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Purpose The survival benefits of patients with inoperable hepatocellular carcinoma (HCC) who undergo transarterial chemoembolization (TACE) and receive sorafenib therapy remain controversial. We aimed to identify clinical predictors in patients with inoperable HCC undergoing TACE and receiving sorafenib. Methods Between January 2014 and December 2017, 148 consecutive patients with inoperable HCC who were treated with TACE plus sorafenib were retrospectively analyzed. Critical clinical factors associated with overall survival (OS) were identified by Cox regression model analysis. Kaplan–Meier methods were used to calculate the survival times, which were compared with the log-rank test. Results Macrovascular invasion (MVI), radiologic response and sorafenib-related dermatologic toxicities were identified as independent factors associated with OS. MVI is a known prognostic factor before treatment. The median OS of patients with either radiologic response or dermatologic toxicities was significantly improved compared with that of patients without it (both 23.0 vs. 7.0 months, P P Conclusion The combination of radiologic response and sorafenib-related dermatologic toxicities is the most robust predictor of survival benefits for HCC patients after TACE plus sorafenib therapy. Level of Evidence Level 3.

Conventional industrial robots are unable to guarantee the inherent safety when working together with humans due to the use of rigid components and the lack of force sensation. To enhance the safety of human–robot collaboration (HRC), the new collaborative robot skin (CoboSkin) with the features of softness, variable stiffness, and sensitivity is designed and studied in this article. The CoboSkin is composed of an array of inflatable units and sensing units. The sensing units made of soft porous materials are capable of measuring distributed contact force in a real-time manner. By leveraging the foaming process, the sensing units are interconnected with inflatable units fabricated by the elastomer of which the deformation is limited by the textile wrapped around it. Variation of stiffness is enabled by adjusting the internal air pressure supplied to inflatable units, thereby changing the sensitivity of the sensing units and reducing the peak impact force. Soft porous materials endowed the CoboSkin with increased sensitivity, minimal hysteresis, excellent cycling stability, and response time in the millisecond range, which enabled sensing feedback for controlling a robot arm at different levels of stiffness. Finally, the validation of the CoboSkin for safer HRC was conducted with a robot arm to detect an unintended collision, illustrating its potential application in robotics.

Variations in the visceral vasculature are often encountered, but rarely cause clinical symptoms. We report a 12-year-old girl with portal hypertension caused by congenital variations in visceral vessels. The clinical manifestations included gastrointestinal hemorrhage and ascites. The common hepatic artery and splenic artery stem shared the same trunk from the aorta, and the common hepatic artery was directly connected with the main portal vein to form an arteriovenous fistula. In addition, the left hepatic artery and the left gastric artery shared a common trunk termed the “hepatic-gastric trunk” which originated from the anterior wall of the aorta, while the right hepatic artery originated from the superior mesenteric artery and supplied the right liver. The patient was treated with interventional embolization and remained in good condition throughout the follow-up and at the time of publication.

In human–robot collaboration, the wrapping material on robots is not only required to have the sensing ability to adapt to the external environment but also need to have the function of cushioning the collision between human and robot. Herein, a fluid‐driven soft robot skin with sensing and actuating function is successfully applied to a collaborative robot and working well with the host robot. The skin is an integration of sponge force sensors and pneumatic actuators. By altering the internal air pressure in pneumatic actuators, the developed robot skin can provide more than ten times tunable stiffness and sensitivity. In addition, the skin can reduce the peak force of the collision and achieve the actuating function. Using three‐dimensional printing and computer‐aided design, the skin is fabricated and attached to a collaborative robot conformally. Drawing upon the data acquisition and control system, the experiment for illustrating the applications of the CoboSkin is successfully performed. The skin provides the robot with multi‐functions, which are similar to the human muscle and skin attached to human bones. By mimicking human skin and muscle with tactile sensing function and stiffness tuning function, CoboSkin can enhance the adaptability of the robot to human daily life.

Background: The economic burden of stroke is high and expected to increase with the growing stroke incidence among younger adults and the aging population. However, we are unaware of a comprehensive review of the cost drivers across the stroke care continuum. We conducted a literature review and summarized the costs incurred in the inpatient and outpatient settings during the acute and post-acute periods. Methods: A systematic search of MEDLINE, EMBASE, CINAHL was conducted to identify cost-of-illness studies published during January 2000-October 2019 that evaluated the direct medical costs of stroke in the US. We extracted both the index hospitalization costs and the costs incurred thereafter. We summarized the costs by stroke type (ischemic, intracerebral hemorrhage, subarachnoid hemorrhage, transient ischemic attack) and by cost component (e.g., inpatient hospital stays, skilled nursing facility for rehabilitation, physician consultation, medication use). Cost estimates were adjusted to 2019 dollars by using the US Consumer Price Index. Results: Thirty-six studies were included. Thirteen studies (36%) focused on inpatient costs only, twenty-one (58%) estimated both inpatient and outpatient costs, two (6%) examined outpatient costs only. Nine studies (25%) estimated the stroke-attributable costs by using propensity score matching and econometric models. The index hospitalization costed $9,050-$74,525 per admission for ischemic stroke (15 studies), $18,554-$117,991 for hemorrhagic stroke (5 studies), and $9,658-$10,544 for transient ischemic attack (2 studies). Among studies that examined costs beyond the index hospitalization (n=22, 61%), follow-up periods varied from 30 days to 4 years. Sixteen of these studies (73%) estimated total costs only; five (23%) identified costs by period. For ischemic stroke, the total cumulative post-stroke costs were estimated at $15,037 (30-day period), $17,968-$29,704 (90-day), $27,072-$37,611 (180-day), $21,642-$87,135 (1-year), $50,153-$117,683 (2-year), and $70,513-$173,904 (4-year); the proportion attributed to inpatient care reduced from 65% (30-day period) to 46% (4-year). Skilled nursing facility care accounted for 19% of the costs four years post ischemic stroke and for 13% four years post intracerebral hemorrhage stroke. For subarachnoid hemorrhage stroke, inpatient care remained the biggest cost driver four years after the index event (70% of the total cost), followed by outpatient physician services (11%) and skilled nursing facility care (8%). Conclusions: While caution should be taken when interpreting the cost findings due to variation in data sources, study population and analytical methods, the costs of stroke are substantial. Inpatient, skilled nursing facility and outpatient physician costs are the main cost drivers and their contribution to total costs vary greatly over time and by stroke type.

Retroperitoneal ectopic pregnancy (REP) is an extremely rare type of ectopic pregnancy. Currently, surgery is the most widely used treatment method although it involves a high likelihood of intraoperative hemorrhage. In this case report, we describe a safe and effective alternative method for managing epigastric REP. We conducted a retrospective analysis of the clinical data of 2 patients with REP in the epigastrium who were treated at our hospital using our nonsurgical method. The treatment involved conservative management by computed tomographic-guided methotrexate injection in the gestational sac. We also present a literature review of 26 case reports and discuss the clinical features and various methods for treating REP. Our experience with the successful treatment of 2 patients suggests that the novel approach of computed tomographic-guided methotrexate injection in the gestational sac may be a safe and effective approach to manage REP. Further studies are warranted to confirm our findings.

Nursing home (NH) residents are disproportionately affected by poor oral health. But little we known about the root causes. We analyzed the 2000-2016 national inspection survey data for all certified-NHs (n=248,975 facility-years). Dental care performance was measured by two designated deficiency citations. Generalized estimating equation models were used to predict if the NH facility and market characteristics were associated with low performance. The rates of deficiency citation tripled from 1.2% in 2000 to 3.4% in 2016 (p

Minority older adults are at higher risks of poor oral health. Little is known about the extent of and the contributing factors to racial/ethnic disparity in dental care quality in the long-term care settings. Previous studies suggest that organizational and system-level factors are key determinants of oral health among minority older adults. We examined the racial/ethnic disparity in dental care delivery in nursing homes (NHs) by facility and market characteristics. We analyzed the 2000-2016 national Inspection Survey data for all certified-NHs (n=248,975 facility-years). Two designated deficiency citations were used to measure dental care performance. Generalized estimating equations were used to compare the rates of deficiency citations among NHs in different quartiles of the share of minority residents, adjusting for facility characteristics, market characteristics, year and state fixed effects. Overall, compared to NHs in the lowest quartile of the share of minority residents (average % minority residents =0.24%), NHs in the highest quartile of the share of minority residents (average % minority residents = 46.5%) and those in the second highest share (average % minority residents=13.9%) had 46.8% and 31.2% higher odds of receiving dental care citations(p

Since 2005 Massachusetts has publicly reported results from biennial surveys of satisfaction with nursing homes, completed by responsible parties for residents, to promote consumer-centered care. Our analysis of the results from 2005, 2007, and 2009 revealed generally high satisfaction with care, which remained stable over time. On a scale of 1 to 5 (from very dissatisfied to very satisfied), average satisfaction with overall care was 4.22-4.31, and satisfaction that overall residents' needs were met was 4.09-4.16. Around 90 percent of respondents would recommend the facility. Satisfaction ratings varied considerably across facilities, with higher scores associated with higher nursing staffinglevels, fewer deficiency citations, and nonprofit or government ownership. Scores for six domains of care were, in general, closely associated with satisfaction scores. However, family members seemed less satisfied with the physical and social activities available to residents and with the food and meals served than with such attributes as the physical environment. Our findings suggest that including the consumer's perspective would improve the Centers for Medicare and Medicaid Services' current nursing home reporting efforts. However, refinements may be necessary to detect the impact of consumer reporting on the quality of patient-centered care. © 2013 Project HOPE-The People-to-People Health Foundation, Inc.

Background The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life. Methods/design This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention. Discussion Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more “skilled” care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services.

Background One proposed strategy to expand primary care capacity is to use nurse practitioners (NPs) more effectively in health care delivery. However, the ability of NPs to provide care to the fullest extent of their education is moderated by state scope-of-practice (SOP) regulations. Purpose The purpose of this study was to examine the impact of state SOP regulations on the following three key issues: (a) NP workforce, (b) access to care and health care utilization, and (c) health care costs. Methods Systematic review. Results/Discussion States granting NPs greater SOP authority tend to exhibit an increase in the number and growth of NPs, greater care provision by NPs, and expanded health care utilization, especially among rural and vulnerable populations. Our review indicates that expanded NP practice regulation can impact health care delivery by increasing the number of NPs in combination with easing restrictions on their SOP. Conclusions Findings show promise that removing restrictions on NP SOP regulations could be a viable and effective strategy to increase primary care capacity.

Background Quality report cards have been shown to be effective in influencing patients' referrals and promoting quality improvement in some instances and not others. In this study, we investigate one of the mechanisms that may detract from their effectiveness: voluntary versus mandatory participation of nursing homes in public quality reporting. Objectives To answer 2 questions: (1) Were the nursing homes choosing not to participate low-quality performers relative to those who chose to participate? (2) Once participation became mandatory, did those that did not voluntarily participate initially, improve more than those that participated voluntarily? Research design Massachusetts published the Massachusetts Satisfaction Survey report card for nursing homes for the years 2005, 2007, and 2009. Nursing homes' participation was voluntary in 2005 and mandatory in 2007 and 2009. We performed a retrospective statistical analysis of the relationship between nursing homes' decision to participate in quality reporting and 12 quality outcomes: deficiency citations, staffing, and 8 survey domains. Subjects A total of 424 Massachusetts nursing homes. Results Sixty-seven percent of nursing homes participated in reporting voluntarily. Volunteer nursing homes had better quality for all measures (significant at the 0.05 level or trending toward significance at the 0.10 level for all but 2). Once reporting became mandatory, nonvolunteers improved more than volunteers in all but 2 staffing measures (trending toward significance at the 0.10 level in 5). Conclusions Report cards are more effective if nursing homes' participation is mandated. Nonmandatory reporting systems, as those implemented by some states and professional associations, lead to missed opportunities for quality improvements.

OBJECTIVETo examine the prevalence of healthcare-associated pathogens and the infection control policies and practices in a national sample of nursing homes (NHs).METHODSIn 2012, we conducted a national survey about the extent to which NHs follow suggested infection control practices with regard to 3 common healthcare-associated pathogens: methicillin-resistant Staphylococcus aureus, Clostridium difficile, and extended-spectrum β-lactamase producers, and their prevalence in NHs. We adapted a previously used and validated NH infection control survey, including questions on prevalence, admission and screening policies, contact precautions, decolonization, and cleaning practices.RESULTSA total of 1,002 surveys were returned. Of the responding NHs, 14.2% were less likely to accept residents with methicillin-resistant Staphylococcus aureus, with the principal reason being lack of single or cohort rooms. NHs do not routinely perform admission screening (96.4%) because it is not required by regulation (56.2%) and would not change care provision (30.7%). Isolation strategies vary substantially, with gloves being most commonly used. Most NHs (75.1%) do not decolonize carriers of methicillin-resistant Staphylococcus aureus, but some (10.6%) decolonize more than 90% of residents. Despite no guidance on how resident rooms on contact precautions should be cleaned, 59.3% of NHs report enhanced cleaning for such rooms.CONCLUSIONOverall, NHs tend to follow voluntary infection control guidelines only if doing so does not require substantial financial investment in new or dedicated staff or infrastructure.Infect Control Hosp Epidemiol 2015;36(7):759–766