Search

Patients are uniquely positioned to identify issues and to provide innovative solutions to problems impacting their care. Yet, patient engagement in quality improvement (QI) and health care governance remains limited and underexplored. In the Veterans Health Administration, the work of women's health managers (WHMs) includes engaging women veterans, a numerical minority with unique health care needs, in QI. We aimed to understand the extent to which WHMs engage women veterans along a continuum, highlight challenges to engagement, and identify potential strategies to facilitate multilevel patient engagement. Data were generated from a multisite evaluation to improve delivery of comprehensive women's health care in Veterans Health Administration primary care sites. We conducted 39 semistructured interviews with WHMs across 21 sites. Guided by Carman et al.'s patient engagement framework, we analyzed the interviews using rapid-qualitative and content analysis methods. When effectively engaged, women veterans were important champions and partners in QI activities to improve the structure and delivery of care. However, most WHMs engaged women veterans in mainly informal or passive ways—that is, solicited feedback through comment cards, surveys, focus groups, and townhall meetings—and did not report pursuing more in-depth or long-term forms of engagement. WHMs also identified a variety of facilitators and challenges to engaging women veterans in QI. There may be unanticipated benefits to health care policy from engaging patients in QI, especially for patients with unique health care needs who represent a minority within the health care system. However, managers require training and workflow integration of patient engagement tasks to increase their efficiency and allow for meaningful patient engagement. [ABSTRACT FROM AUTHOR]

Introduction Our objective was to use meta-analytic techniques to assess the strength of the overall relationship and role of potential moderators in the association between smoking and depression in adults. Methods Two popular health and social science databases (PubMed and PsycINFO) were systematically searched to identify studies which examined the association between adult smoking behavior and major depressive disorder (MDD) or depressive symptoms. A total of 85 relevant studies were selected for inclusion. Studies were analyzed using a linear mixed effects modeling package ("lme4" for R) and the Comprehensive Meta-Analysis program version 2. Results Multiple nested linear mixed-effects models were compared. The best fitting models were those that included only random study effects and smoking status. In cross-sectional studies, current smokers were more likely to be depressed than never smokers (OR=1.50, CI=1.39-1.60), and current smokers were more likely to be depressed than former smokers (OR=1.76, CI=1.48-2.09). The few available prospective studies, that used the requisite statistical adjustments, also showed smokers at baseline had greater odds of incident depression at follow-up than never smokers (OR=1.62, CI=1.10-2.40). Conclusions In cross-sectional studies, smoking was associated with a nearly two-fold increased risk of depression relative to both never smokers and former smokers. In the smaller set of prospective studies, the odds of subsequent depression were also higher for current than never smokers. Attesting to its robustness, the relationship between smoking and depression was exhibited across several moderators. Findings could help health care providers to more effectively anticipate co-occurring health issues of their patients. Several methodological recommendations for future research are offered. [ABSTRACT FROM AUTHOR]

Context: Approximately 22% of U.S. young adults (aged 18–24 years) are smokers. Young adults typically display an interest in quitting, but it is unknown whether the evidence-based cessation programs designed for adults will be equally effective for young adults. This meta-analysis investigated the efficacy of smoking-cessation programs for this population. Evidence acquisition: In 2009–2011, studies published between 2004 and 2008 that investigated smoking cessation were first found through the DHHS Clinical Practice Guidelines for Treating Tobacco Use and Dependence as well as a PubMed search (2009–2010) and were then subjected to a rigorous inclusion process. Authors were contacted to glean raw data for young adults. Fourteen studies provided data that were coded for descriptive information and aggregated using the Comprehensive Meta-Analysis, version 2.0. Evidence synthesis: Among young adults, any type of intervention was more effective in producing successful smoking cessation than the control. This was the case for intent-to-treat analyses as well as complete cases. When interventions were effective for the larger adult sample, they were also effective for the younger adult sample. Conclusions: Although young adults tend to underutilize evidence-based cessation treatments, the current meta-analysis showed that these treatments should be as effective for young adults as they are for the general adult population. Thus, it may be useful to focus on motivating young adults to seek cessation treatment to increase utilization. [ABSTRACT FROM AUTHOR]

Abstract: The extensive removal of competing broadleaved shrubs in forest plantations typically results in structural and compositional simplification of early seral habitat. However, information on the tradeoffs between such intensive forestry practices and biodiversity is scant. Here we assess the magnitude and direction of potential impacts of intensive forest management on populations of early seral-associated breeding birds. Observed population declines of several Neotropical migrant bird species are hypothesized to be linked to the loss of early seral habitat on the breeding grounds. We investigated the association between broadleaved hardwood cover and avian abundance and diversity in intensively managed early seral Douglas-fir (Pseudotsuga menziesii) stands of the Pacific Northwest. Bird species richness decreased across an elevational gradient, but did not vary as a function of either local vegetation composition or structure. In contrast, bird abundance was strongly associated with hardwood cover at local and landscape scales, especially for foliage-gleaning species. We found strong support for the existence of a threshold in relative bird abundance as a function of hardwood at the stand scale; abundance doubled with an increase from 1% to ∼6% hardwood and then reached a plateau. Though abundance of leaf-gleaners increased even more strongly across a gradient in hardwood cover, evidence for a distinct threshold was less clear. We conclude that when early seral hardwood forest is scarce, even small increases in hardwood may provide substantial conservation benefits. However, for some species (i.e., foliage gleaners), there may be more direct trade-offs in abundance and juvenile recruitment with hardwood management intensity. [Copyright &y& Elsevier]

Abstract: Studies investigating gender differences in human circadian rhythms report equivocal results. In addition, many of these studies have been limited to examination of one circadian variable. This study examined gender differences in circadian rhythms of multiple physiological variables of rhesus monkeys under highly controlled conditions. Under general anesthesia, eight female and seven male rhesus were implanted with a biotelemetry transmitter to measure body temperature (Tb) and heart rate. An external accelerometer was used to measure physical activity. The Psychomotor Task System (PTS) provided environmental enrichment and delivered a pelletized diet and water was available ad libitum. Data were collected continuously under LD 16:8 for a minimum of 31days. Mean, phase and amplitude of each rhythm were calculated and compared between genders. Although there were no significant differences between genders in mean or amplitude, circadian rhythms in females were significantly delayed compared to males in all variables (p range 0.001 to 0.030). The consistent pattern of delay suggests that a fundamental gender difference may be present in the circadian timing system. Mechanisms underlying this difference require further exploration. [Copyright &y& Elsevier]

Abstract: Previous studies have shown that VEGF expression in forebrain increases after experimental manipulations that increase neuronal activity. One question is whether this also occurs in motor neurons. If so, it could be potentially advantageous from a therapeutic perspective, because VEGF prevents motor neuron degeneration. Therefore, we asked whether endogenous VEGF expression in motor neurons could be modulated. We also asked how VEGF exposure would influence motor neurons using electrophysiology. Immunocytochemistry showed that motor neuron VEGF expression increased after a stimulus that increases neuronal and motor activity, i.e., convulsive seizures. The increase in VEGF immunoreactivity occurred in all motor neuron populations that were examined 24h later. This effect was unlikely to be due to seizure-induced toxicity, because silver degeneration stain did not show the typical appearance of a dying or dead neuron. To address the effects of VEGF on motor neuron function, VEGF was applied directly to motor neurons while recording intracellularly, using a brainstem slice preparation. Exposure to exogenous VEGF (200ng/ml) in normal conditions depressed stimulus-evoked depolarization of hypoglossal motor neurons. There was no detectable effect of VEGF on membrane properties or firing behavior. We suggest that VEGF is upregulated in neurons when they are strongly activated, and VEGF depresses neuronal excitation as a compensatory mechanism. Failure of this mechanism may contribute to diseases that involve a dysregulation of VEGF, excessive excitation of motor neurons, and motor neuron loss, such as amyotrophic lateral sclerosis (ALS). [Copyright &y& Elsevier]

Aim The National Kidney Registry (NKR) has reduced wait time for patients with incompatible donors. Utilizing Virtual crossmatch (vXM) to predict viable NKR donors with sensitized NKR recipients can expedite exploratory crossmatch (EXM) orders and place recipients in a chain swap sooner. Evaluating weak DSA will help clarify the need for an EXM or declining the donor. Methods vXM was done using patient HLA-Ab information and donor allelic level DSA. HLA-Ab assignment was performed by Luminex single antigen beads using EDTA treated patient serum. If clarification was needed, Phenotyping beads and/or Flow Single Antigen beads were tested. A vXM was done to evaluate need for an EXM to prevent swap failures and/or include recipients in a chain swap. EXM were executed using cryo-preserved cells. Due to limited cell yield only flow XM were done for EXM. Final XM were performed using T and B CDC and flow XM. Results At the Cleveland Clinic, cutoff for HLA-Ab reported to the NKR is > ̲ 4000 Mean Fluorescence Intensity (MFI). Seventy vXM were performed between January 2016 and March 2017. Twenty-eight vXM had weak (MFI = 1000–3999 MFI) DSA. EXM’s were suggested when weak DSA was observed in the vXM or for highly sensitized patients. Results of twenty-two EXM/screening XM (screening XM were the result of donor preselects) that were ordered showed seventeen cases had single DSA (CI = 9 CII = 8). These were predicted by vXM to be negative. This was 100% concordant to the EXM and final XM (Table 1A). Five cases had multiple DSA (CI = 2, CII = 2, CI & CII = 1), all predicted by vXM to be negative to weak positive. This was 100% concordant to the EXM and final XM (Table 1B). Conclusions vXM based on number and intensity of DSA was 100% concordant with EXM and Final XM. This assists in reliable donor selection for NKR recipients. vXM provides a quick evaluation of NKR donors for highly sensitized patients or patients with weak DSA. Reporting EXM quickly to the NKR reduces wait time and enables NKR recipients to become part of a successful chain swap. [ABSTRACT FROM AUTHOR]

Managers and leaders have a critical role to play in sexual and gender-based harassment prevention within organizations. Although the Veterans Health Administration has committed to eliminating harassment through national directives and training programs, it is unclear how aware local-level managers and leaders are about public harassment at their facilities and how they perceive sexual and gender-based harassment. We examined middle managers' and leaders' views about whether harassment is perceived as a problem locally, and what policies and procedures (if any) are in place to address public harassment. We conducted 69 semistructured telephone interviews with middle managers and facility leaders before implementation of an evidence-based quality improvement project designed to improve delivery of comprehensive women's health care. Transcripts were coded using the constant comparative method and analyzed for overarching themes. Perceptions of the prevalence of sexual and gender-based public harassment varied among middle managers and leaders. A little more than one-half of respondents were unaware of facility-level policies and procedures to address public harassment between patients. To decrease patient-to-patient harassment, both groups generally supported the creation of separate clinical spaces for women. However, middle managers also stated that education was needed to change patient harassing behavior, which they tied to male military culture. Aligning divergent perspectives of what constitutes sexual and gender-based harassment and how to address it is a necessary step towards tackling harassment at the local level. Managers and leaders should continue to assess environments of care and share findings widely among employees and leadership to improve awareness and inform a unified response. [ABSTRACT FROM AUTHOR]

One in four women veteran patients experience public harassment by men veterans at Veterans Affairs (VA) health care facilities. Bystander intervention training—teaching bystanders to identify harassment, assess appropriate responses, and safely intervene before, during, or after an event—is a popular strategy for addressing harassment in military and education settings. We explored staff and veteran patient perspectives on bystander intervention training to address harassment of women veterans in VA health care settings. We conducted 24 staff interviews and 15 veteran patient discussion groups (eight men's groups and seven women's groups) at four VA Medical Centers. We analyzed transcripts using the constant comparative method. Participants expressed divergent views about bystander intervention training to address harassment of women veteran patients at VA. Most participants supported training staff in bystander intervention, but support for training patients was mixed. Participants identified potential benefits of bystander intervention, including staff and patient empowerment and improvements to organizational culture. They also identified potential concerns, including provocation of conflict between patients, lack of buy-in among the VA community, and difficulty in identifying intervention-appropriate situations. Finally, participants offered recommendations for tailoring training content and format to the VA context. Bystander intervention training has the potential to raise collective responsibility for addressing harassment of women in VA and other health care contexts. However, our results illustrate divergent stakeholder views that underscore the importance of engaging and educating stakeholders, securing buy-in, and tailoring bystander intervention programs to local contexts before implementation. [ABSTRACT FROM AUTHOR]

Abstract: Background: Postural control deficits in individuals with Autism Spectrum Disorders (ASD) are widely acknowledged; however, the underlying biomechanical features of these deficits remain unknown. Nonlinear analyses provide insight into the nature of how movement is controlled and have the potential to provide new insight into the postural control abnormalities associated with ASD. The purpose of this study was to further investigate postural control deficits in children with ASD through linear and nonlinear analyses of center of pressure (COP) data. Methods: We evaluated COP data during quiet standing for 16 children with ASD and 17 age-matched typically developing (TD) children. The magnitude of COP fluctuations (COP ranges, velocity, and sway area) and complexity of postural control dynamics, quantified by multiscale entropy (MSE), were compared across groups. Results: Children with ASD displayed larger fluctuations in their COP data, observed in COP ranges (95.5% mediolaterally and 46.9% anteroposteriorly, p <0.05 respectively) and COP sway area (885%, p <0.05). Children with ASD also displayed less complexity in their COP data, observed in the MSE complexity index (C I) (32.4% mediolaterally and 35.7% anteroposteriorly, p <0.05 respectively). Conclusions: The present study successfully revealed that children with ASD have more repetitive patterns in their COP data, indicating a less complex control of posture, on multiple time scales, during quiet stance. These findings suggest a more regular or restricted control of posture and may be an initial step in linking postural instability to stereotypic behavior and the neurobiology of ASD. [Copyright &y& Elsevier]

Highlights from the article: Simultaneous liver and kidney transplantation (SLKT) is the best therapeutic option for HLA sensitized patients with end stage liver disease and renal failure. Reduction of pDSA at post-liver/pre-kidney transplantations and its impact on renal allograft function during post-operative SLKT were reviewed.