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Author(s): Sorensen, Andrea; Grotts, Jonathan F; Tseng, Chi-Hong; Moreno, Gerardo; Maranon, Richard; Whitmire, Natalie; Viramontes, Omar; Atkins, Sandy; Sefilyan, Ester; Simmons, June W; Mangione, Carol M | Abstract: Background/objectivesMedication discrepancies and adverse drug events are common following hospital discharge. This study evaluates whether a collaboration between community-based health coaches and primary care-based pharmacists was associated with a reduction in inpatient utilization following hospitalization.DesignRetrospective cohort study using propensity score matching.SettingUrban academic medical center and surrounding community.ParticipantsIntervention patients (n = 494) were adults aged 65 and older admitted to the University of California, Los Angeles (UCLA) Ronald Reagan Medical Center during the study period and who met study inclusion criteria. A matched-control group was composed of patients with similar demographic and clinical characteristics who were admitted to the study site during the study period but who received usual care (n = 2,470). A greedy algorithm approach was used to conduct the propensity score match.InterventionFollowing acute hospitalization, a health coach conducted a home visit and transmitted all medication-related information to a pharmacist based in a primary care practice. The pharmacist compared this information with the patient's electronic medical record medication list and consulted with the patient's primary care provider to optimize medication management.MeasurementsThirty-day readmissions (primary outcome), 60- and 90-day readmissions, and 30-day emergency department (ED) visits (secondary outcomes) to UCLA Health.ResultsAmong 494 patients who received the intervention, 307 (62.1%) were female with a mean age of 83.0 years (interquartile range [IQR] = 76-90 years). Among 2,470 matched-control patients, 1,541 (62.4%) were female with a mean age of 82.7 years (IQR = 74.9-89.5 years). For the propensity score match, standardized mean differences were below .1 for 23 of 25 variables, indicating good balance. Patients who received this intervention had a significantly lower predicted probability of being readmitted within 30 days compared with matched-control patients (10.6%; 95% confidence interval [CI] = 7.9-13.2) vs 21.4%; 95% CI = 19.8-23.0; P value l .001).ConclusionA home visit conducted by a health coach combined with a medication review by a primary care-based pharmacist may prevent subsequent inpatient utilization.

BACKGROUND This pilot assessed transfusion requirements during resuscitation with whole blood followed by standard component therapy (CT) versus CT alone, during a change in practice at a large urban Level I trauma center. METHODS This was a single-center prospective cohort pilot study. Male trauma patients received up to 4 units of cold-stored low anti-A, anti-B group O whole blood (LTOWB) as initial resuscitation followed by CT as needed (LTOWB + CT). A control group consisting of women and men who presented when LTOWB was unavailable, received CT only (CT group). Exclusion criteria included antiplatelet or anticoagulant medication and death within 24 hours. The primary outcome was total transfusion volume at 24 hours. Secondary outcomes were mortality, morbidity, and intensive care unit- and hospital-free days. RESULTS Thirty-eight patients received LTOWB, with a median of 2.0 (interquartile range [IQR] 1.0-3.0) units of LTOWB transfused. Thirty-two patients received CT only. At 24 hours after presentation, the LTOWB +CT group had received a median of 2,138 mL (IQR, 1,275-3,325 mL) of all blood products. The median for the CT group was 4,225 mL (IQR, 1,900-5,425 mL; p = 0.06) in unadjusted analysis. When adjusted for Injury Severity Score, sex, and positive Focused Assessment with Sonography for Trauma, LTOWB +CT group patients received 3307 mL of blood products, and CT group patients received 3,260 mL in the first 24 hours (p = 0.95). The adjusted median ratio of plasma to red cells transfused was higher in the LTOWB + CT group (0.85 vs. 0.63 at 24 hours after admission; p = 0.043. Adjusted mortality was 4.4% in the LTOWB + CT group, and 11.7% in the CT group (p = 0.19), with similar complications, intensive care unit-, and hospital-free days in both groups. CONCLUSION Beginning resuscitation with LTOWB results in equivalent outcomes compared with resuscitation with CT only. LEVEL OF EVIDENCE Therapeutic (Prospective study with 1 negative criterion, limited control of confounding factors), level III.

Among patients with HIV and with probable/confirmed TB, using the focused assessment with sonography for HIV-associated TB (FASH) protocol led to a 5-fold increase in the clinician's decision to initiate TB treatment on that day. FASH is a supplementary tool that can help clinicians diagnose patients with HIV-associated TB at the point-of-care and reduce delays in their treatment, particularly when access to other diagnostics is limited or unavailable., Background: The focused assessment with sonography for HIV-associated tuberculosis (TB) (FASH) ultrasound protocol has been increasingly used to help clinicians diagnose TB. We sought to quantify the diagnostic utility of FASH for TB among individuals with HIV in Malawi. Methods: Between March 2016 and August 2017, 210 adults with HIV who had 2 or more signs and symptoms that were concerning for TB (fever, cough, night sweats, weight loss) were enrolled from a public HIV clinic in Lilongwe, Malawi. The treating clinicians conducted a history, physical exam, FASH protocol, and additional TB evaluation (laboratory diagnostics and chest radiography) on all participants. The clinician made a final treatment decision based on all available information. At the 6-month follow-up visit, we categorized participants based on clinical outcomes and diagnostic tests as having probable/confirmed TB or unlikely TB; association of FASH with probable/confirmed TB was calculated using Fisher's exact tests. The impact of FASH on empiric TB treatment was determined by asking the clinicians prospectively about whether they would start treatment at 2 time points in the baseline visit: (1) after the initial history and physical exam; and (2) after history, physical exam, and FASH protocol. Results: A total of 181 participants underwent final analysis, of whom 56 were categorized as probable/confirmed TB and 125 were categorized as unlikely TB. The FASH protocol was positive in 71% (40/56) of participants with probable/confirmed TB compared to 24% (30/125) of participants with unlikely TB (odds ratio=7.9, 95% confidence interval=3.9,16.1; P

Introduction While the Diabetes Prevention Program Study demonstrated that intensive lifestyle change and metformin both reduce type 2 diabetes incidence, there are little data on patient preferences in real-world, clinical settings. Methods The Prediabetes Informed Decisions and Education (PRIDE) study was a cluster-randomized trial of shared decision making (SDM) for diabetes prevention. In PRIDE, pharmacists engaged patients with prediabetes in SDM using a decision aid with information about both evidence-based options. We recorded which diabetes prevention option(s) participants chose after the SDM visit. We also evaluated logistic regression models examining predictors of choosing intensive lifestyle change ± metformin, compared to metformin or usual care, and predictors of choosing metformin ± intensive lifestyle change, compared to intensive lifestyle change or usual care. Results Among PRIDE participants ( n = 515), 55% chose intensive lifestyle change, 8.5% chose metformin, 15% chose both options, and 21.6% declined both options. Women (odds ratio [OR] = 1.60, P = 0.023) had higher odds than men of choosing intensive lifestyle change. Patients >60 years old (OR = 0.50, P = 0.028) had lower odds than patients Conclusions Patients with prediabetes are making choices for diabetes prevention that generally align with recommendations and expected benefits from the published literature. Our results are important for policy makers and clinicians, as well as program planners developing systemwide approaches for diabetes prevention.

Author(s): Moreno, Gerardo; Mangione, Carol M; Tseng, Chi-Hong; Weir, Melanie; Loza, Rosaneli; Desai, Lisa; Grotts, Jonathan; Gelb, Eve | Abstract: ObjectivePatients with multiple medical conditions and complex social issues are at risk for high utilization and poor outcomes. The Connecting Provider to Home program deployed teams of a social worker and a community health worker (CHW) to support patients with social issues and access to primary care. Our objectives were to examine the impact of the program on utilization and satisfaction with care among older adults with complex social and medical issues.DesignRetrospective quasi-experimental observational study with matched comparator group.SettingCommunity-based program in Southern California.ParticipantsFour hundred twenty community dwelling adults.InterventionCommunity-based healthcare program delivered by a social worker and CHW team for older adults with complex medical and social needs.MeasurementsAcute hospitalization and emergency department (ED) visits in the 12 months preceding and following enrollment in the pilot program. A "difference-in-difference" analysis using a matched comparator group was conducted. Comparator group data of patients receiving usual care were obtained. Surveys were conducted to assess patient satisfaction and experiences with the program.ResultsThe mean age of patients was 74 years, and the program demonstrated statistically significant reductions in acute hospitalizations and ED use compared with 700 comparator patients. Pre/post-acute hospitalizations and ED visits were reduced in the intervention group. The average per patient per year reduction in acute hospitalizations was -0.66, whereas the average per patient reduction in ED use was -0.57. Patients enrolled in the program reported high levels of satisfaction and rated the program favorably.ConclusionsA care model with a social worker and CHW can be linked to primary care to address patient social needs and potentially reduce utilization of healthcare services and enhance patient experiences with care.

Author(s): Moreno, Gerardo; Fu, Jeffery Y; Chon, Janet S; Bell, Douglas S; Grotts, Jonathan; Tseng, Chi-Hong; Maranon, Richard; Skootsky, Samuel S; Mangione, Carol M | Abstract: BackgroundPharmacists are effective at improving control of cardiovascular risk factors, but it less clear whether these improvements translate into less emergency department (ED) use and fewer hospitalizations. The UCMyRx program embed pharmacists in primary care.ObjectiveThe objective of this study was to examine if the integration of pharmacists into primary care was associated with lower ED and hospital use for patients with diabetes.DesignThis was a quasi-experimental study with a comparator group.SubjectsThe analytic sample included patients with diabetes with uncontrolled cardiovascular risk factors (A1C g9%, blood pressure g140/90 mm Hg, low-density lipoprotein-cholesterol g130 mg/dL) who had 1 or more visits in either a UCMyRx (648 patients, 14 practices) or usual care practice (1944 patients, 14 practices).MeasuresOur outcomes were ED and hospitalization rates as measured before and after the consultations between UCMyRx and usual care. Our predictor variable was the pharmacist consultation. Poisson generalized estimating equations model was used to estimate the adjusted predicted change in utilization before and after the pharmacist consultation. The Average Treatment Effect on the Treated was estimated.ResultsIn models adjusted, the adjusted mean predicted number of emergency department visits/month during the year before the consultation was 0.09 among UCMyRx patients. During the year after initiating the care with the pharmacists, this rate decreased to an adjusted mean monthly rate of 0.07, with an Average Treatment Effect on the Treated=0.021 (P=0.035), a predicted reduction of 21% in emergency department visits associated with the clinical pharmacist consults. There was a nonsignificant predicted 3.2% reduction in hospitalizations over time for patients in the UCMyRx program.ConclusionClinical pharmacists are an important addition to clinical care teams in primary care practices and significantly decreased utilization of the ED among patients with poorly controlled diabetes.

BackgroundPatient activation is associated with better outcomes in chronic conditions.ObjectiveWe evaluated the psychometric properties of the 12-item Altarum Consumer Engagement™ Measure (ACE-12) in patients with prediabetes.ParticipantsACE-12 was administered to patients in the Prediabetes Informed Decisions and Education Study.Main measuresWe conducted an exploratory factor analysis followed by confirmatory factor analytic models. We evaluated item response categories using item characteristic curves. Construct validity was assessed by examining correlations of the ACE-12 scales with education, depressive symptoms, self-rated health, hemoglobin A1c, body mass index, and weight loss.Key resultsParticipants (n = 515) had a median age of 58; 56% were female; 17% Hispanic; 54% were non-White. The scree plot and Tucker and Lewis reliability coefficient (0.95) suggested three factors similar to the original scales. One item loaded on the navigation rather than the informed choice scale. Ordinal alpha coefficients for the original scales were commitment (0.75); informed choice (0.71); and navigation (0.54). ICCs indicated that one or more of the response categories for 5 of the 12 items were never most likely to be selected. Patients with lower education were less activated on the commitment (r = - 0.124, p = 0.004), choice (r = - 0.085, p = 0.009), and overall score (r = - 0.042, p = 0.011). Patients with depressive symptoms had lower commitment (r = - 0.313, p ≤ 0.001) and overall scores (r = - 0.172, p = 0.012). Patients with poorer health scored lower on the Commitment (r = - 0.308, p ≤ 0.001), Navigation (r = - 0.137, p ≤ 0.001), and overall score (r = - 0.279, p ≤ 0.001).ConclusionThe analyses provide some support for the psychometric properties of the ACE-12 in prediabetic patients. Future research evaluating this tool among patients with other chronic conditions are needed to determine whether Q1 (I spend a lot of time learning about health) should remain in the informed choice or be included in the navigation scale. Additional items may be needed to yield acceptable reliability for the navigation scale.

Background Nonalcoholic steatohepatitis (NASH) is a common cause of liver disease which can progress to cirrhosis and hepatocellular carcinoma (HCC). American Association for the Study of Liver Diseases (AASLD) guidelines recommend abdominal ultrasound, with or without serum alpha-fetoprotein, every 6 months for HCC surveillance in cirrhotic patients. Goals Describe HCC surveillance rates in NASH cirrhosis compared with hepatitis C (HCV) cirrhosis and the impact of surveillance on tumor size, treatment, and mortality. Study Adults with NASH and HCV cirrhosis diagnosed with HCC from 2009 to 2016 were retrospectively evaluated. Patients were categorized into 3 mutually exclusive disease screening groups based on abdominal imaging with or without serum alpha-fetoprotein testing before HCC diagnosis. Results In total, 99 patients with NASH cirrhosis and 162 patients with HCV cirrhosis were evaluated. In total, 51.5% of NASH cirrhosis patients and 25.9% of HCV cirrhosis patients had no screening before HCC diagnosis. Patients with HCV cirrhosis were significantly more likely to undergo surveillance compared with patients with NASH cirrhosis (P=0.002). NASH cirrhosis patients who underwent complete screening had smaller tumors compared with those with incomplete screening and no screening (P=0.006). There were no differences in number of tumors at diagnosis or mortality between screening groups in patients with NASH cirrhosis (P=0.281 and 0.468, respectively). Conclusions There is suboptimal HCC surveillance in NASH and HCV cirrhotic patients, with a greater proportion of patients with NASH cirrhosis not undergoing surveillance. Patients with NASH cirrhosis who had complete surveillance had smaller tumors at diagnosis, but there were no differences in treatment outcomes or mortality.

Orthotopic liver transplant (OLT) recipients are at high risk for postoperative pulmonary complications. We aim to determine factors associated with morbidity and mortality in OLT recipients that required thoracic surgery for pleural space complications. A retrospective review was performed of 42 patients who underwent thoracic surgery after OLT between 2005 and 2015. Preoperative data and postoperative outcomes were reviewed. Time to mortality was summarized using Kaplan-Meier curves. Outcomes associated with 30-day morbidity and mortality as well as long-term mortality were analyzed with univariate analysis. Between 2005 and 2015, 1735 OLTs were performed at our institution. We identified 42 patients who required thoracic surgery. Of these 42 OLT recipients, 33 patients required thoracic surgery for pleural space complications. The median interval between OLT and thoracic surgery for pleural space complications was 5.7 months (interquartile range 2.2-14.1). The most common surgical indications were chronic pleural effusion (n = 12, 36.4%) and empyema (n = 10, 30.3%). The most common thoracic operations were decortication and empyema evacuation. The 30-day morbidity was 69.7%. Bilirubin and empyema were significantly associated with 30-day morbidity (odds ratio [OR] = 2.3, P = 0.023; OR = 16.3, P = 0.015). The 30-day, 1-year, and 5-year mortality rates were 15.2%, 57.6%, and 70.2%, respectively. Vasopressor requirement was significantly associated with 30-day mortality (OR = 10.2, P = 0.031). The development of pleural space complications requiring surgery in OLT recipients suggests a poor prognosis. Hyperbilirubinemia and pleural space infections were associated with high postoperative morbidity in OLT recipients requiring thoracic surgery for pleural space complications.

Both intravenous (IV) and oral (PO) cyclophosphamide (CYC) showed beneficial effects on skin and lung involvement in systemic sclerosis (SSc) in placebo-controlled randomised clinical trials and observational studies. Our goal was to compare the relative efficacy and safety of PO- versus IV-CYC for treating interstitial lung disease and/or skin involvement in SSc.Patients were derived from the EUSTAR centres and the Scleroderma Lung Studies I and II. A minimum of 6 months of CYC treatment and 12 months follow-up were required. Serious (SAEs) and non-serious adverse events and efficacy data (change in FVC%, DLCO%, mRSS) were analysed at the end of CYC treatment (EoT) and at follow-up (FU). Analysis included descriptive statistics and linear regressions.Differences in ethnicity, previous DMARD exposure, previous and concomitant steroid exposure/dosage were observed in the PO (n=149) and IV (n=153) CYC groups. Adjusted and unadjusted changes in FVC%, DLCO% and mRSS were similar irrespective of mode of administration. PO patients had more leukopenia (p0.001), haemorrhagic cystitis (p=0.011) and alopecia (p0.001) at the EoT visit, while the IV group had more SAEs (p=0.025) and need for oxygen supplementation at FU (p=0.049).In a comparison of PO- to IV-CYC for SSc, we found no differences in lung function or cutaneous sclerosis after one year. Some differences in side effects were seen. The results need to be considered as preliminary; however, because we needed to use a combination of RCT and registry data, with some differences in demographics and concomitant medications, well-controlled studies are warranted.

Introduction Angiotensin II type 1 receptor antibody (AT1R-Ab), is a non–human leukocyte antigen (HLA) antibody implicated in poor renal allograft outcomes, although its actions may be mediated through a different pathway than HLA donor-specific antibodies (DSAs). Our aim was to examine serum cytokine profiles associated with AT1R-Ab and distinguish them from those associated with HLA DSA in serially collected blood samples from a cohort of pediatric renal transplant recipients. Methods Blood samples from 65 pediatric renal transplant recipients drawn during the first 3 months posttransplant, at 6, 12, and 24 months posttransplant, and during suspected episodes of kidney transplant rejection were tested for AT1R-Ab, HLA DSA, and a panel of 6 cytokines (tumor necrosis factor [TNF]-α, interferon [IFN]-γ, interleukin [IL]-8, IL-1β, IL-6, and IL-17). Associations between antibodies and cytokines were evaluated. Results AT1R-Ab, but not HLA DSA, was associated with elevations in TNF-α, IFN-γ, IL-8, IL-1β, IL-6, and IL-17. This relationship remained significant even after controlling for relevant clinical factors and was consistent across all time points. In contrast to HLA DSA, AT1R-Ab was associated with elevations in vascular inflammatory cytokines in the first 2 years posttransplant. Conclusions This profile of vascular cytokines may be informative for clinical monitoring and designing future studies to delineate the distinct pathophysiology of AT1R-Ab–mediated allograft injury in kidney transplantation., Graphical abstract

Background and Aims: Recurrent hepatitis C (HCV) disease in liver transplant (LT) recipients is associated with significant morbidity and mortality. With the availability of noninterferon-based therapy, eliminating HCV may be achievable in LT recipients. Methods: We studied all consecutive recipients who underwent LT at the University of California Los Angeles between January 2005 and June 2017. We collected data on date of transplant and last follow-up, as well as laboratory values. We also recorded type and timing of antiviral therapy relative to LT. Analyses were performed to assess the proportion of LT recipients who are viremic after transplant. Results: Six hundred thirty-four patients underwent LT with a diagnosis of HCV. There was a statistically significant trend for patients to be cured before (p < 0.001) and after liver transplantation (p < 0.001) for the study period of 2014 to 2016 relative to 2005 and 2013, respectively. Of the 634 recipients eligible for therapy, 8% and 74% were treated within 12 months of transplant for the study periods 2005 to 2013 and 2014 to 2016, respectively. There was a significant decrease between the two study periods in the proportion of patients undergoing re-LT 1 year after the original LT: 5.5% (n = 28/510) and 1.5% (n = 2/124) respectively for study periods 2005 to 2013 and 2014 to 2016 respectively (p = 0.011). Conclusions: The proportion of LT recipients who are viremic has decreased over time. Eliminating HCV in LT recipients is feasible after the introduction of direct-acting agents. Curing HCV should translate to improved clinical outcomes in LT recipients who were transplanted for HCV infection with longer follow-up. Preliminary results suggest the decreased need for transplant in the direct-acting agents era.

Use of an Internet portal to refill medicines positively affects medication adherence among English-speakers. No prior studies, however, have specifically examined the relationship between Internet refills and medication adherence among patients who are limited English proficient (LEP). (1) Examine the relationship between Internet medication refill system use and medication adherence among linguistically diverse patients with chronic conditions and (2) compare this relationship between LEP and English-proficient (EP) patients. We analyzed 2013–2014 cross-sectional data from 509 surveyed adults in the Group Health Cooperative. Surveys were merged with plan enrollment, claims data, and electronic medical records. Medication adherence was calculated by the “Continuous Measure of Medication Gaps” (CMG) method. For Internet refill system use, patients were asked, “Have you used the health systems Internet site to refill any medications in the last 12 months?” LEP status was captured in the electronic medical record by a non-English primary language and a claims record of interpreter use in at least one clinical encounter between 2005 and 2012. We used multivariate linear regression models to examine Internet refill system use and medication adherence and compared the association between LEP and EP patients. Three hundred eighty-four patients (75%) had a calculable CMG: 134 EP and 250 LEP in the adherence analyses. In unadjusted analyses, LEP patients had lower use of the Internet refill system (p

Skin ulcers in scleroderma (SSc) patients are considered a major challenge, both in clinical assessment and treatment decisions. The objective of our study is to assess ultrasonographic (US) morphology of skin ulcers in SSc patients and evaluate if US will be of value in enhancing our clinical information and influence our management plans. We examined a convenience sample of 21 skin ulcers reported in 10 SSc patients by US. We used a previously published US definition of normal skin and developed a preliminary US definition of skin ulcer. Skin ulcers were evaluated by gray scale (GS) and power Doppler (PD) and separated into ulcer and non-ulcer lesions; pain and ulcer measures were obtained using visual analogue scales (VAS). Lesions were characterized and ulcers were clinically and sonographically measured. Ten patients presenting with 21 skin lesions were examined by US. Applying our US definition of skin ulcer, all ulcers were available to measure by ultrasound. Eight lesions were sonographically defined as ulcers, and 13 lesions as non-ulcer lesions. Three ulcers had high PD signals suggestive of infection requiring antibiotic treatment and were monitored for 2 weeks showing a decrease of the pain, VAS, and PD signals. Five lesions showed subclinical calcinosis. This is the first study to show the promising role of US in defining skin ulcers of SSc patients. US may support the assessment of morphology and extent of skin ulcers in SSc and can be a helpful tool for detecting underlying pathology.

The objective of this study was to evaluate usage and outcomes of emergency laparoscopic versus open surgery at a single tertiary academic center. Over a three-year period 165 patients were identified retrospectively using National Surgical Quality Improvement Program results. Appendectomies and cholecystectomies were excluded. Open and laparoscopic approaches were compared regarding preoperative and operative characteristics, the development of postoperative complications, 30-day mortality, and length of hospital stay. Indications for operation were similar between groups. Patients who underwent open surgery had more severe comorbidities and higher ASA class. Laparoscopy was associated with reduced complication rates, operative time, length of stay, and discharges to skilled nursing facilities on univariate analysis. In a multivariate model, surgical approach was not associated with the development of complications. Older age, dependent status, and dyspnea were predictors of conversion from attempted laparoscopic to open approaches.

Background and Aims: Given the increased risk of post-transplant metabolic syndrome (PTMS; defined by hypertension, diabetes mellitus and hyperlipidemia), we aimed to identify the potential role of food addiction in the development of metabolic complications in the post-liver transplant population. Methods: Inclusion criteria included adult liver transplant recipients followed at our institution between June 2016 and November 2016. Participants were administered a demographic survey as well as the Yale Food Assessment Scale 2.0, a 35-item questionnaire used to assess frequency of food addiction in accordance with the DSM-V guidelines of substance use disorders. Demographic and clinical data were collected. Results: Our study included 236 liver transplant recipients (139 males, 97 females). The median (interquartile range [IQR]) BMI of participants was 26.8 kg/m2 (24.2, 30.4), and median (IQR) time since transplantation was 50.9 months (19.6, 119.8). The prevalence rates of hypertension, hypercholesterolemia and diabetes mellitus were 54.7%, 25.0% and 27.1%, respectively. Twelve participants (5.1%) were found to have a diagnosis of food addiction. A diagnosis of food misuse was made in 94 (39.8%) of the transplant recipients. Conclusions: Our findings are consistent with prior data that indicate high prevalence of metabolic complications among liver transplant recipients. Food addiction was not predictive of metabolic complications within this population. Nevertheless, we found that this population was at high risk of demonstrating symptoms of food misuse, and they were not likely to appreciate the risks of pathologic patterns of eating. Given the increasing risk of cardiovascular morbidity and mortality in this population, efforts should be made to identify risk factors for the development of PTMS.

Background and Aims: Recurrent infection of hepatitis C virus (HCV) in liver transplant (LT) recipients is universal and associated with significant morbidity and mortality. Methods: We retrospectively evaluated the safety and efficacy of ledipasvir/sofosbuvir with and without ribavirin in LT recipients with recurrent genotype 1 hepatitis C. Results: Eighty-five LT recipients were treated for recurrent HCV with ledipasvir/sofosbuvirwith and without ribavirin for 12 or 24 weeks. The mean (± standard deviation [SD]) time from LT to treatment initiation was 68 (±71) months. The mean (± SD) age of the cohort was 63 (±8.6) years old. Most recipients were male (70%). Baseline alanine transaminase, total bilirubin, and HCV ribonucleic acid (RNA) values (± SD) were 76.8 (±126) mg/dL, 0.8 (±1.3) U/L, and 8,010,421.9 (±12,420,985) IU/mL, respectively. Five of 43 recipients who were treated with ribavirin required drug cessation due to side effects, with 4 of those being anemia complications. No recipient discontinued the ledipasvir/sofosbuvir. Eighty-one percent of recipients had undetectable viral levels at 4 weeks after starting therapy, and all recipients had complete viral suppression at the end of therapy. The sustained viral response at 12 weeks after completion of therapy was 94%. Conclusion: Ledipasvir and sofosbuvir with and without ribavirin therapy is an effective and well-tolerated interferon-free treatment for recurrent HCV infection after LT. Anemia is not uncommon in LT recipients receiving ribavirin.

With increasing life expectancy, the elderly are participating in recreational activities traditionally pursued by younger persons. Elderly patients have many reasons for worse outcomes after trauma, one of which may be the rising use of anticoagulant and/or antiplatelet medications. This study aimed to determine whether preinjury use of these agents yielded worse outcomes in geriatric patients injured during high-impact recreational activities. The National Trauma Data Bank was reviewed from 2007 to 2010 for patients ≥65 years admitted to Level I or II trauma centers with ICD-9 E-codes for specific mechanisms of injury. These included motorcycles, bicycles, snowmobiles, all-terrain vehicles, equestrian, water and alpine skiing, snowboarding, and others. Patients with preinjury bleeding disorder (BD), including warfarin and clopidogrel use, were compared with controls via a coarsened exact matching analysis. BD patients (294) were compared with 3929 controls. Although increased in BD patients, no significant mortality differences were observed in unmatched or matched analyses. BD patients yielded greater hospital length of stay (5 vs 4 days, P = 0.020) with increased odds of receiving five units or more of blood (7.0% vs 2.1%, odds ratio = 4.7, P < 0.001) and of deep vein thrombosis (7.6% vs 3.8%, odds ratio = 2.1, P = 0.018). Elderly patients with BD, including warfarin or clopidogrel use, do not seem to have significantly increased mortality after injury during specified recreational activities. BD patients had greater hospital length of stay, transfusion requirements, and deep vein thrombosis rates. These findings may inform counseling for those taking such medications as to the potential for adverse outcomes.

ObjectiveTo investigate the relationship between amyloid burden and frequency of existing and incidence of new neuropsychiatric symptoms (NPS) in elderly with and without cognitive decline.Methods275 cognitively normal controls (NC), 100 subjective memory complaint (SMC), 559 mild cognitive impairment (MCI) and 143 Alzheimer’s disease dementia subjects from the Alzheimer’s Disease Neuroimaging Initiative received (18F)-florbetapir positron emission tomography (PET) scans. Yearly neuropsychiatric inventory (Neuropsychiatric Inventory (NPI)/NPI-Questionnaire) data were collected from the study partners at each visit. Mean standard uptake volume ratios (SUVR) normalised to whole cerebellum were obtained. Positive amyloid PET scan was defined as mean SUVR ≥1.17. Fisher’s exact test was used to compare frequency and incidence between amyloid positive and amyloid negative subjects. Survival analyses were used to estimate of neuropsychiatric symptoms (NPS) between amyloid positive and amyloid negative subjects. Survival analyses were used to estimate hazard ratios for developing the most common NPS by amyloid status.ResultsNo differences in NPS frequency were seen between amyloid positive and amyloid negative NC, SMC, MCI or dementia groups. MCI subjects with amyloid pathology however tended to have greater frequency x severity (FxS) of anxiety, hallucinations, delusions, apathy, disinhibition, irritability, aberrant motor behavior, and appetite, but not agitation, depression, night-time disturbances, or elation. MCI subjects with amyloid pathology were at greater risk for developing apathy, anxiety and agitation over time. Baseline presence of agitation and apathy and new onset agitation, irritability and apathy predicted faster conversion to dementia among MCI subjects.ConclusionsAmyloid pathology is associated with greater rate of development of new NPS in MCI. Anxiety and delusions are significant predictors of amyloid pathology. Agitation, irritability and apathy are significant predictors for conversion from MCI to dementia.

Background High-dose chemotherapy (HDC) with autologous stem cell transplantation (ASCT) has been investigated in patients with primary central nervous system lymphoma (PCNSL) and non-Hodgkin lymphoma (NHL) with CNS involvement and has shown promising results. Patients and Methods A retrospective analysis was performed of 48 consecutive patients who had undergone HDC/ASCT with TBC (thiotepa, busulfan, cyclophosphamide) conditioning for PCNSL (27 patients), secondary CNS lymphoma (SCNSL) (8 patients), or relapsed disease with CNS involvement (13 patients) from July 2006 to December 2017. Of the 27 patients with PCNSL, 21 had undergone ASCT at first complete remission (CR1). Results The 2-year progression-free survival (PFS) rate was 80.5% (95% confidence interval [CI], 69.9-92.9) and the 2-year overall survival (OS) rate was 80.1% (95% CI, 69.2%-92.7%) among all patients. The 2-year PFS and OS rate for patients with PCNSL in CR1 was 95.2% (95% CI, 86.6%-100%) and 95.2% (95% CI, 86.6%-100%), respectively. On univariate analysis of the patients with PCNSL, ASCT in CR1 was the only variable statistically significant for outcome (P = .007 for PFS; P = .008 for OS). Among patients with SCNSL or CNS relapse, the 2-year PFS and OS rate were comparable at 75.9% (95% CI, 59.5%-96.8%) and 75.3% (95% CI, 58.6%-98.6%), respectively. The most common side effects were febrile neutropenia (89.6%; of which 66.7% had an infectious etiology identified), nausea/vomiting (85.4%), diarrhea (93.8%), mucositis (89.6%), and electrolyte abnormalities (89.6%). Four patients (8.3%) died of treatment-related overwhelming infection; of these patients, 3 had SCNSL. Conclusion HDC and ASCT using TBC conditioning for both PCNSL and secondary CNS NHL appears to have encouraging long-term efficacy with manageable side effects.

BACKGROUND Increased participation of adolescents in organized sports has led to an increase in pediatric sports injury. Limited health literacy puts patients at risk for worse outcomes through decreased compliance. We aim to evaluate the extent of health literacy disparities in pediatric sports medicine populations. METHODS Patients aged 10 to 17 years and their consenting guardians visiting clinic for treatment of a sports-related injury completed a unique questionnaire including self-reported health literacy measures and direct assessment of knowledge regarding care for musculoskeletal injuries. Statistical analysis based on socioeconomic factors and demographics was performed using t tests. RESULTS A total of 268 patient surveys (14.37±1.94 y) and 251 guardian surveys (43.62±9.08 y) were collected. In self-reported general health literacy scores for guardians, all categories except ethnicity played a statistically significant role, with higher health literacy scores associated with higher education, use of English as the primary language at home, private insurance, and female guardians (P

Background and Aims: The lack of specificity has limited the role of serum alpha-fetoprotein (AFP) for hepatocellular carcinoma (HCC) screening among patients with cirrhosis related to hepatitis C virus (HCV) infection. We sought to examine whether AFP may decrease after achieving a sustained virological response (SVR) in patients with HCV-related cirrhosis. Methods: We performed a retrospective study of patients with HCV-related cirrhosis who were cured with direct-acting antiviral (DAA) therapy at the University of California, Los Angeles. Laboratory values, including serum AFP, were measured before and after completing the DAA treatment. Results: Fifty-six patients met the inclusion criteria, with median (interquartile range [IQR]) age of 67 (58–69) years and with 51.8% being male. All patients received DAA therapy without interferon. AFP decreased from median (IQR) 7.2 (4.2–13.4) ng/mL before DAAs to 4.2 (2.7–6.3) ng/mL at the end of treatment and 4.2 (2.9–6.8) ng/mL at 12 weeks after treatment (p < 0.001). Model for end-stage liver disease (MELD), fibrosis-4 (FIB4), and aspartate transaminase (AST) to platelet ratio index (APRI) scores at baseline were not significantly associated with AFP reduction. On multivariate analysis, platelet count, AST and total bilirubin at baseline were significantly correlated to AFP reduction (p = 0.04, 0.009 and 0.04, respectively). The higher the baseline AFP, the greater the reduction in AFP. There was no statistically significant correlation between baseline AFP and MELD, FIB4 or APRI scores. Conclusion: There was a significant decrease in AFP in patients with cirrhosis who achieved a SVR with DAAs. Given a reduction in AFP after DAA treatment, AFP should be further studied as a screening modality for HCC in patients with cirrhosis.

Background and Aims: Unintentional acetaminophen overdose remains the leading cause of acute liver failure in the United States. Patients with underlying liver disease are at higher risk of poor outcomes from acetaminophen overdose. Limited knowledge of acetaminophen may be a preventable contributor to elevated rates of overdose and thus acute liver failure. The purpose of this study is to assess knowledge of acetaminophen dosing and presence of acetaminophen in common combination products in patients with liver disease. Methods: We performed a cross-sectional study of patients with liver disease at the Pfleger Liver Institute at the University of California, Los Angeles between June 2015 and August 2016. Patients completed a demographic questionnaire and an acetaminophen knowledge survey. Additional information was obtained from the medical record. Results: Of 401 patients with liver disease, 30 (15.7%) were able to correctly identify that people without liver disease can safely take up to 4 g/day of acetaminophen. The majority of patients (79.9%–86.8%) did not know that Norco® (hydrocone/acetaminophen), Vicodin® (hydrocone/acetaminophen) and Percocet® (oxycodone/acetaminophen) contained acetaminophen. Only 45.3% of the patients knew that Tylenol® #3 contained acetaminophen. Conclusions: We conclude that patients with liver disease have critically low levels of knowledge of acetaminophen, putting them at risk both of acetaminophen overdose, as well as undermedication, and inadequate management of chronic pain. We recommend an increase in education efforts regarding acetaminophen dosage and its safety in the setting of liver disease. Increasing education for those at risk of low acetaminophen knowledge is essential to minimizing acetaminophen overdose rates and optimizing pain management.

Over two million Americans receive treatment for pressure ulcers (PUs) annually, but national surgical outcomes are not well described. This study investigated rates and risk factors of postoperative complications in patients with PU. The 2011 and 2012 American College of Surgeons-National Surgical Quality Improvement Project database was queried and PU patients undergoing flap closure were identified. Descriptive statistics and multivariate regression analysis was used and reported as odds ratios (ORs) if ( P < 0.05). Of 1196 patients identified with a primary diagnosis of PU, 327 (27%) underwent flap closure. Emergency interventions were performed in seven patients who were excluded from analysis. Characteristics were average age 53.3 (±17); 65 per cent male; 41 per cent with grossly contaminated or infected wounds; 29 per cent frail; and 16 per cent with an American Society of Anesthesiologists score of four or five. Myocutaneous or fasciocutaneous flaps were performed in 82 per cent of patients, local skin rearrangements in 17 per cent, and free flap in one patient. Complications were low with 1.9 per cent recurrence and 4.7 per cent reoperation rates. Higher American Society of Anesthesiologists was independently associated with mortality (odds ratio = 6.6) and steroid use correlated with flap failure (odds ratio = 15). No differences in complication profiles were identified based on technique, frailty, or contamination. Surgical closure can be considered reasonable in all patients fit for anesthesia.

Purpose/objectives To explore family members' experience of a bathing and honoring practice after a loved one's death in the acute care setting. . Research approach A descriptive, qualitative design using a semistructured telephone interview script. . Setting The Inpatient Adult Oncology Unit at Santa Barbara Cottage Hospital in California. . Participants 13 family members who participated in the bathing and honoring practice after their loved one's death on the oncology unit. . Methodologic approach Participants were selected by purposive sampling and interviewed by telephone three to six months after their loved one's death. Interviews using a semistructured script with open-ended questions were recorded, transcribed, verified, and analyzed using phenomenologic research techniques to identify common themes of experience. . Findings 24 first-level themes and 11 superordinate themes emerged from the data. All participants indicated that the bathing and honoring practice was a positive experience and supported the grieving process. The majority found the practice to be meaningful and stated that it honored their loved one. Many expressed that the bathing and honoring was spiritually significant in a nondenominational way and that they hope it will be made available to all families of patients who die in the hospital. . Conclusions After patient death, a bathing and honoring practice with family member participation is positive and meaningful, and it supports family members' initial grieving. . Interpretation This study is a first step toward establishing specific nursing interventions as evidence-based practice that can be incorporated in routine nursing care for patients and families at the end of life.

Nonoperative management of acute appendicitis is becoming widespread, but recurrence and the potential for a complicated course are important concerns. An admission report-based institutional database was created to monitor appendicitis treatment outcomes. Complications and complexity of surgery were recorded based on manual chart review. A cohort of patients spanning one year was analyzed. Initial management was operative in 181 (82%) and nonoperative in 39 (18%) cases. There were no differences in demographics, BMI, or Alvarado score. One operative patient and 17 non-operative patients required additional treatment for recurrence/nonresolution (0.6% vs 44%, P < 0.00001). Twenty-eight (15%) operative patients and 17 (44%) nonoperative patients had complications ( P = 0.0003). Thirty-six (19.9%) operations in the operative group and 8 (53.3%) in the non-operative group were classified as complex ( P = 0.007). Hospital stay was longer in the nonoperative group (one vs two days, P = 0.005). Two incidental malignancies in the operative group and one in the nonoperative group were identified. These results are consistent with prior studies showing that recurrence/nonresolution is common after nonoperative management. For patients with recurrence/nonresolution, surgery may be more complex.

Objectives We assessed the effect on subjective knowledge of a pilot educational comic decision aid about contraceptive methods. Study design We designed four comics ( www.birthcontroltales.com ), each about a different contraceptive method choice. The comics employ a theoretical framework, and the methods addressed were injection, intrauterine device, implant and combined hormonal contraceptives (including pill, patch and ring). The study population included young women presenting to a college student health clinic whose preferred language is English. Participants had not used the contraceptive method described in the comic and viewed the comics in color printed copy. We assessed contraception subjective knowledge using a pretest/posttest six-question survey with Likert scale responses before and after exposure to the comics. Surveys conducted during the participants' visit also measured participant satisfaction with the comic and participant sexual history. Results A total of 120 individual participants divided into groups of 30 each viewed one of four separate comics. Across the four groups, the difference in the pretest/posttest scores of the six-question subjective knowledge survey indicated a 72% average increase (p value Conclusion Comics about contraceptive methods can be a communications tool that increases subjective knowledge of contraceptive methods. Comics that model contraceptive choice decision processes can increase individual subjective knowledge of the contraceptive method mechanism, effect, usage, side effects, feasibility and benefits. Possessing subjective knowledge of contraceptive methods can influence contraceptive initiation and use and therefore has potential implications for changing contraceptive attitudes and behavior. Implications Contraceptive method comics should be further examined in other clinic settings with broader demographic populations to glean the effect on patient decision and contraceptive behavior. Integration of the comics into a contraceptive counseling practice can be assessed in an observational trial. Additionally, studies should also consider testing long-term patient behavior, and both patient and provider satisfaction.

The Diabetes Prevention Program (DPP) is a 12-month behavior change program designed to increase physical activity and improve dietary patterns among patients at risk for Type 2 diabetes, in order to facilitate modest weight loss and improve cardio-metabolic profiles. It is unknown whether baseline patient activation is related to increased DPP uptake, and whether DPP attendance leads to subsequent improvement in patient activation. We analyzed data from 352 adult participants in the Prediabetes Informed Decisions and Education (PRIDE) trial of shared decision-making (SDM) in diabetes prevention, collected from November 2015 through September 2017. PRIDE participants completed baseline and 4-month follow-up surveys, including the Altarum Consumer Engagement (ACE) Measure™ of patient activation. We tracked DPP attendance over 8 months using data from partnering DPP providers. In multivariate models, we measured whether self-reported baseline activation was associated with DPP "uptake" (1+ session attended) or DPP "attendance" (9+ sessions). We also examined whether DPP attendance was associated with change in activation at 4-months follow-up. We did not find an association between baseline activation and DPP uptake or attendance. However, we did find that DPP attendance was associated with an increase in the overall ACE score (6.68 points, 95% CI 1.97-11.39, p = 0.005) and increased activation in 2 of the 3 ACE subscales (Commitment and Informed Choice). Our finding of increased patient activation with DPP attendance suggests a mechanism for the improved health outcomes seen in DPP real-world translational studies. This work has important implications for diabetes prevention and other behavior change programs.

Objective.To date, “healed/non-healed” and clinical judgment are the only available assessment tools for digital ulcers (DU) in patients with systemic sclerosis (SSc). The aim of our study is to examine a preliminary composite DU clinical assessment score (DUCAS) for SSc for face, content, and construct validity.Methods.Patients with SSc presenting at least 1 finger DU were enrolled and assessed with the Health Assessment Questionnaire–Disability Index, Cochin scale, visual analog scale (VAS) for DU-related pain, patient global DU status, and global assessment as patient-reported outcomes (PRO), and physician VAS for DU status (phyGDU) as an SSc-DU expert physician/nurse measure. The DUCAS included 7 DU-related variables selected by a committee of SSc DU experts and weighted on a clinical basis. Face validity was examined by consensus and partial construct validity was tested through convergent correlation with other measures of hand function, using Spearman’s correlations. A range of patients with SSc was examined. A linear regression model with backward stepwise analysis was used to determine the relationship of individual variables with the primary clinical parameter, phyGDU.Results.Forty-four patients with SSc (9 males, mean age 55 ± 15 yrs, mean disease duration 9.9 ± 5.8 yrs) were enrolled in the study. Overall DUCAS showed significant positive correlations with all abovementioned PRO (r > 0.4, p < 0.01). When all scores and scales were modeled, only DUCAS significantly predicted phyGDU (r = 0.59, R2 = 0.354, Akaike information criterion = 385.4).Conclusion.Preliminarily, we suggest that the DUCAS may be a new clinical score for SSc-related DU, having face and content validity and convergent/divergent correlations (construct validity). These early data suggest that this score deserves further evaluation.

Background In the last decade, oral CYC has shown modest but significant effect on SSc-ILD and skin thickness in two large randomised controlled trials, with superiority to placebo and similar efficacy to mycophenolate. However, many centres give priority to monthly IV CYC for expected milder toxicity. Objectives To compare efficacy and safety of oral versus iv CYC for treating ILD and/or skin involvement in SSc. Methods SSc patients treated with oral or iv CYC for at least 6 months were followed for 1 year from the last administration. Data were obtained from the EUSTAR database and the Scleroderma Lung Studies I and II regarding safety [both serious (SAEs) and non-serious adverse events (AEs)] and efficacy (%FVC,%DLCO, mRSS) at end of treatment and after one-year follow-up were analysed [mean ±SD or median(IQR) as appropriate]. Results 322 patients were eligible: 149 patients received oral CYC with median daily dose 106(93–134) mg, treatment duration 365(364–366) days, while 153 patients received IV CYC median monthly dose 1000(700–1200) mg, treatment duration 335(291–374) days. Ethnicity, previous DMARD exposure, previous and concomitant steroid exposure and dosage, current/previous smoking exposure, prevalence of digital ulcers and arterial hypertension were different between the two groups (see table 1 for further details). For efficacy: despite different baseline%FVC and%DLCO, adjusted changes in pulmonary measures from end of treatment (EOT) vs baseline and follow-up visit (FU) vs EOT were, respectively: %FVC [0(−5–5) vs 0(−7–7) and 1 (−6–4) vs −2(−7–4), p=NS],%DLCO [−4 (−9–3) vs −3 (−9–6), 1(−6–5) vs −1 (−9–6), p=NS] and mRSS [−3 (−5–0) vs −1 (−5–0), −1(−4–1) vs 0(−3–1), p=NS]. In a multivariate analysis, no independent variable significantly influenced%FVC change at any visit.%DLCO change was influenced by baseline%DLCO and history of SSc-related cardiomyopathy at EOT assessment and by history of SSc-muscle involvement at FU visit. Baseline mRSS was the only variable having a significant impact on mRSS change. For safety: in the oral group, there were more leukopenia (WBC Conclusions In this hypothesis generating study, similar efficacy of one year of oral and iv CYC were seen. In contrast, a different safety profile for AE time courses and types of AEs were seen in the two groups. Although significantly higher dosage of steroids at all visits and prevalence of DMARDs use were present in the IV CYC group (as a post-treatment maintenance), these did not have an impact on either safety or efficacy. Case-control or randomised studies are warranted to extend and confirm our data. Disclosure of Interest None declared

Background and Aims: All-oral interferon-free antivirals are highly effective in treating recurrent hepatitis C (HCV) infection in liver transplant (LT) recipients. The aim of the study was to assess immunosuppression needs after achieving a sustained viral response (SVR). Methods: We compared immunosuppression needs before and after achieving a SVR in adult LT recipients treated for recurrent HCV infection with all-oral direct acting agents. Results: We identified 52 liver LT treated recipients who achieved a SVR. The median (25th and 75th percentile interquartile range [IQR]) age was 62 years (57.75, 65). Most recipients received tacrolimus (TAC) for their immunosuppressant regimen. After achieving SVR, there was no statistically significant difference in daily dose of TAC unadjusted per weight (p > 0.05). However, there was a statistically significant decrease in daily dose of TAC adjusted per weight, serum levels of TAC, and the product of glomerular filtration rate and TAC. No statistically significant differences in cyclosporine unadjusted/adjusted per weight daily dose or serum levels were noted. Conclusions: Immunosuppression needs were increased for those patients treated with TAC but not cyclosporine. LT recipients prescribed TAC require close monitoring after treatment completion to avoid potential risk of acute rejection.

Patients on anticoagulation are at increased risk for intracranial hemorrhage (ICH) after trauma. This is important for geriatric trauma patients, who are increasing in number, frequently fall, and often take anticoagulants. This study sought to evaluate whether prehospital use of dabigatran, a newer anticoagulant, is associated with outcome differences in geriatric trauma patients suffering falls when compared with warfarin. The registry of a Level II community trauma center was used to identify 247 patients aged 65 and older who sustained a fall while taking prehospital dabigatran or warfarin admitted between December 2010 and March 2014. Patients on warfarin were included if their International Normalized Ratio was therapeutic (2–3). About 176 of the 247 patients were then compared using coarsened exact matching. In the matched analysis, overall population means for age, Glasgow Coma Score, and Injury Severity Score were 83.5, 14.7, and 5.1, respectively. The overall rate of ICH was 12.5 per cent, with a mortality rate of 16.1 per cent for patients who sustained an ICH. There were no observed differences in ICH, hospital length of stay, intensive care unit length of stay, or mortality between patients taking prehospital warfarin or dabigatran.

Small bowel obstruction (SBO) is commonly encountered by surgeons and has traditionally been handled via an open approach, especially when small bowel resection (SBR) is indicated, although recent series have shown improved outcomes with a laparoscopic approach. In this retrospective study, we sought to evaluate outcomes and identify risk factors for adverse events after emergency SBR for SBO with an emphasis on surgical approach.In this retrospective review using American College of Surgeons National Surgical Quality Improvement Program data, 1750 patients were identified who had emergency SBR with the principal diagnosis of SBO from 2006 to 2011. Mortality and postoperative adverse events were evaluated.Of 1750 patients who had emergency SBR, 51 (2.9%) had laparoscopic bowel resection (LBR). There was no difference in surgery duration (open bowel resection [OBR] versus LBR, 100 minutes versus 92 minutes; P=.38). Compared with the LBR group, the OBR group had a higher rate of baseline cardiac comorbidities and postoperative complications, and their length of stay was longer (10 versus 8 days; P.001). Using multivariate analysis, perioperative variables of age70 years, pulmonary, renal, neurological, and cardiac comorbidities, preoperative sepsis, steroid use, and body mass index of30 kg/m(2) were associated with increased odds of mortality. OBR was associated with overall increased odds of morbidity (2.8; P=.003) and postoperative wound (2.9; P=.018) and respiratory (6.5; P=.011) infections.LBR was associated with equivalent operative time, shorter length of stay, less morbidity, and equivalent mortality compared with OBR. Although therapy for SBO secondary to adhesive disease remains controversial, our study shows numerous benefits to the laparoscopic approach to SBOs and thus should be considered a first-line treatment option for the management of this common surgical problem.

OBJECTIVES:Our aim in this study was to understand usage patterns of pediatric palliative care (PPC) consultation and associations with end-of-life preparation among pediatric patients who are deceased.METHODS:We reviewed 233 pediatric mortalities. Data extraction from the electronic health record included determination of PPC consultation by using Current Procedural Terminology codes. Diagnoses were identified by International Classification of Disease codes and were classified into categories of life-threatening complex chronic conditions (LT-CCCs). Data analysis included Student’s t test, Wilcoxon rank test, Fisher’s exact test, χ2 test, and multivariable logistic regression.RESULTS:The overall PPC consultation rate for pediatric patients who subsequently died was 24%. A PPC consultation for patients admitted to the pediatric ward and PICU was more likely than for patients cared for in the NICU (31% vs 12%, P < .01) and was more likely for those with an LT-CCC (40% vs 10%, P < .01), particularly malignancy (65% vs 35%, P < .01). Also noted were increased completion of Physician Orders for Life-Sustaining Treatment forms (8 vs 0, P < .01) and increased documentation of mental health disorders (60% vs 40%, P = .02).CONCLUSIONS:Our findings suggest that PPC consultation for patients in the pediatric ward and PICU is more likely among patients with a greater number of LT-CCCs, and is associated with increased Physician Orders for Life-Sustaining Treatment preparation and documentation of mental health disorders. Patients at risk to not receive PPC consultation are those with acute illness and patients in the NICU.

Importance Late-onset Alzheimer disease (AD) is highly heritable. Genome-wide association studies have identified more than 20 AD risk genes. The precise mechanism through which many of these genes are associated with AD remains unknown. Objective To investigate the association of the top 20 AD risk variants with brain amyloidosis. Design, Setting, and Participants This study analyzed the genetic and florbetapir F 18 data from 322 cognitively normal control individuals, 496 individuals with mild cognitive impairment, and 159 individuals with AD dementia who had genome-wide association studies and 18 F-florbetapir positron emission tomographic data from the Alzheimer’s Disease Neuroimaging Initiative (ADNI), a prospective, observational, multisite tertiary center clinical and biomarker study. This ongoing study began in 2005. Main Outcomes and Measures The study tested the association of AD risk allele carrier status (exposure) with florbetapir mean standard uptake value ratio (outcome) using stepwise multivariable linear regression while controlling for age, sex, and apolipoprotein E e4 genotype. The study also reports on an exploratory 3-dimensional stepwise regression model using an unbiased voxelwise approach in Statistical Parametric Mapping 8 with cluster and significance thresholds at 50 voxels and uncorrected P Results This study included 977 participants (mean [SD] age, 74 [7.5] years; 535 [54.8%] male and 442 [45.2%] female) from the ADNI-1, ADNI-2, and ADNI–Grand Opportunity. The adenosine triphosphate–binding cassette subfamily A member 7 ( ABCA7 ) gene had the strongest association with amyloid deposition (χ 2 = 8.38, false discovery rate–corrected P ABCA7 in the asymptomatic and early symptomatic disease stages, suggesting an association with rapid amyloid accumulation. The fermitin family homolog 2 ( FERMT2 ) gene had a stage-dependent association with brain amyloidosis ( FERMT2 × diagnosis χ 2 = 3.53, false discovery rate–corrected P = .05), which was most pronounced in the mild cognitive impairment stage. Conclusions and Relevance This study found an association of several AD risk variants with brain amyloidosis. The data also suggest that AD genes might differentially regulate AD pathologic findings across the disease stages.

Background: Elderly patients, with considerable fall risk, are increasingly anticoagulated to prevent thromboembolic disease. We hypothesized that a policy of prophylactic fresh frozen plasma (FFP) infusion in patients having falls would reverse vitamin K antagonists (VKAs) and that reversal would decrease delayed intracranial hemorrhage (ICH). Methods: A retrospective review of patients with trauma admitted to a level 2 community trauma center was performed from January 2010 until November 2012. Inclusion criteria were: ground level fall (GLF) with suspected head trauma, on VKA, an international normalized ratio (INR) of >1.5, and a negative head computed tomography (CT). Patients were transfused with FFP to a goal INR of 1.5. Chi-square and logistic regression were performed. Results: A total of 194 patients met the criteria. In all, 43 (22%) patients were able to be REV, and 151 (78%) patients remained NREV. Unreversed patients were male and younger ( P < .05). There was no difference in mean FFP received. Unreversed patients had a higher initial INR of 3.0 compared to REV patients (2.5; P = .018). One patient developed a delayed ICH and belonged to the REV group. Conclusion: The incidence of delayed hemorrhage was 0.5%. A strategy of prophylactic FFP infusion was ineffective in VKA reversal. We recommend against prophylactic infusion of FFP during a period of observation for patients on VKA with suspected head trauma and a negative initial CT.

Background No objective measure is presently available to assess digital ulcer (DU) in SSc patients apart from “healed/non healed” and experience-based clinical judgment. Objectives The aim of the current study is to propose a composite DU clinical assessment score (DUCAS) and, to lend it, test its face validity by correlating it with commonly used disease related patient-reported outcomes (PROs) and physician evaluation. Methods SSc patients presenting at least one DU and attending the Rheumatology Wound Care Clinic of the Florence University Hospital or the London Royal Free Hospital were enrolled. Patients were assessed with HAQ-DI, Cochin scale, Visual analogic scale (VAS) for DU-related pain (DU_pain, 0–100 mm), patient VAS for global DU status (ptGDU, 0–100mm) and patient global assessment (PtGA, 0–100 mm) as PROs and physician VAS for DU status (phyGDU, 0–100mm). The DUCAS included 7 DU related variables selected by a committee of 8 SSc DU experts - they are outlined in figure 1. Each variable was weighted on a clinical basis and the DUCAS score was the sum of the values for the 7 variables (max=19.5). Spearman9s correlation tests were calculated for to examine face validity. A linear regression model with forward and backward stepwise analysis was used to determine the relationship of individual variables with the primary clinical parameter, phyGDU. Results 44 SSc patients (9 males, mean age 54,3±15,6 years, mean disease duration 9,9±5,8 years) were enrolled in the study. Mean phyGDU was 44,3±23mm, mean ptGDU was 54±30mm (Wilcoxon p=0.022, phyGDU VAS vs ptGDU) and mean DUCAS score was 4,2±2. Overall DUCAS showed significant positive correlations with all PROs, but when all the individual clinician and patient9s variables were modelled, only the overall DUCAS significantly predicted PhyGDU; after backwards stepwise analysis overall DUCAS and ptGDU best predicted PhyGDU, with an adjusted R2=0,437 and AIC=380,3 (Table 2). Conclusions DUCAS is a newly proposed clinical score for SSc related DU which has face validity and which may reflect DU status as judged by SSc experts. Further validation of this score will be undertaken. Acknowledgements Cosimo Bruni received a EULAR travel bursary to run this project in the UK. Disclosure of Interest None declared

With increasing life expectancy, the elderly are participating in recreational activities traditionally pursued by younger persons. Elderly patients have many reasons for worse outcomes after trauma, one of which may be the rising use of anticoagulant and/or antiplatelet medications. This study aimed to determine whether preinjury use of these agents yielded worse outcomes in geriatric patients injured during high-impact recreational activities. The National Trauma Data Bank was reviewed from 2007 to 2010 for patients ≥65 years admitted to Level I or II trauma centers with ICD-9 E-codes for specific mechanisms of injury. These included motorcycles, bicycles, snowmobiles, all-terrain vehicles, equestrian, water and alpine skiing, snowboarding, and others. Patients with preinjury bleeding disorder (BD), including warfarin and clopidogrel use, were compared with controls via a coarsened exact matching analysis. BD patients (294) were compared with 3929 controls. Although increased in BD patients, no significant mortality differences were observed in unmatched or matched analyses. BD patients yielded greater hospital length of stay (5 vs 4 days, P = 0.020) with increased odds of receiving five units or more of blood (7.0% vs 2.1%, odds ratio = 4.7, P0.001) and of deep vein thrombosis (7.6% vs 3.8%, odds ratio = 2.1, P = 0.018). Elderly patients with BD, including warfarin or clopidogrel use, do not seem to have significantly increased mortality after injury during specified recreational activities. BD patients had greater hospital length of stay, transfusion requirements, and deep vein thrombosis rates. These findings may inform counseling for those taking such medications as to the potential for adverse outcomes.

Every nurse leader is challenged to provide an infrastructure for patient care that facilitates the highest quality of patient care services, the adoption of innovative practices, and the satisfaction of caregivers. Nurses are expected to provide the best possible care to patients and their families in ways that are safe, respectful, timely, and appropriate, even if there is not a specific policy to support it-all within the scope of practice. The purpose of this article is to share an exemplar that illustrates an effective change dynamic as the framework for changing nursing practice. The exemplar describes a new approach for postmortem care that began with creative problem solving at the bedside and evolved to a nurse-led research study. Results from the study continue to be disseminated with the intention that the nursing intervention will become standard of care.

Angiotensin II type 1 receptor (AT1R)-antibody has been linked to poor allograft outcomes in adult kidney transplantation. However, its clinical consequences in children are unknown. To study this, we examined the relationship of AT1R-antibody with clinical outcomes, biopsy findings, inflammatory cytokines, and HLA donor specific antibodies (DSA) in a cohort of pediatric renal transplant recipients. Sixty-five patients were longitudinally monitored for AT1R-antibody, HLA DSA, IL-8, TNF-α, IL-1β, IFN-γ, IL-17, and IL-6, renal dysfunction, hypertension, rejection, and allograft loss during the first two years post transplantation. AT1R-antibody was positive in 38 of the 65 of children but was not associated with HLA DSA. AT1R-antibody was associated with renal allograft loss (odds ratio of 13.1 (95% confidence interval (1.48 – 1728)), the presence of glomerulitis or arteritis, and significantly higher TNF-α, IL-1β, and IL-8 levels, but not rejection or hypertension. AT1R-antibody was associated with significantly greater declines in eGFR in patients both with and without rejection. Furthermore, in patients without rejection, AT1R-antibody was a significant risk factor for worsening eGFR over the two year follow-up period. Thus, AT1R-antibody is associated with vascular inflammation in the allograft, progressive decline in eGFR, and allograft loss. AT1R-antibody and inflammatory cytokines may identify those at risk for renal vascular inflammation and lead to early biopsy and intervention in pediatric kidney transplantation.