installing an electronic tracking system; designating staff members to be responsible for tracking patients; and developing meaningful performance metrics. To be successful, such interventions need to take place within a broader improvement strategy that entails: recognition that ED crowding is a hospital-wide issue; leadership provided by the CEO and other senior staff; vigilance in pursuing change, reviewing outcomes, and working to improve; transparency; and a commitment to quality for safety-net populations

Refining pathological evaluation of neoadjuvant therapy for adenocarcinoma of the esophagus

AIM: To assess tumour regression grade (TRG) and lymph node downstaging to help define patients who benefit from neoadjuvant chemotherapy.METHODS: Two hundred and eighteen consecutive patients with adenocarcinoma of the esophagus or gastro-esophageal junction treated with surgery alone or neoadjuvant chemotherapy and surgery between 2005 and 2011 at a single institution were reviewed. Triplet neoadjuvant chemotherapy consisting of platinum, fluoropyrimidine and anthracycline was considered for operable patients (World Health Organization performance status ? 2) with clinical stage T2-4 N0-1. Response to neoadjuvant chemotherapy (NAC) was assessed using TRG, as described by Mandard et al. In addition lymph node downstaging was also assessed. Lymph node downstaging was defined by cN1 at diagnosis: assessed radiologically (computed tomography, positron emission tomography, endoscopic ultrasonography), then pathologically recorded as N0 after surgery; ypN0 if NAC given prior to surgery, or pN0 if surgery alone. Patients were followed up for 5 years post surgery. Recurrence was defined radiologically, with or without pathological confirmation. An association was examined between t TRG and lymph node downstaging with disease free survival (DFS) and a comprehensive range of clinicopathological characteristics.RESULTS: Two hundred and eighteen patients underwent esophageal resection during the study interval with a mean follow up of 3 years (median follow up: 2.552, 95%CI: 2.022-3.081). There was a 1.8% (n = 4) inpatient mortality rate. One hundred and thirty-six (62.4%) patients received NAC, with 74.3% (n = 101) of patients demonstrating some signs of pathological tumour regression (TRG 1-4) and 5.9% (n = 8) having a complete pathological response. Forty four point one percent (n = 60) had downstaging of their nodal disease (cN1 to ypN0), compared to only 15.9% (n = 13) that underwent surgery alone (pre-operatively overstaged: cN1 to pN0), (P < 0.0001). Response to NAC was associated with significantly increased DFS (mean DFS; TRG 1-2: 5.1 years, 95%CI: 4.6-5.6 vs TRG 3-5: 2.8 years, 95%CI: 2.2-3.3, P < 0.0001). Nodal down-staging conferred a significant DFS advantage for those patients with a poor primary tumour response to NAC (median DFS; TRG 3-5 and nodal down-staging: 5.533 years, 95%CI: 3.558-7.531 vs TRG 3-5 and no nodal down-staging: 1.114 years, 95%CI: 0.961-1.267, P < 0.0001).CONCLUSION: Response to NAC in the primary tumour and in the lymph nodes are both independently associated with improved DFS

Effectiveness of antiarrhythmic drugs for shockable cardiac arrest : a systematic review

Purpose The purpose of this systematic review is to provide up-to-date evidence on effectiveness of antiarrhythmic drugs for shockable cardiac arrest to help inform the 2018 International Liaison Committee on Resuscitation Consensus on Science with Treatment Recommendations. Methods A search was conducted in electronic databases Medline, Embase, and Cochrane Library from inception to August 15, 2017. Results Of the 9371 citations reviewed, a total of 14 RCTs and 17 observational studies met our inclusion criteria for adult population and only 1 observational study for pediatric population. Based on RCT level evidence for adult population, none of the anti-arrhythmic drugs showed any difference in effect compared with placebo, or with other anti-arrhythmic drugs for the critical outcomes of survival to hospital discharge and discharge with good neurological function. For the outcome of return of spontaneous circulation, the results showed a significant increase for lidocaine compared with placebo (RR = 1.16; 95% CI, 1.03–1.29, p = 0.01). Conclusion The high level evidence supporting the use of antiarrhythmic drugs during CPR for shockable cardiac arrest is limited and showed no benefit for critical outcomes of survival at hospital discharge, survival with favorable neurological function and long-term survival. Future high quality research is needed to confirm these findings and also to evaluate the role of administering antiarrhythmic drugs in children with shockable cardiac arrest, and in adults immediately after ROSC

Ibrutinib Unmasks Critical Role of Bruton Tyrosine Kinase in Primary CNS Lymphoma.

Bruton tyrosine kinase (BTK) links the B-cell antigen receptor (BCR) and Toll-like receptors with NF-κB. The role of BTK in primary central nervous system (CNS) lymphoma (PCNSL) is unknown. We performed a phase I clinical trial with ibrutinib, the first-in-class BTK inhibitor, for patients with relapsed or refractory CNS lymphoma. Clinical responses to ibrutinib occurred in 10 of 13 (77%) patients with PCNSL, including five complete responses. The only PCNSL with complete ibrutinib resistance harbored a mutation within the coiled-coil domain of CARD11, a known ibrutinib resistance mechanism. Incomplete tumor responses were associated with mutations in the B-cell antigen receptor-associated protein CD79B

Intergenerational Wealth Transmission and the Dynamics of Inequality in Small-Scale Societies

Small-scale human societies range from foraging bands with a strong egalitarian ethos to more economically stratified agrarian and pastoral societies. We explain this variation in inequality using a dynamic model in which a population’s long-run steady-state level of inequality depends on the extent to which its most important forms of wealth are transmitted within families across generations. We estimate the degree of intergenerational transmission of three different types of wealth (material, embodied, and relational), as well as the extent of wealth inequality in 21 historical and contemporary populations. We show that intergenerational transmission of wealth and wealth inequality are substantial among pastoral and small-scale agricultural societies (on a par with or even exceeding the most unequal modern industrial economies) but are limited among horticultural and foraging peoples (equivalent to the most egalitarian of modern industrial populations). Differences in the technology by which a people derive their livelihood and in the institutions and norms making up the economic system jointly contribute to this pattern

Developing the practice context to enable more effective pain management with older people: an action research approach

Background\ud \ud This paper, which draws upon an Emancipatory Action Research (EAR) approach, unearths how the complexities of context influence the realities of nursing practice. While the intention of the project was to identify and change factors in the practice context that inhibit effective person-centred pain management practices with older people (65 years or older), reflective critical engagement with the findings identified that enhancing pain management practices with older people was dependent on cultural change in the unit as a whole. \ud \ud Methods\ud \ud An EAR approach was utilised. The project was undertaken in a surgical unit that conducted complex abdominal surgery. Eighty-five percent (n = 48) of nursing staff participated in the two-year project (05/NIR02/107). Data were obtained through the use of facilitated critical reflection with nursing staff. \ud \ud Results\ud \ud Three key themes (psychological safety, leadership, oppression) and four subthemes (power, horizontal violence, distorted perceptions, autonomy) were found to influence the way in which effective nursing practice was realised. Within the theme of 'context,' effective leadership and the creation of a psychologically safe environment were key elements in the enhancement of all aspects of nursing practice. \ud \ud Conclusions\ud \ud Whilst other research has identified the importance of 'practice context' and models and frameworks are emerging to address this issue, the theme of 'psychological safety' has been given little attention in the knowledge translation/implementation literature. Within the principles of EAR, facilitated reflective sessions were found to create 'psychologically safe spaces' that supported practitioners to develop effective person-centred nursing practices in complex clinical environments