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Enhanced osteoclast-mediated bone resorption and diminished formation may promote bone loss. Pleckstrin homology (PH) domain and leucine-rich repeat protein phosphatase 1 (Phlpp1) regulates protein kinase C (PKC) and other proteins in the control of bone mass. Germline Phlpp1 deficiency reduces bone volume, but the mechanisms remain unknown. Here, we found that conditional Phlpp1 deletion in murine osteoclasts increases their numbers, but also enhances bone mass. Despite elevating osteoclasts, Phlpp1 deficiency did not increase serum markers of bone resorption, but elevated serum markers of bone formation. These results suggest that Phlpp1 suppresses osteoclast formation and production of paracrine factors controlling osteoblast activity. Phlpp1 deficiency elevated osteoclast numbers and size in ex vivo osteoclastogenesis assays, accompanied by enhanced expression of proto-oncogene C-Fms (C-Fms) and hyper-responsiveness to macrophage colony-stimulating factor (M-CSF) in bone marrow macrophages. Although Phlpp1 deficiency increased TRAP(+) cell numbers, it suppressed actin-ring formation and bone resorption in these assays. We observed that Phlpp1 deficiency increases activity of PKCζ, a PKC isoform controlling cell polarity, and that addition of a PKCζ pseudosubstrate restores osteoclastogenesis and bone resorption of Phlpp1-deficient osteoclasts. Moreover, Phlpp1 deficiency increased expression of the bone-coupling factor collagen triple helix repeat-containing 1 (Cthrc1). Conditioned growth medium derived from Phlpp1-deficient osteoclasts enhanced mineralization of ex vivo osteoblast cultures, an effect that was abrogated by Cthrc1 knockdown. In summary, Phlpp1 critically regulates osteoclast numbers, and Phlpp1 deficiency enhances bone mass despite higher osteoclast numbers because it apparently disrupts PKCζ activity, cell polarity, and bone resorption and increases secretion of bone-forming Cthrc1.

Purpose To review the medical literature on the outcomes and complications of various Food and Drug Administration-approved botulinum toxins for benign essential blepharospasm (BEB) and hemifacial spasm (HFS). Methods Literature searches were last conducted in February 2017 in PubMed for articles published in English and in the Cochrane Library database without language limitations; studies published before 2000 were excluded. The combined searches yielded 127 citations. Of these, 13 articles were deemed appropriate for inclusion in this assessment, and the panel methodologist assigned ratings to them according to the level of evidence. Results A combined total of 1523 patients (1143 with BEB and 380 with HFS) were included in the 13 studies. Five studies provided level I evidence, 2 studies provided level II evidence, and 6 studies provided level III evidence. Pretarsal injections were more efficacious than preseptal injections (96% vs. 86%, respectively). Pretarsal injections also resulted in a higher response rate on clinical scales ( P Conclusions Level I evidence supports the efficacy of Botox (Allergan Corp., Irvine, CA), Meditoxin, and Xeomin (Merz Pharmaceuticals, Frankfurt am Main, Germany) for the treatment of BEB. Meditoxin and Botox have equivalent effectiveness and incidence of adverse events for BEB and HFS. Dysport (Ipsen Biopharmaceuticals, Inc, Paris, France) seems to have efficacy similar to Botox and Meditoxin for BEB and HFS, but any definitive conclusions from the 2 level II studies in this review are limited by differences in the methodologies used. Higher doses of Botox and Dysport result in more adverse events. Repeated treatments using Botox seem to maintain efficacy for treatment of facial dystonias over a follow-up period of at least 10 years, based on level III evidence.

Purpose To review the literature to determine the efficacy of available treatments for ocular adnexal lymphoma (OAL) and to evaluate the outcomes and complications of treatments in patients older than 13 years. Methods A literature search was conducted last in March 2017 in the PubMed and Cochrane Library databases for English-language original research investigations that evaluated treatment outcomes for OAL. The searches identified 307 unique citations, and 27 studies were selected according to the criteria outlined for this assessment. Results The 27 studies reviewed comprised 2009 patients. Seventy-five percent of the cases reported were extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT). Twenty-five studies reported results using radiotherapy with or without chemotherapy or surgery. The local control rate of MALT lymphomas with treatments involving radiotherapy averaged 95.9%. Distant and local relapses can occur, and in studies reporting only on MALT lymphomas (884 patients), the 5-year and 10-year disease-free survival rates were reported to be 86.4% and 78.7%, respectively. However, overall survival in patients receiving radiotherapy remained very good, with the 5-year and 10-year survival rates reported to be 93.8% and 84.9%, respectively. Studies that included data on multiple histologic subtypes of lymphoma or non-MALT lymphomas (988 patients) reported local control rates to be 93.1%; 5-year and 10-year disease-free survival rates to be 75.7% and 71.0%, respectively; and 5-year and 10-year overall survival rates to be 78.9% and 73.5%, respectively. Studies on the use of doxycycline for MALT lymphomas (137 patients) reported complete responses of between 4.4% and 13%. Complete and partial responses combined were between 26.7% and 65%. Disease-free survival was not reported for these 2 studies, although progression-free survival was reported to be between 55% and 60.9%. The most frequently reported complications of treatment were cataracts (12.1%) and dry eye (8.5%). Conclusions For MALT lymphomas, local control, disease-free survival, and overall survival are good with radiation treatment. The results of treatment of non-MALT lymphomas using radiotherapy also were good, but they were not as favorable as the treatment results of MALT lymphomas.

Objective The pleckstrin homology domain leucine-rich repeat protein phosphatases (Phlpp1/2) were recently identified as potential therapeutic targets for cartilage regeneration in osteoarthritic joints. Phlpp inhibitors NSC 117079 and NSC 45586 increase chondrocyte proliferation and matrix production, but the pharmacodynamics and pharmacokinetics of these compounds are not known. Design Chondrocytic effects of Phlpp inhibitors, NSC 117079 and NSC 45586, were measured by western blotting of Phlpp substrates, glycosaminoglycan (GAG) assays, and transcriptomic assays. Liquid chromatography/mass spectroscopy assays were established to measure NSC 117079 and NSC 45586 in vitro and in vivo. The effects of NSC 117079 and NSC 45586 on articular cartilage structure in vivo after intra-articular injection were determined by histology. Results The Phlpp inhibitors NSC 117079 and NSC 45586 were highly stable in vitro and stimulated GAG, Sox9, proteoglycan 4 and collagen 2 production in maturing but not more differentiated chondrocytes in vitro. Both molecules reduced Phlpp1/2 levels and suppressed matrix degradation to functionally extend their inhibitory effect on these phosphatases. In vivo, NSC 117079 was eliminated from the bloodstream within 4 ​h after intravenous injection, while NSC 45586 was eliminated in 8 ​h and had a higher volume distribution. Both molecules increased articular cartilage area on lateral and medial tibial plateaus and femoral condyles by 15% in C57Bl/6 mice between four and five weeks of age. Conclusion These data advance our understanding of how Phlpp inhibitors promote and preserve cartilage formation and provide a basis for understanding their safety and activity in vivo.

Maintenance of optimal bone mass is controlled through the concerted functions of several cell types, including bone resorbing osteoclasts. Osteoclasts function to remove calcified tissue during developmental bone modeling, and degrade bone at sites of damage during bone remodeling. Changes to bone homeostasis can arise with alterations in osteoclastogenesis and/or catabolic activity that are not offset by anabolic activity; thus, factors that regulate osteoclastogenesis and bone resorption are of interest to further our understanding of basic bone biology, and as potential targets for therapeutic intervention. Several key cytokines, including Rankl and M-csf, as well as co-stimulatory factors elicit kinase signaling cascades that promote osteoclastogenesis. These kinase cascades are offset by the action of protein phosphatases, including members of the serine/threonine phosphatase family. Here we review the functions of serine/threonine phosphatases and their control of osteoclast differentiation and function, while highlighting deficiencies in our understanding of this understudied class of proteins within the field.

Summary Objective Osteoarthritis (OA) is the most common form of arthritis and a leading cause of disability. OA is characterized by articular chondrocyte deterioration, subchondral bone changes and debilitating pain. One strategy to promote cartilage regeneration and repair is to accelerate proliferation and matrix production of articular chondrocytes. We previously reported that the protein phosphatase Phlpp1 controls chondrocyte differentiation by regulating the activities of anabolic kinases. Here we examined the role of Phlpp1 in OA progression in a murine model. We also assessed PHLPP1 expression and promoter methylation. Design Knee joints of WT and Phlpp1 −/− mice were surgically destabilized by transection of the medial meniscal ligament (DMM). Mice were assessed for signs of OA progression via radiographic and histological analyses, and pain assessment for mechanical hypersensitivity using the von Frey assay. Methylation of the PHLPP1 promoter and PHLPP1 expression were evaluated in human articular cartilage and chondrocyte cell lines. Results Following DMM surgeries, Phlpp1 deficient mice showed fewer signs of OA and cartilage degeneration. Mechanical allodynia associated with DMM surgeries was also attenuated in Phlpp1 −/− mice. PHLPP1 was highly expressed in human articular cartilage from OA patients, but was undetectable in cartilage specimens from femoral neck fractures (FNFxs). Higher PHLPP1 levels correlated with less PHLPP1 promoter CpG methylation in cartilage from OA patients. Blocking cytosine methylation or treatment with inflammatory mediators enhanced PHLPP1 expression in human chondrocyte cell lines. Conclusion Phlpp1 deficiency protects against OA progression while CpG demethylation and inflammatory cytokines promote PHLPP1 expression.

Objective To review the existing medical literature on the role of oral antibiotics in the management of ocular surface disease (OSD) that arises from disorders of the meibomian glands and to assess the efficacy of oral antibiotics in the management of this common ocular disease. Methods A literature search was last conducted on August 12, 2015, in the PubMed and Cochrane databases for English-language original research investigations that evaluated the role of doxycycline, minocycline, and azithromycin in OSD among adult patients. The searches identified 87 articles, and 8 studies ultimately met the criteria outlined for this assessment. Results The 8 studies identified in the search documented an improvement in meibomian gland-related OSD after treatment with these agents, although side effects were common. This search identified only 1 randomized, controlled trial to assess the efficacy of these medications. Conclusions Although oral antibiotics are used commonly in the management of OSD, there is no level I evidence to support their use. There are only a few studies that have assessed the efficacy of oral antibiotics in clinically meaningful ways in the management of OSD that arises from disorders of the meibomian glands. The current level of evidence is insufficient to conclude that antibiotics are useful in managing OSD arising from disorders of the meibomian glands. The few existing studies on the topic indicate that oral antibiotics may be an effective treatment for OSD that results from meibomian gland disease.

To examine contemporary trends in end-of-life cancer care and geographic variation of end-of-life care aggressiveness among Medicare beneficiaries.Using the Surveillance, Epidemiology, and End Results-Medicare data, we identified 132,051 beneficiaries who died as a result of cancer in 2006-2011. Aggressiveness of end-of-life care was measured by chemotherapy received within 14 days of death,1 emergency department (ED) visit within 30 days of death,1 hospitalization within 30 days of death, ≥1 intensive care unit (ICU) admission within 30 days of death, in-hospital death, or hospice enrollment ≤3 days before death. Using hierarchical generalized linear models, we assessed potentially aggressive end-of-life care adjusting for patient demographics, tumor characteristics, and hospital referral region (HRR)-level market factors.The proportion of beneficiaries receiving at least one potentially aggressive end-of-life intervention increased from 48.6% in 2006 to 50.5% in 2011 (P.001). From 2006 to 2011, increases were apparent in repeated hospitalization (14.1% vs. 14.8%; P=.01), repeated ED visits (34.3% vs. 36.6%; P.001), ICU admissions (16.2% vs. 21.3%; P.001), and late hospice enrollment (11.2% vs. 12.9%; P.001), whereas in-hospital death declined (23.5% vs. 20.9%; P.001). End-of-life chemotherapy use (4.4% vs. 4.5%) did not change significantly over time (P=.12). The use of potentially aggressive end-of-life care varied substantially across HRRs, ranging from 40.3% to 58.3%. Few HRRs had a decrease in aggressive end-of-life care during the study period.Despite growing focus on providing appropriate end-of-life care, there has not been an improvement in aggressive end-of-life cancer care in the Medicare program.

Grants and services provided by the government may crowd out informal arrangements, thus weakening informal caring relations and networks. In this paper, we examine the impact of social security expansion on neighborhood cohesion of elders using China’s New Rural Pension Scheme (NRPS), one of the largest existing pension program in the world. Since its launch in 2009, more than 400 million Chinese have enrolled in NRPS. We use two waves of China Health and Retirement Longitudinal Study (CHARLS) to examine the effect of pension receipt on two dimensions of neighborhood cohesion among older adults, i.e. participation in collective recreational activities (e.g., socializing and organizational activities) and altruistic activities (e.g., helping those in need in the community), and the frequencies of these activities. Employing an instrumental variable approach, our empirical strategy addresses the endogeneity of pension receipt via exploiting geographic variation in pension program roll-out. We find evidence that receiving pension only slightly reduces collective recreational activities while significantly crowding out altruistic activities in the communities.

Objective To review the published literature assessing the efficacy and safety of lacrimal drainage system plug insertion for dry eye in adults. Methods Literature searches of the PubMed and Cochrane Library databases were last conducted on March 9, 2015, without date restrictions and were limited to English language abstracts. The searches retrieved 309 unique citations. The primary authors reviewed the titles and abstracts. Inclusion criteria specified reports that provided original data on plugs for the treatment of dry eyes in at least 25 patients. Fifty-three studies of potential relevance were assigned to full-text review. The 27 studies that met the inclusion criteria underwent data abstraction by the panels. Abstracted data included study characteristics, patient characteristics, plug type, insertion technique, treatment response, and safety information. All studies were observational and rated by a methodologist as level II or III evidence. Results The plugs included punctal, intracanalicular, and dissolving types. Fifteen studies reported metrics of improvement in dry eye symptoms, ocular-surface status, artificial tear use, contact lens comfort, and tear break-up time. Twenty-five studies included safety data. Plug placement resulted in ≥50% improvement of symptoms, improvement in ocular-surface health, reduction in artificial tear use, and improved contact lens comfort in patients with dry eye. Serious complications from plugs were infrequent. Plug loss was the most commonly reported problem with punctal plugs, occurring on average in 40% of patients. Overall, among all plug types, approximately 9% of patients experienced epiphora and 10% required removal because of irritation from the plugs. Canaliculitis was the most commonly reported problem for intracanalicular plugs and occurred in approximately 8% of patients. Other complications were reported in less than 4% of patients on average and included tearing, discomfort, pyogenic granuloma, and dacryocystitis. Conclusions On the basis of level II and III evidence in these studies, plugs improve the signs and symptoms of moderate dry eye that are not improved with topical lubrication, and they are well tolerated. There are no level I studies that describe the efficacy or safety of lacrimal drainage system plugs.

Objective To describe patient preferences regarding payment for blepharoplasty and blepharoptosis repair and physician practices before and after the 2009 change in reimbursement for these 2 procedures by the Centers for Medicare and Medicaid Services (CMS). Design Cross-sectional study. Participants Fifty patients presenting for functional blepharoplasty and blepharoptosis repair at an academic oculoplastic practice and 198 members of the American Society of Ophthalmic Plastic and Reconstructive Surgery. Methods A 5-question paper survey was administered to patients, and a 5-question web-based survey was distributed to 510 unique physician e-mail addresses obtained from the American Society of Ophthalmic Plastic and Reconstructive Surgery mailing list server in 2010. Main Outcome Measures The surveys elicited patient knowledge and attitudes regarding the reimbursement policy of the CMS and physician knowledge and behaviors before and after the reimbursement policy change. Results Ninety-one percent of patients would be opposed to having to pay out of pocket for blepharoplasty or having to wait at least 3 months after ptosis repair to have a blepharoplasty. When asked to choose between these options, 62% of the patients would rather have the 2 surgeries performed separately than pay out-of-pocket. Before the reimbursement policy change by the CMS, 77% of oculoplastic surgeons performed blepharoplasty and blepharoptosis repair in the same sitting, whereas 37% did so after the policy change ( P P P = 0.009). Conclusions Our study suggests that oculoplastic surgeons have made a change in the delivery of ptosis and blepharoplasty surgical services after the reimbursement policy change for these procedures by the CMS in 2009. This change, in which patients undergo separate surgical visits for ptosis repair and blepharoplasty, is not desirable to most patients.

Purpose: This report describes accelerated visual recovery in a child following protracted hypoxic cortical visual loss and reviews mechanisms responsible for visual recovery. Observations: A 12-year-old boy developed cortical blindness after a severe snowboarding crash. Magnetic resonance imaging showed severe multifocal hypoxic brain injury, with multifocal restricted diffusion and extensive T2/FLAIR hyperintensities throughout the visual cortex, basal ganglia and midbrain. The mismatch of affected areas on FLAIR and DWI sequences indicated a combination of cytotoxic and vasogenic edema, which suggested partial reversibility with potential for recovery. Two weeks after his injury, he began to experience an accelerated improvement in vision with recovery of 20/20 visual acuity and 40 sec/arc stereoacuity over the following week. Three months later, visual field examination showed a steep-margined horizontal band of spared visual field, which showed further expansion on repeat testing 1 year later. Conclusions and importance: Protracted hypoxic cortical visual loss can be followed by dramatic visual recovery in children. Magnetic resonance imaging can provide useful prognostic information. Keywords: Cortical blindness, Hypoxic brain injury, Visual recovery

Study objective Evidence suggests that active collaboration between hospitals and emergency medical services (EMS) is significantly associated with lower acute myocardial infarction mortality rates; however, the nature of such collaborations is not well understood. We seek to characterize views of key hospital staff about collaboration with EMS in the care of patients hospitalized with acute myocardial infarction. Methods We performed an exploratory analysis of qualitative data previously collected from site visits and detailed interviews with 11 US hospitals that ranked in the top or bottom 5% of performance on 30-day risk-standardized acute myocardial infarction mortality rates, using Centers for Medicare & Medicaid Services data from 2005 to 2007. We selected all codes from the previous analysis in which EMS was most likely to have been discussed. A multidisciplinary team analyzed the data with the constant comparative method to generate recurrent themes. Results Both higher- and lower-performing hospitals reported that EMS is critical to the provision of timely care for patients with acute myocardial infarction. However, close collaborative relationships with EMS were more apparent in the higher-performing hospitals, which demonstrated specific investment in and attention to EMS through respect for EMS as valued professionals and colleagues, strong communication and coordination with EMS and active engagement of EMS in hospital acute myocardial infarction quality improvement efforts. Conclusion Hospital staff from higher-performing hospitals described broad, multifaceted strategies to support collaboration with EMS in providing acute myocardial infarction care. The association of these strategies with hospital performance should be tested quantitatively in a larger representative study.

Histone deacetylase 3 (Hdac3) is a nuclear enzyme that removes acetyl groups from lysine residues in histones and other proteins to epigenetically regulate gene expression. Hdac3 interacts with bone-related transcription factors and co-factors such as Runx2 and Zfp521, and thus is poised to play a key role in the skeletal system. To understand the role of Hdac3 in osteoblasts and osteocytes, Hdac3 conditional knockout (CKO) mice were created with the osteocalcin (OCN) promoter driving Cre expression. Hdac3 CKO(OCN) mice were of normal size and weight, but progressively lost trabecular and cortical bone mass with age. The Hdac3 CKO(OCN) mice exhibited reduced cortical bone mineralization and material properties and suffered frequent fractures. Bone resorption was lower, not higher, in the Hdac3 CKO(OCN) mice, suggesting that primary defects in osteoblasts caused the reduced bone mass. Indeed, reductions in bone formation were observed. Osteoblasts and osteocytes from Hdac3 CKO(OCN) mice showed increased DNA damage and reduced functional activity in vivo and in vitro. Thus, Hdac3 expression in osteoblasts and osteocytes is essential for bone maintenance during aging.

Breastfeeding (BF) promotion is one of the most cost-effective interventions to advance mother–child health. Evidence-based frameworks and models to promote the effective scale up and sustainability of BF programs are still lacking. A systematic review of peer-reviewed and gray literature reports was conducted to identify key barriers and facilitators for scale up of BF programs in low- and middle-income countries. The review identified BF programs located in 28 countries in Africa, Latin America and the Caribbean, and Asia. Study designs included case studies, qualitative studies, and observational quantitative studies. Only 1 randomized, controlled trial was identified. A total of 22 enabling factors and 15 barriers were mapped into a scale-up framework termed “AIDED” that was used to build the parsimonious breastfeeding gear model (BFGM). Analogous to a well-oiled engine, the BFGM indicates the need for several key “gears” to be working in synchrony and coordination. Evidence-based advocacy is needed to generate the necessary political will to enact legislation and policies to protect, promote, and support BF at the hospital and community levels. This political-policy axis in turn drives the resources needed to support workforce development, program delivery, and promotion. Research and evaluation are needed to sustain the decentralized program coordination “gear” required for goal setting and system feedback. The BFGM helps explain the different levels of performance in national BF outcomes in Mexico and Brazil. Empirical research is recommended to further test the usefulness of the AIDED framework and BFGM for global scaling up of BF programs.

Objectives This study sought to determine the range and prevalence of practices being implemented by hospitals to reduce 30-day readmissions of patients with heart failure or acute myocardial infarction (AMI). Background Readmissions of patients with heart failure or AMI are both common and costly; however, evidence on strategies adopted by hospitals to reduce readmission rates is limited. Methods We used a Web-based survey to conduct a cross-sectional study of hospitals' reported use of specific practices to reduce readmissions for patients with heart failure or AMI. We contacted all hospitals enrolled in the Hospital to Home (H2H) quality improvement initiative as of July 2010. Of 594 hospitals, 537 completed the survey (response rate of 90.4%). We used standard frequency analysis to describe the prevalence of key hospital practices in the areas of: 1) quality improvement resources and performance monitoring; 2) medication management efforts; and 3) discharge and follow-up processes. Results Nearly 90% of hospitals agreed or strongly agreed that they had a written objective of reducing preventable readmission for patients with heart failure or AMI. More hospitals reported having quality improvement teams to reduce preventable readmissions for patients with heart failure (87%) than for patients with AMI (54%). Less than one-half (49.3%) of hospitals had partnered with community physicians and only 23.5% had partnered with local hospitals to manage patients at high risk for readmissions. Inpatient and outpatient prescription records were electronically linked usually or always in 28.9% of hospitals, and the discharge summary was always sent directly to the patient's primary medical doctor in only 25.5% of hospitals. On average, hospitals used 4.8 of 10 key practices; Conclusions Although most hospitals have a written objective of reducing preventable readmissions of patients with heart failure or AMI, the implementation of recommended practices varied widely. More evidence establishing the effectiveness of various practices is needed.

Objective To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results. Methods Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis. Results The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Muller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty. Conclusions Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD 1 ) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Context Self-management involves behaviors that individuals perform to handle health conditions. Self-management may be particularly challenging during transitions—shifts from one life phase or status to another, for example, from cure- to noncure-oriented care—because they can be disruptive and stressful. Little is known about individuals' experiences with self-management, especially during transitions. Objectives Our purpose was to describe experiences of self-management in the context of transitions among women with advanced breast cancer. Methods We interviewed a purposive sample of 15 women with metastatic breast cancer about their self-management preferences, practices, and experiences, including how they managed transitions. Interviews were recorded and transcribed. The qualitative method of interpretive description was used to code and analyze the data. Results Participants' mean age was 52 years (range 37–91 years); most were White (80%), married (80%), and college educated (60%). Self-management practices related to womens' health and to communication with loved ones and providers. Participants expressed a range of preferences for participation in self-management. Self-management included developing skills, becoming empowered, and creating supportive networks. Barriers to self-management included symptom distress, difficulty obtaining information, and lack of knowledge about the cancer trajectory. Women identified transitions as shifts in physical, emotional, and social well-being, as when their cancer progressed and there was a need to change therapy. Transitions often prompted changes in how actively women self-managed and were experienced as positive, negative, and neutral. Conclusion Self-management preferences can vary. Providers should explore and revisit patients' preferences and ability to self-manage over time, particularly during transitions.

There has been increasing attention paid to quality assessment in hospice as the industry has grown and diversified. In response, policymakers have called for standardized approaches to monitoring hospice quality. The experiences of a set of hospices involved with the National Association for Home CareHospice (NAHC) Quality Assessment and Performance Improvement Collaborative, which was designed to test the use of a standardized patient symptom assessment tool as an exemplar of efforts to standardize symptom assessment in hospice, were examined.Transcripts of semistructured telephone interviews with 24 individuals from eight of the nine participating hospices, which were conducted in July-August 2007, were analyzed using the constant comparative method. Interview questions centered on the collaborative's impact on the process of quality assessment at the hospices.The collaborative activities influenced several hospices' quality assessment processes, most beneficially by prompting greater attention to quality assessment processes, by promoting the adoption of quality assessment tools, and by creating a supportive community. Challenges included the limits of distance communication technology, participants' misconceptions about data to be received, and potential lack of support and resources for quality assessment.The experiences of the participating hospices in the NAHC collaborative are intended to inform the design of future interorganizational learning efforts to promote quality assessment initiatives within hospice settings. Future hospice collaboratives should use multiple methods of communication to build a close participant network and be clear about collaborative goals and participant expectations and about the reciprocal relationship of the collaborative and the participants.

Study objective Prolonged emergency department (ED) wait time and length of visit reduce quality of care and increase adverse events. Previous studies have not examined hospital-level performance on ED wait time and visit length in the United States. The purpose of this study is to describe hospital-level performance on ED wait time and visit length. Methods We conducted a retrospective cross-sectional study of a stratified random sampling of 35,849 patient visits to 364 nonfederal US hospital EDs in 2006, weighted to represent 119,191,528 visits to 4,654 EDs. Measures included EDs' median wait times and visit lengths, EDs' median proportion of patients treated by a physician within the time recommended at triage, and EDs' median proportion of patients dispositioned within 4 or 6 hours. Results In the median ED, 78% (interquartile range [IQR], 63% to 90%) of all patients and 67% (IQR, 52% to 82%) of patients who were triaged to be treated within 1 hour were treated by a physician within the target triage time. A total of 31% of EDs achieved the triage target for more than 90% of their patients; 14% of EDs achieved the triage target for 90% or more of patients triaged to be treated within an hour. In the median ED, 76% (IQR 54% to 94%) of patients were admitted within 6 hours. A total of 48% of EDs admitted more than 90% of their patients within 6 hours, but only 25% of EDs admitted more than 90% of their patients within 4 hours. Conclusion A minority of hospitals consistently achieved recommended wait times for all ED patients, and fewer than half of hospitals consistently admitted their ED patients within 6 hours.

Background Previous research has suggested that comprehensive teenage pregnancy prevention programs that address sexual education and life skills development and provide academic support are effective in reducing births among enrolled teenagers. However, there have been limited data on the costs and cost effectiveness of such programs. Purpose The study used a community-based participatory research approach to develop estimates of the cost–benefit of the Pathways/Senderos Center, a comprehensive neighborhood-based program to prevent unintended pregnancies and promote positive development for adolescents. Methods Using data from 1997–2003, an in-time intervention analysis was conducted to determine program cost–benefit while teenagers were enrolled; an extrapolation analysis was then used to estimate accrued economic benefits and cost–benefit up to age 30 years. Results The program operating costs totaled $3,228,152.59 and reduced the teenage childbearing rate from 94.10 to 40.00 per 1000 teenage girls, averting $52,297.84 in total societal costs, with an economic benefit to society from program participation of $2,673,153.11. Therefore, total costs to society exceeded economic benefits by $559,677.05, or $1599.08 per adolescent per year. In an extrapolation analysis, benefits to society exceed costs by $10,474.77 per adolescent per year by age 30 years on average, with social benefits outweighing total social costs by age 20.1 years. Conclusions This comprehensive teenage pregnancy prevention program is estimated to provide societal economic benefits once participants are young adults, suggesting the need to expand beyond pilot demonstrations and evaluate the long-range cost effectiveness of similarly comprehensive programs when they are implemented more widely in high-risk neighborhoods.

The Door-to-Balloon (D2B) Alliance is a collaborative effort of more than 900 hospitals aimed at improving D2B times for ST-segment elevation myocardial infarction. Although such collaborative efforts are increasingly used to promote improvement, little is known about the types of health care organizations that enroll and their motivations to participate.To examine the types of hospitals enrolled and reasons for enrollment, a cross-sectional study was conducted of 915 D2B Alliance hospitals and 654 hospitals that did not join the D2B Alliance. Data were obtained from the American Hospital Association's Annual Survey of Hospitals and a Web-based survey completed by 797 enrolled hospitals (response rate, 87%). Chi-square statistics were used to examine statistical associations, and qualitative data analysis was used to characterize reported reasons for enrolling.Hospitals that enrolled in the D2B Alliance were significantly (p values.05) more likely to be larger, nonprofit (versus for-profit), and teaching (versus nonteaching) hospitals. Earlier- versus later-enrolling hospitals were more likely to have key recommended strategies already in place at the time of enrollment. Improving quality and "doing the right thing" were commonly reported reasons for enrolling; however, hospitals also reported improving market share, meeting regulatory and accreditation requirements, and enhancing reputation as primary reasons for joining.The findings highlight the underlying goals of organizations to improve their position in the external environment--including economic, regulatory, accreditation, and professional environments. Designing quality improvement collaborative efforts to appeal to these goals may be an important strategy for enhancing participation and, in turn, increasing the uptake of evidence-based innovations.

Hand hygiene is considered one of the most important infection control measures for preventing healthcare-associated infections. However, compliance rates with recommended hand hygiene practices in hospitals remain low. Previous literature on ways to improve hand hygiene practices has focused on the USA and Europe, whereas studies from developing countries are less common. In this study, we sought to identify common issues and potential strategies for improving hand hygiene practices in hospitals in China. We used a qualitative survey design based on in-depth interviews with 25 key hospital and public health staff in eight hospitals selected by the Chinese Ministry of Health. We found that hospital workers viewed hand hygiene as paramount to effective infection control and had adequate knowledge about proper hand hygiene practices. Despite these positive attitudes and adequate knowledge, critical challenges to improving rates of proper hand hygiene practices were identified. These included lack of needed resources, limited organisational authority of hospital infection control departments, and ineffective use of data monitoring and feedback to motivate improvements. Our study suggests that a pivotal issue for improving hand hygiene practice in China is providing infection control departments adequate attention, priority, and influence within the hospital, with a clear line of authority to senior management. Elevating the place of infection control on the hospital organisational chart and changing the paradigm of surveillance to continuous monitoring and effective data feedback are central to achieving improved hand hygiene practices and quality of care.

We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time.Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals asor =1 hour,1-2 hours,2-3 hours, etc, up to11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time.In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P.0001 for linear trend). For patients presentingor =1 hour,1-2 hours,2-3 hours,9-10 hours,10-11 hours, and11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively.Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times.

Determining the underlying mechanisms of macrophage colony-stimulating factor (M-CSF)-mediated osteoclast survival may be important in identifying novel approaches for treating excessive bone loss. This study investigates M-CSF-mediated MEK/ERK activation and identifies a downstream effector of this pathway. M-CSF activates MEK/ERK and induces MEK-dependent expression of the immediate early gene Egr2. Inhibition of either MEK1/2 or inhibition of Egr2 increases osteoclast apoptosis. In contrast, wild-type Egr2 or an Egr2 point mutant unable to bind the endogenous repressors Nab1/2 (caEgr2) suppresses basal osteoclast apoptosis and rescues osteoclasts from apoptosis induced by MEK1/2 or Egr2 inhibition. Mechanistically, Egr2 induces pro-survival Blc2 family member Mcl1 while stimulating proteasome-mediated degradation of pro-apoptotic Bim. In addition, Egr2 increased the expression of c-Cbl, the E3 ubiquitin ligase that catalyzes Bim ubiquitination. M-CSF, therefore, promotes osteoclast survival through MEK/ERK-dependent induction of Egr2 to control the Mcl1/Bim ratio, documenting a novel function of Egr2 in promoting survival.

Objective To investigate whether orbital radiation offers effective and safe treatment for Graves ophthalmopathy. Methods Medical literature databases were searched to identify all published reports relating to orbital radiation treatment for Graves ophthalmopathy. To be included in the technology assessment, reports had to provide original data, to report on a case series or uncontrolled trial of at least 100 subjects or a randomized clinical trial of any size, to focus on orbital radiation for the treatment of Graves ophthalmopathy, and to follow-up patients for at least 3 months. Abstracted data included study characteristics, patient characteristics, treatment response, and safety information. Results Fourteen studies were included in the technology assessment: 5 observational studies and 9 randomized controlled trials. Three of the observational studies report on treatment response, with overall favorable outcomes for 40% to 97% of patients. Three of the observational studies provided intermediate-term safety data. The risk of definite radiation retinopathy is 1% to 2% within 10 years after treatment. Patients treated with orbital radiation did not have an increased risk of secondary malignancy or premature death. The 9 randomized trials were qualitatively heterogeneous. Patients with optic neuropathy generally were excluded from participating in the randomized trials. Three of the randomized trials were sham controlled. None of these studies showed that orbital radiation was more efficacious than sham irradiation for improving proptosis, lid fissure, or soft tissue changes such as eyelid swelling. Two of the 3 sham-controlled randomized trials demonstrated improved vertical range of motion in radiation-treated subjects compared with controls. Conclusions Systematic review of the effect of orbital radiation on Graves ophthalmopathy is limited by the lack of standardization and variable quality of published reports. Extraocular motility impairment may improve with radiotherapy, although the evidence of a treatment effect is mixed in clinical trials. Future studies are needed to determine if a potentially beneficial motility effect results in improved patient function and quality of life. Level I evidence indicates that proptosis, eyelid retraction, and soft tissue changes do not improve with radiation treatment. The efficacy of orbital radiation for compressive optic neuropathy resulting from Graves ophthalmopathy has not been investigated in clinical trials and merits further study. Radiation retinopathy, although rare, is a risk of orbital radiation, even in patients without diabetes who receive appropriate radiation dose and delivery.

Objectives We sought to describe the rationale and methods for Door-to-Balloon (D2B): An Alliance for Quality, an international effort organized by the American College of Cardiology in partnership with the American Heart Association and 37 other organizations to rapidly translate research about how best to achieve outstanding D2B times for patients with ST-segment elevation myocardial infarction (STEMI) into practice. Background The D2B time, the time between hospital arrival and primary percutaneous coronary intervention for patients with STEMI, is strongly associated with the likelihood of survival, yet the majority of patients are not treated within the guideline-recommended time of ≤90 min. Recent research has revealed key and underused strategies that are associated with achieving faster D2B times. Methods The D2B Alliance has enrolled approximately 1,000 hospitals. Its goal is to achieve a D2B time of ≤90 min for at least 75% of non-transferred patients. The key strategies chosen by the D2B Alliance include having the emergency medicine physician activate the catheterization laboratory with a single call, having the team prepared within 20 to 30 min of the call; rapid data feedback; a team-based approach; and administrative support. The use of a pre-hospital electrocardiogram by emergency medical services personnel to activate the catheterization laboratory was also noted as an additional optional strategy. The project has many approaches to promote participation and adoption of effective strategies. An evaluation component is also described. Conclusions The design of the D2B: An Alliance for Quality, a novel campaign to improve D2B time, is described.

Purpose As a first step in the development of a health-related quality of life (HRQOL) instrument, we conducted in-depth interviews to identify the specific concerns of adults with strabismus. Design Prospective cross-sectional study. Methods Thirty adults with strabismus, 17 with diplopia, and 13 without were recruited. Individual interviews, using 11 open-ended questions, were audiotaped, transcribed, and transcripts reviewed independently by three investigators. Phrases regarding how strabismus affected everyday life were grouped into topic areas and the frequency of each topic analyzed for subjects with and without diplopia. Results A total of 1,508 phrases were extracted: 207 (14%) of 1,508 were excluded because they did not pertain to HRQOL. From the remaining 1,301 phrases, 48 topic areas were apparent. For patients with diplopia, the most frequently occurring topics were: nonspecific negative feeling (15/17; 88%) ("really hard"); general disability (15/17; 88%) ("affects everything"); and driving (14/17; 82%). In those without diplopia, the most frequently mentioned topics were appearance to others (12/13; 92%) ("people notice my eyes") followed by problems with eye contact (10/13; 77%) and interpersonal relationships (10/13; 77%). Of the topics that were common to both groups (n = 42), two of the most frequent were driving and nonspecific negative feeling. Conclusions Multiple individual interviews revealed many topics that negatively affect quality of life in patients with strabismus. The frequency and type of concerns confirm the importance of HRQOL assessment as an important aspect of strabismus management.

Fibrinolytic therapy is the most common reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), particularly in smaller centers. Previous studies evaluated the relation between time to treatment and outcomes when few patients were treated within 30 minutes of hospital arrival and many did not receive modern adjunctive medications. To quantify the impact of a delay in door-to-needle time on mortality in a recent and representative cohort of patients with STEMI, a cohort of 62,470 patients with STEMI treated using fibrinolytic therapy at 973 hospitals that participated in the National Registry of Myocardial Infarction from 1999 to 2002 was analyzed. Hierarchical models were used to evaluate the independent effect of door-to-needle time on in-hospital mortality. In-hospital mortality was lower with shorter door-to-needle times (2.9% foror =30 minutes, 4.1% for 31 to 45 minutes, and 6.2% for45 minutes; p0.001 for trend). Compared with those experiencing door-to-needle timesor =30 minutes, adjusted odd ratios (ORs) of dying were 1.17 (95% confidence interval [CI] 1.04 to 1.31) and 1.37 (95% CI 1.23 to 1.52; p for trend0.001) for patients with door-to-needle times of 31 to 45 and45 minutes, respectively. This relation was particularly pronounced in those presenting within 1 hour of symptom onset to presentation time (OR 1.25, 95% CI 1.01 to 1.54; OR 1.54, 95% CI 1.27 to 1.87, respectively; p for trend0.001). In conclusion, timely administration of fibrinolytic therapy continues to significantly impact on mortality in the modern era, particularly in patients presenting early after symptom onset.

Background Patients of low socioeconomic status (SES) have higher mortality after acute myocardial infarction (AMI). Little is known about the underlying mechanisms or the relationship between SES and rehospitalization after AMI. Methods We analyzed data from the PREMIER observational study, which included 2142 patients hospitalized with AMI from 18 US hospitals. Socioeconomic status was measured by self-reported household income and education level. Sequential multivariable modeling assessed the relationship of socioeconomic factors with 1-year all-cause mortality and all-cause rehospitalization after adjustment for demographics, clinical factors, and quality-of-care measures. Results Both household income and education level were associated with higher risk of mortality (hazard ratio 2.80, 95% CI 1.37-5.72, lowest to highest income group) and rehospitalization after AMI (hazard ratio 1.55, 95% CI 1.17-2.05). Patients with low SES had worse clinical status at admission and received poorer quality of care. In multivariable modeling, the relationship between household income and mortality was attenuated by adjustment for demographic and clinical factors (hazard ratio 1.19, 95% CI 0.54-2.62), with a further small decrement in the hazard ratio after adjustment for quality of care. The relationship between income and rehospitalization was only partly attenuated by demographic and clinical factors (hazard ratio 1.38, 95% CI 1.01-1.89) and was not influenced by adjustment for quality of care. Conclusions Patients' baseline clinical status largely explained the relationship between SES and mortality, but not rehospitalization, among patients with AMI.

Purpose To determine the potential suitability of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) for measuring health-related quality of life (HRQL) in patients with Graves' ophthalmopathy. Design Cross-sectional study. Participants Thirty adult patients with mild to severe Graves' ophthalmopathy. Methods Participants self-administered the NEI VFQ-25 and completed a semistructured interview to provide feedback about the questionnaire. The percentage of responses at the maximum and minimum value was calculated to assess ceiling and floor effects, respectively, for the 12 subscales of the NEI VFQ-25. The NEI VFQ-25 scores were compared for Graves' ophthalmopathy patients who reported symptomatic diplopia and those who did not report diplopia using univariate and multivariate linear regression models. Main Outcome Measures The NEI VFQ-25 subscale and composite scores. Results Health-related quality of life in those with Graves' ophthalmopathy was moderately impaired, with median composite score of 69. The greatest impairment was measured in the Mental Health (median, 50) and the Role Difficulties (median, 50) subscales. Significant ceiling effects were seen in 7 of the 12 subscales. More than two thirds of Graves' ophthalmopathy patients perceived that the NEI VFQ-25 lacked items relevant to their disease. The NEI VFQ-25 scores were lower for those with diplopia symptoms (composite score, 61) compared with those without diplopia (composite score, 90). Comparing these 2 groups, the largest differences were measured in the Driving and Peripheral Vision subscales. Conclusions The NEI VFQ-25 includes many items that are applicable to Graves' ophthalmopathy patients. However, it shows significant ceiling effects in more than half of the subscales and it lacks items on issues that are important to Graves' ophthalmopathy patients, such as altered appearance and ocular discomfort. Efforts to develop an HRQL instrument that adds Graves' ophthalmopathy-specific items to relevant aspects of the NEI VFQ-25 are warranted.

ObjectivesWe sought to determine the effect of door-to-balloon time on mortality for patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).BackgroundStudies have found conflicting results regarding this relationship.MethodsWe conducted a cohort study of 29,222 STEMI patients treated with PCI within 6 h of presentation at 395 hospitals that participated in the National Registry of Myocardial Infarction (NRMI)-3 and -4 from 1999 to 2002. We used hierarchical models to evaluate the effect of door-to-balloon time on in-hospital mortality adjusted for patient characteristics in the entire cohort and in different subgroups of patients based on symptom onset-to-door time and baseline risk status.ResultsLonger door-to-balloon time was associated with increased in-hospital mortality (mortality rate of 3.0%, 4.2%, 5.7%, and 7.4% for door-to-balloon times of ≤90 min, 91 to 120 min, 121 to 150 min, and >150 min, respectively; p for trend 90 min had increased mortality (odds ratio 1.42; 95% confidence interval [CI] 1.24 to 1.62) compared with those who had door-to-balloon time ≤90 min. In subgroup analyses, increasing mortality with increasing door-to-balloon time was seen regardless of symptom onset-to-door time (≤1 h, >1 to 2 h, >2 h) and regardless of the presence or absence of high-risk factors.ConclusionsTime to primary PCI is strongly associated with mortality risk and is important regardless of time from symptom onset to presentation and regardless of baseline risk of mortality. Efforts to shorten door-to-balloon time should apply to all patients.

Objectives The aim of this study was to determine the use of pre-hospital electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing reperfusion therapy, and evaluate the effect of pre-hospital ECG on door-to-reperfusion times. Background Although national guidelines recommend the use of pre-hospital ECG, there is limited contemporary information about its current use and effectiveness. Methods Using data from the National Registry of Myocardial Infarction-4, we studied patients with STEMI or left bundle branch block who received acute reperfusion with either fibrinolytic therapy (n = 35,370) or primary percutaneous coronary intervention (PCI) (n = 21,277) within 6 h of admission. We determined the prevalence of pre-hospital ECG use, evaluated the association between pre-hospital ECG and door-to-reperfusion time, and estimated the incremental reduction in time to reperfusion using hierarchical models to adjust for differences in patient and hospital characteristics. Results A pre-hospital ECG was performed in 4.5% of the fibrinolytic therapy cohort and in 8.0% of the PCI cohort. After adjusting for patient and hospital characteristics, the use of pre-hospital ECG was associated with a significantly shorter geometric mean door-to-drug time: 24.6 min (95% confidence interval [CI]: 23.7 to 25.5) vs. 34.7 min (95% CI: 34.2 to 35.3; p Conclusions The national use of pre-hospital ECG to diagnose and facilitate the treatment of STEMI remains low. When used, however, pre-hospital ECG is associated with a significantly shorter time to reperfusion.

Objective Although more people are using hospice than ever before, the average length of hospice enrollment is decreasing. Little is known about the effect of hospice length of enrollment on surviving family caregivers. The authors examine the association between patient length of hospice enrollment and major depressive disorder (MDD) among the surviving primary family caregivers 13 months after the patient's death. Methods The authors conducted a three-year longitudinal study of 175 primary family caregivers of patients with terminal cancer who consecutively enrolled in the participating hospice from October 1999 through September 2001. Interviews were conducted with the primary family caregiver when the patient first enrolled with hospice and again 13 months after the patient's death. The authors used multivariate logistic regression models to estimate caregivers' adjusted risk at 13 months postloss for MDD, assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). Results The effect of very short hospice length of enrollment (three days or less) compared with longer lengths of enrollment on caregiver MDD 13 months after their loss was nonsignificant in unadjusted analyses. The adjusted risk of MDD was significantly elevated for caregivers of patients who had very short hospice enrollments (adjusted odds ratio: 8.76, 95%confidence interval: 1.09–70.19) only after adjusting for baseline MDD, caregiver gender, caregiver age, kinship relationship to patient, caregiver education, caregiver chronic conditions, and caregiver burden. The adjustment for caregiver burden resulted in the greatest increase in odds ratio for very short hospice length of enrollment on risk of caregiver MDD 13 months after the loss. Conclusions This study identifies a potential target group of family caregivers, characterized by hospice length of enrollment and several caregiver features, who might be most in need of mental health interventions.

OBJECTIVES The purpose of this study was to analyze recent trends in door-to-reperfusion time and to identify hospital characteristics associated with improved performance. BACKGROUND Rapid reperfusion improves survival for patients with acute ST-segment elevation myocardial infarction (STEMI). METHODS In this retrospective observational study from the National Registry of Myocardial Infarction (NRMI)-3 and -4, between 1999 and 2002, we analyzed door-to-needle and door-to-balloon times in patients admitted with STEMI and receiving fibrinolytic therapy (n = 68,439 patients in 1,015 hospitals) or percutaneous coronary intervention (n = 33,647 patients in 421 hospitals) within 6 h of hospital arrival. RESULTS In 1999, only 46% of the patients in the fibrinolytic therapy cohort were treated within the recommended 30-min door-to-needle time; only 35% of the patients in the percutaneous coronary intervention cohort were treated within the recommended 90-min door-to-balloon time. Improvement in these times to reperfusion over the four-year study period was not statistically significant (door-to-needle: -0.01 min/year, 95% confidence interval [CI] -0.24 to +0.23, p > 0.9; door-to-balloon: -0.57 min/year, 95% CI -1.24 to +0.10, p = 0.09). Only 33% (337 of 1,015) of hospitals improved door-to-needle time by more than one min/year, and 26% (110 of 421) improved door-to-balloon time by more than three min/year. No hospital characteristic was significantly associated with improvement in door-to-needle time. Only high annual percutaneous coronary intervention volume and location in New England were significantly associated with greater improvement in door-to-balloon time. CONCLUSIONS Fewer than one-half of patients with STEMI receive reperfusion in the recommended door-to-needle or door-to-balloon time, and mean time to reperfusion has not decreased significantly in recent years. Relatively few hospitals have shown substantial improvement.

Objectives We sought to recommend an approach for minimizing preventable delays in door-to-balloon time on the basis of experiences in top-performing hospitals nationally. Background Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity; however, door-to-balloon times often exceed the 90-min guideline set forth by the American College of Cardiology (ACC) and the American Heart Association (AHA). Methods We conducted a qualitative study using in-depth interviews (n = 122) of hospital staff at hospitals (n = 11) selected as top performers based on data from the National Registry of Myocardial Infarction from January 2001 to December 2002. We used the constant comparative method of qualitative data analysis to synthesize best practices across the hospitals. Results Top performers were those with median door-to-balloon times of ≤90 min for their most recent 50 PCI cases through December 2002 and the greatest improvement in median door-to-balloon times during the preceding four-year period 1999 to 2002. Several critical innovations are described, including use of pre-hospital electrocardiograms (ECGs) to activate the catheterization laboratory, allowing emergency physicians to activate the catheterization laboratory, and substantial interdisciplinary collaboration throughout the process. In the ideal approach, door-to-balloon time is 60 min for patients transported by paramedics with a pre-hospital ECG and 80 min for patients who arrive without paramedic transport and a pre-hospital ECG. Conclusions Hospitals can achieve the recommended ACC/AHA guidelines for door-to-balloon time with specific process design efforts. However, the recommended best practices involve extensive interdisciplinary collaboration and will likely require explicit strategies for overcoming barriers to organizational change.

Article-at-a-Glance Background Little is known about current attitudes and practices among residents and nurses regarding error reporting. A survey was conducted to suggest differing needs for training and other interventions to enhance reporting. Methods The authors surveyed 24 residents and 60 nursing staff in all inpatient care units at a community hospital from 2001 to 2002. The authors used self-administered questionnaires to assess respondents' knowledge and use of the hospital's error-reporting system, perceptions and attitudes toward error reporting, reported behaviors in hypothetical error scenarios, and conditions that influence error reporting. Results Only half of the residents (54%) knew about the hospital's error-reporting system, whereas nearly all nurses did (97%; p = .001). Only 13% of the residents (versus 72% of the nurses) had ever used the reporting system ( p = .001). Residents (29%) were less likely than nurses (64%) to report being comfortable discussing mistakes with supervisors ( p = .006), and residents (38%) were more likely than nurses (0%) to rate the hospital atmosphere as nonsupportive of error reporting ( p =.001). Discussion Error-reporting systems may give a biased picture of the true pattern of medical errors, and hospitals may need to initiate other interventions to improve residents' error reporting.

The study objective was to develop a taxonomy of psychosocial factors that may influence individual decisions for financing nursing home care. Focus groups (18 groups with a total of 155 participants) were conducted to explore personal constructs regarding nursing home financing. Data were collected through a standardized discussion guide. Qualitative analysis was accomplished with NUD*IST 4.0 for coding, sorting, and development of recurrent themes at multiple levels using a node structure, which was reviewed and modified through an iterative process by the investigators. Participants' expectations of, and planning for, future long term care needs varied. Findings illustrate the multifaceted nature of planning behaviors in financing nursing home care, suggesting that in addition to economic variables, psychosocial factors are important determinants of such behaviors. Identified factors may inform the development of more comprehensive psychosocial measures in future investigations.

Purpose To evaluate intraobserver reliability and interobserver reliability of a computer-based digital image measurement of eyelid position in Graves' ophthalmopathy and to compare digital image measurement with clinical measurement. Design Cross-sectional study. Participants Eighty-four eyes of 42 patients with mild to moderate bilateral Graves' ophthalmopathy. Methods Digital images were created from 35-mm color slides of both eyes of participants and projected onto a 15-inch flat-screen computer monitor. Three observers (2 oculoplastic surgeons and 1 ophthalmology resident) independently recorded eyelid fissure height, margin–reflex distance, and inferior scleral show for each eye. Main outcome measures Intraobserver reliability and interobserver reliability of eyelid parameter measurements, as described by the intraclass correlation coefficient (ICC) and Bland–Altman plots. Agreement between digital image measurements of the investigators and clinical measurements taken on the same day as the photographs also was assessed. Results Excellent intraobserver agreement was found for the measurement of all eyelid parameters for all 3 investigators (ICC range, 0.93–0.99). Interobserver agreement for all eyelid parameters was also excellent for all investigators (ICC, 0.86–0.97). Agreement between the photographic and clinical measurements for eyelid parameters was fair to moderate (ICC range, 0.38–0.62). Conclusion Measurement of several eyelid parameters in Graves' ophthalmopathy patients from computer-based digital images is reliable. Associations between photographic and clinical measurements for all parameters are weaker. Relative to clinical measurements, the photographic technique offers the advantages of potential for masking and ease of transmission that might be useful in clinical trials.

Article-at-a-Glance Background Despite the many proposed methods for improving quality, little is known about which methods are being applied in practice across the United States or their perceived effectiveness. Methods A descriptive, cross-sectional analysis of data from a telephone survey of quality improvement staff in 234 randomly selected hospitals participating in the National Registry of Myocardial Infarction was conducted to examine the prevalence and perceived effectiveness of various quality improvement interventions directed at increasing beta-blocker use after acute myocardial infarction. Results The mean and median number of quality improvement interventions directed at beta-blocker use in the past 4years was 5.0 per hospital. The most commonly reported effort was performance reporting about beta-blocker use (87.9%), although only 26.7% used physician-specific performance reporting. More than half the hospitals implemented clinical pathways (58.1%), standing orders (56.8%), or care coordinators (50.4%). Care coordinators (63.4%) and computer support systems (61.6%) were most frequently rated as "very effective." Clinical pathways (24.2%), counseling physicians who had poor performance (26.9%), and reminder forms (23.0%) were most frequently rated as not effective. Conclusions Substantial variation in the types of quality improvement efforts implemented to increase beta-blocker use and perceived effectiveness were evident.

Objective The authors evaluated the performance of the Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) scale, a new tool to assess caregiver exposure to patient distress, and the fear and helplessness evoked by these experiences. Methods The SCARED was administered to 76 hospice-patient caregivers (e.g., family members). Major depressive disorder (MDD) was diagnosed with the Structured Clinical Interview for the DSM-IV; complicated grief (CG) "caseness" was diagnosed with the Inventory of Complicated Grief–Caregiver items, and quality-of-life domains were assessed with the Medical Outcomes Survey Short Form–36. Results Respondents endorsed frequent exposure to each SCARED experience—from 30.3% who mistakenly thought the patient had died, to 80.3% who witnessed the patient in severe pain. Adjusted analyses revealed that the odds of MDD increased by 3.08 for each standard-deviation increase in the SCARED event frequency score and that higher SCARED scores were positively associated (p Conclusion The SCARED may be a clinically useful tool for identifying caregivers at risk for MDD and quality-of-life impairments, as well as potential aspects of caregiving to target for treatment.

We examine whether workload has an impact on a direct measure of the health status of patients discharged from Intensive Care Units (ICUs). We use data collected from the medical ICU and the surgical ICU of a major teaching hospital and a relatively new measure of patient acuity called the Rothman Index (RI). The RI is frequently updated during a patient’s hospital stay, which enables us to track patients health status very close to the time of their ICU discharge. Leveraging the RI, we measure ICU workload in a novel way that takes into account not only the census but also patient acuity. To our knowledge, this is the first study to show that more acutely ill patients are discharged from an ICU when the severity-adjusted workload is high rather than low. Further, we find that higher severity-adjusted workload is associated with ICU discharge times that start earlier and end later, a shorter ICU length-of-stay (LOS), and an increased likelihood of discharge to a step-down unit. We also find that downstream unit census influences the effect of workload on health status at ICU discharge.

and extended hospital stays. Non-serious complications included formation of a hematoma, discoloration, oozing, swelling, or bleeding at the entry site. P values < 0.05 were considered significant. Results: An independent T-test indicated a significant (p < .001) increase in the mean percentage in the number of reused SUDs at BBH. There was no difference in the number of complications that developed after surgery between the hospitals, despite the significant difference in the number of SUDs per procedure. When analyzing length of stay, the results showed significant (p < .001) increase in the average mean stay for patients in BBH which may be attributed to the initial health status of patients. No significant differences were found between hospitals in the severity of complications was analyzed (serious vs. non-serious). Conclusion: There was no significant correlation between the reuse of single use medical devices and adverse outcomes for PTCA at either of the two hospitals in which the study took place. Funding: No funding listed. Abstract #: 02NCD005

Purpose Previous studies have suggested the importance of communicating with patients about prognosis at the end of life, yet the prevalence, content, and consequences of such communication have not been fully investigated. The purposes of this study were to estimate the proportion of terminally ill inpatients with documented discussions about prognosis, describe the nature and correlates of such discussions, and assess the association between documented discussions about prognosis and subsequent advance care planning. Subjects and methods Inpatients (n = 232) at least 65 years old who had brain, pancreas, liver, gall bladder, or inoperable lung cancer were randomly selected from six randomly chosen community hospitals in Connecticut. The presence and content of discussions about prognosis, advanced care planning efforts, and sociodemographic and clinical factors were ascertained by comprehensive review of medical records using a standardized abstraction form. Results Discussions about prognosis were documented in the medical records of 89 (38%) patients. Physicians and patients were both present during the discussion in 46 (52%) of these cases. Time until expected death was infrequently documented. Having a documented discussion about prognosis was associated with documented discussions of life-sustaining treatments (adjusted odds ratio [OR] = 5.8; 95% confidence interval [CI]: 2.8 to 12.0) and having a do-not-resuscitate order (adjusted OR=2.2; 95% CI: 1.1 to 4.2). Conclusions Among terminally ill patients with cancer, discussions about prognosis as documented in medical charts are infrequent and limited in scope. In some cases, such documented discussions may be important catalysts for subsequent discussions of patient and family preferences regarding treatment and future care.

Implantable Cardioverter-Defibrillators (ICDs) reduce sudden cardiac death. However, about 25% of patients with ICDs are shocked in the last month of life(1), and these shocks may cause frightening and painful deaths. Little is known about how physicians’ attitudes influence their decisions to discuss ICD deactivation with patients. We created a simple random sample of the American Medical Association Masterfile by choosing 100 physicians from each of four strata: electrophysiologists, cardiologists, geriatricians, and internists. Eligible clinicians had to be in active practice and had to have cared for at least one patient with an ICD. We mailed letters to all physicians introducing the study, and then followed up by telephone to administer the survey. Physicians who could not be contacted telephonically were mailed surveys, and a series of incentives were used to encourage participation. All surveys were anonymous. This project was exempt from review by the Mount Sinai School of Medicine IRB. We based the survey on our previous qualitative work.(2,3) The instrument included Likert scales (1 (strongly disagree) to 5 (strongly agree)) to determine physicians’ attitudes relating to ICD conversations (Table 1). Data were analyzed as both continuous and dichotomous variables. As the results of these analyses were similar, the Likert scales are reported as strongly agree or agree versus all others. For between group comparisons, the chi-square test was used; Fisher’s Exact test was used for smaller cell sizes. P-values reflect comparisons across the four groups. There was no difference in response patterns between phone and written surveys. ANOVA was used to evaluate the differences in age of respondents across the four groups. Significance levels for individual tests were not adjusted as the survey was based on qualitative data and the sample size was small thus making it unlikely that any observed association would be due to chance alone.(4) All calculations were performed using SAS v9.0 (Cary, NC). Table 1 Results of 5-point Likert scales to Determine Physicians’ Attitudes Relating to Care of Patients with ICDs Of the 400 physicians selected for the survey, 11 were deemed ineligible (7 were retired and 4 had never cared for a patient with an ICD) and 52 could not be located. Of the remaining 337 eligible physicians, 147 completed surveys, yielding a response rate among physicians who could be located of 44% (147/337). Electrophysiologists had a higher response rate (58%) compared with cardiologists (36%), internists (37%) and geriatricians (41%) (p=.013). Geriatricians tended to be older than cardiologists, electrophysiologists, or internists (mean age 54.1 years vs. 48.3, 49.0, and 48.1 respectively, p-value

The process of setting goals for medical care in the context of chronic disease has received little attention in the medical literature, despite the importance of goal-setting in the achievement of desired outcomes. Using qualitative research methods, this paper develops a theory of goal-setting in the care of patients with dementia. The theory posits several propositions. First, goals are generated from embedded values but are distinct from values. Goals vary based on specific circumstances and alternatives whereas values are person-specific and relatively stable in the face of changing circumstances. Second, goals are hierarchical in nature, with complex mappings between general and specific goals. Third, there are a number of factors that modify the goal-setting process, by affecting the generation of goals from values or the translation of general goals to specific goals. Modifying factors related to individuals include their degree of risk-taking, perceived self-efficacy, and acceptance of the disease. Disease factors that modify the goal-setting process include the urgency and irreversibility of the medical condition. Pertinent characteristics of the patient-family-clinician interaction include the level of participation, control, and trust among patients, family members, and clinicians. The research suggests that the goal-setting process in clinical medicine is complex, and the potential for disagreements regarding goals substantial. The nature of the goal-setting process suggests that explicit discussion of goals for care may be necessary to promote effective patient-family-clinician communication and adequate care planning.

David Magid, MD, MPH Elizabeth H. Bradley, PhD From the Colorado Permanente Clinical Research Unit, Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver, CO (Magid); and the Departments of Epidemiology and Public Health and Medicine, Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, CT (Bradley).

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