Search

Temporomandibular joint replacement (TJR) with an alloplastic (metal/ultra-high-molecular-weight polyethylene) device has proven to be a successful and predictable procedure. This paper describes a novel technique for performing TJR with an endaural incision alone. The technique we are describing uses only an endaural incision with supplemental trocar incision(s), to perform a TJR. There were 4 patients for a total of 8 temporomandibular joints that were selected. All 4 patients were assessed immediately following surgery, on postoperative days 1 and 7 and at 6 months following surgery. Maximal interincisal opening and subjective variables were assessed at each of the time points. Additionally, the total operative time was measured and compared to a previous age and diagnosis matched control group using the traditional 2 incisions TJR.There were 3 females and 1 male (ages 19-67) who underwent TJR with an endaural incision alone. There were 4 females (ages 19-68) who underwent traditional TJR surgery. None of the patients in either group had major complications and all patients were discharged on postoperative day 1. All patients in the endaural incision alone group had increased maximal interincisal opening and reported a quicker subjective decrease in pain and disability following surgery with less average time in the operating room. However, all patients in the endaural incision alone group had CN VII weakness that lasted longer than those in the traditional TJR group.The minimally invasive approach for TJR was successful in the present pilot study and could be used in specific situations to decrease the morbidity associated with additional incisions for this procedure. Ultimately, the endaural only incision approach offers promising outcomes for future patients undergoing temporomandibular joints TJR in the right patient population.

As orthodontic treatment has advanced in complexity and in frequency, more recent techniques, using temporary skeletal anchorage, were developed to help correct more severe occlusal and dentofacial discrepancies that were treated with orthognathic surgery alone previously. These techniques have allowed the orthodontist to move teeth against a rigid fixation, allowing for more focused movements of teeth and for orthopedic growth modification. These types of treatments using rigid fixation have allowed for greater interaction between the orthodontist and the oral and maxillofacial surgeon, and have vastly enhanced the treatment planning for the orthodontist in today's society.

Précis: Modeling of visual field and pharmacy data (Kaiser Permanente, 2001 to 2014) from open-angle/pseudoexfoliation glaucoma patients in clinical practice indicated a significant inverse association between the level of medication adherence and rate of visual field progression. Purpose: The aim was to quantify the effect of nonadherence to topical hypotensive medication on glaucomatous visual field progression in clinical practice. Methods: Retrospective analysis of combined visual field and pharmacy data from Kaiser Permanente Southern California’s HealthConnect electronic health record database. Patients with a diagnosis of primary open-angle glaucoma or pseudoexfoliation glaucoma (2001 to 2011) and ≥3 subsequent visual field tests of the same Swedish Interactive Threshold Algorithm type were followed up from first medication fill to final visual field test. Medication adherence (proportion of days covered) was estimated from pharmacy refill data. A conditional growth model was used to estimate the effect of adherence level in modifying the progression of mean deviation over time after adjusting for potential confounders, including age, sex, race/ethnicity, baseline glaucoma severity, and comorbidity. Results: In total, 6343 eligible patients were included in the study and followed for (mean) 5.8 years; average treatment adherence during follow-up was 73%. After controlling for confounders and the interaction between time and baseline disease severity, the model indicated that mean deviation progression was significantly (P=0.006) reduced by 0.006 dB per year for each 10% (absolute) increase in adherence. Model estimates of time to glaucoma progression (mean deviation change −3 dB from baseline) were 8.3 and 9.3 years for patients with adherence levels of 20% and 80%, respectively. Conclusions: Improving patient adherence to topical glaucoma medication may result in slower deterioration in visual function over time.

Purpose Although many oral and maxillofacial surgical (OMS) procedures might seem to be profitable, no current data have analyzed the costs versus benefits of performing office-based OMS procedures. The purpose of the present study was to analyze the costs of performing 6 common office-based OMS procedures compared with the reimbursement rates for those same procedures. Materials and Methods The present study was a cross-sectional, microcosting survey analyzing the costs of materials used in the outpatient Oral-Maxillofacial Surgery clinic at the University of Texas Health Science Center at San Antonio. The costs incurred were based on dental procedure coding and national statistical databases and not on actual patient interactions. The primary predictor variable was the procedure costs for 6 commonly performed outpatient OMS procedures using 3 types of trays: a simple tray, a surgical tray, and an implant tray. The ancillary materials were listed for as-needed use for each tray. The primary outcome variable was the revenue after expenses per procedure. Descriptive statistics were computed. The net profit or net loss of performing 6 commonly performed outpatient OMS procedures was analyzed by subtracting the cost of performing the procedure from the insurance reimbursement for those procedures. Results Without the addition of sedation to the procedures, routine extractions had a net loss of $230 to $261, surgical extractions had a net loss of $153 to $242, and incision and drainage procedures had a net loss of $212 to $311. Furthermore, preprosthetic procedures had a net loss to net profit of −$269 to +$140, and pathologic procedures had a net loss to net profit of −$269 to +$326. Only implant procedures yielded a net profit of $847. Conclusions The results of the present study have demonstrated that not all routine OMS procedures are profitable when performed alone without the inclusion of additional procedures or sedation.

Electric, thermal, and mechanical strain fields drive the degradation of AlGaN/GaN high-electron mobility transistors (HEMTs). The resulting mechanical strains within the devices are particularly important. However, a lack of high-resolution measurements of device deformation has limited progress in understanding the related phenomena. This paper presents the atomic force microscope measurements of thermomechanical deformation of AlGaN/GaN HEMT devices during pulsed operation. We investigate the devices with various operating conditions: drain–source voltage, $V_{\mathrm {\mathrm {DS}}}$ , of 0–50 V; drain–source power of 0–6 W/mm; and operating frequency of 55–400 kHz. As $V_{\mathrm {\mathrm {DS}}}$ increases, thermomechanical deformation decreases, especially in the region above the gate. An electrothermomechanical model closely matches with and helps to explain the measurements. According to the model, the maximum periodic tensile thermal stress, which occurs at the drain-side edge of the gate footprint, is 55% larger for $V_{\mathrm {\mathrm {DS}}} = 10$ V than for $V_{\mathrm {\mathrm {DS}}} = 48$ V for the same device power. The maximum tensile thermal stress in the device depends on the gate temperature and not the maximum device temperature. As $V_{\mathrm {\mathrm {DS}}}$ increases, the hotspot moves away from the gate, leading to lower gate temperature rise and lower tensile thermal stress.

Objectives Pneumonia severity tools were primarily developed in cohorts of hospitalized patients, limiting their applicability to the emergency department (ED). We describe current community ED admission practices and examine the accuracy of the CURB-65 to predict 30-day mortality for patients, either discharged or admitted with community-acquired pneumonia (CAP). Methods A retrospective, observational study of adult CAP encounters in 14 community EDs within an integrated healthcare system. We calculated CURB-65 scores for all encounters and described the use of hospitalization, stratified by each score (0–5). We then used each score as a cutoff to calculate sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratios, and negative likelihood ratios for predicting 30-day mortality. Results The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 for predicting 30-day mortality in the full sample was 0.761 (95% confidence interval [CI], 0.747–0.774). The C-statistic was 0.864 (95% CI, 0.821–0.906) among patients discharged from the ED compared with 0.689 (95% CI, 0.672–0.705) among patients who were admitted. Among all ED encounters a CURB-65 threshold of ≥1 was 92.8% sensitive and 38.0% specific for predicting mortality, with a 99.9% NPV. Among all encounters, 62.5% were admitted, including 36.2% of those at lowest risk (CURB-65 = 0). Conclusions CURB-65 had very good accuracy for predicting 30-day mortality among patients discharged from the ED. This severity tool may help ED providers risk stratify patients to assist with disposition decisions and identify unwarranted variation in patient care.

Objective This survey-based study was undertaken to investigate how total debt loads are impacting the personal and professional decisions made by graduating oral and maxillofacial surgery (OMS) residents. The aim of this study was to evaluate differences in total debt load on graduating residents and analyze the effects of this debt on career, family, and lifestyle choices after graduation. Study Design This study was a cross-sectional, web-based survey of all graduating OMS residents in accredited OMS residency programs in the United States. Participation in the survey was optional, and all responses were anonymously collected and the data analyzed by using Qualtrics software. The respondents were analyzed as a collective, with the predictor of the study being program training length and the outcome being total debt load, with independent analysis of select other financial variables. Results For the 246 deliverable emails, there were 120 respondents (48.7% response rate). The average graduating OMS resident was a Caucasian male (median age 32 years), living with a significant other or spouse who independently earned money, and had no dependents. The average range of accumulated debt of graduating residents was between $300,000 and $350,000, with 50.83% of the respondents having $350,000 or less in overall debt and 49.17% of the respondents having $350,000 or greater in accumulated debt. For those respondents completing 4-year programs, the average range of accumulated debt was between $250,000 and $300,000, and for those respondents completing 6-year programs, the average range of accumulated debt was between $400,000 and $450,000 (P Conclusions Graduating OMS residents carry with them a significant amount of debt whether graduating from a 4-year program or a 6-year program. However, when subjectively queried, most of these residents stated they would again choose OMS as a career choice.

In this paper, we present finite element simulation results of the transient stress response of an AlGaN/GaN high electron mobility transistor (HEMT). The modeling technique involves a small-scale electro-thermal model coupled to a large-scale mechanics model to determine the resulting stress distribution within a device operated under radio frequency (RF) conditions. The electrical characteristics of the modeled device were compared to experimental measurements and existing simulation data from literature for validation. The results show critical regions around the gate Schottky contact undergo drastically different transient stresses during pulsed operation. Specifically, stress profiles within the AlGaN layer around the gate foot print (GFP) undergo highly tensile electro-thermal stresses while stresses within the AlGaN outside the gate connected field plate (GCFP) towards the drain contact undergo highly tensile electrical stress and compressive thermoelastic stress. It is shown AlGaN/GaN HEMTs undergo large amounts of cyclic loading during typical transient operation. Based on these findings, transient failure mechanisms may differ from those previously studied under DC operation due to large amount of cyclic loading of a device around the gate structure.

Study objective Despite evidence that guideline adherence improves clinical outcomes, management of pneumonia patients varies in emergency departments (EDs). We study the effect of a real-time, ED, electronic clinical decision support tool that provides clinicians with guideline-recommended decision support for diagnosis, severity assessment, disposition, and antibiotic selection. Methods This was a prospective, controlled, quasi-experimental trial in 7 Intermountain Healthcare hospital EDs in Utah's urban corridor. We studied adults with International Classification of Diseases, Ninth Revision codes and radiographic evidence for pneumonia during 2 periods: baseline (December 2009 through November 2010) and post–tool deployment (December 2011 through November 2012). The tool was deployed at 4 intervention EDs in May 2011, leaving 3 as usual care controls. We compared 30-day, all-cause mortality adjusted for illness severity, using a mixed-effect, logistic regression model. Results The study population comprised 4,758 ED pneumonia patients; 14% had health care–associated pneumonia. Median age was 58 years, 53% were female patients, and 59% were admitted to the hospital. Physicians applied the tool for 62.6% of intervention ED study patients. There was no difference overall in severity-adjusted mortality between intervention and usual care EDs post–tool deployment (odds ratio [OR]=0.69; 95% confidence interval [CI] 0.41 to 1.16). Post hoc analysis showed that patients with community-acquired pneumonia experienced significantly lower mortality (OR=0.53; 95% CI 0.28 to 0.99), whereas mortality was unchanged among patients with health care–associated pneumonia (OR=1.12; 95% CI 0.45 to 2.8). Patient disposition from the ED postdeployment adhered more to tool recommendations. Conclusion This study demonstrates the feasibility and potential benefit of real-time electronic clinical decision support for ED pneumonia patients.

Severe shock is a life-threatening condition with very high short-term mortality. Whether the long-term outcomes among survivors of severe shock are similar to long-term outcomes of other critical illness survivors is unknown. We therefore sought to assess long-term survival and functional outcomes among 90-day survivors of severe shock and determine whether clinical predictors were associated with outcomes. Seventy-six patients who were alive 90 days after severe shock (received ≥1 μg/kg per minute of norepinephrine equivalent) were eligible for the study. We measured 3-year survival and long-term functional outcomes using the Medical Outcomes Study 36-Item Short-Form Health Survey, the EuroQOL 5-D-3L, the Hospital Anxiety and Depression Scale, the Impact of Event Scale-Revised, and an employment instrument. We also assessed the relationship between in-hospital predictors and long-term outcomes. The mean long-term survival was 5.1 years; 82% (62 of 76) of patients survived, of whom 49 were eligible for follow-up. Patients who died were older than patients who survived. Thirty-six patients completed a telephone interview a mean of 5 years after hospital admission. The patients' Physical Functioning scores were below U.S. population norms (P < 0.001), whereas mental health scores were similar to population norms. Nineteen percent of the patients had symptoms of depression, 39% had symptoms of anxiety, and 8% had symptoms of posttraumatic stress disorder. Thirty-six percent were disabled, and 17% were working full-time. Early survivors of severe shock had a high 3-year survival rate. Patients' long-term physical and psychological outcomes were similar to those reported for cohorts of less severely ill intensive care unit survivors. Anxiety and depression were relatively common, but only a few patients had symptoms of posttraumatic stress disorder. This study supports the observation that acute illness severity does not determine long-term outcomes. Even extremely critically ill patients have similar outcomes to general intensive care unit survivor populations.

Introduction Heart rate variability (HRV) reflects autonomic nervous system tone as well as the overall health of the baroreflex system. We hypothesized that loss of complexity in HRV upon intensive care unit (ICU) admission would be associated with unsuccessful early resuscitation of sepsis. Methods We prospectively enrolled patients admitted to ICUs with severe sepsis or septic shock from 2009 to 2011. We studied 30 minutes of electrocardiogram, sampled at 500 Hz, at ICU admission and calculated heart rate complexity via detrended fluctuation analysis. Primary outcome was vasopressor independence at 24 hours after ICU admission. Secondary outcome was 28-day mortality. Results We studied 48 patients, of whom 60% were vasopressor independent at 24 hours. Five (10%) died within 28 days. The ratio of fractal alpha parameters was associated with both vasopressor independence and 28-day mortality ( P = .04) after controlling for mean heart rate. In the optimal model, Sequential Organ Failure Assessment score and the long-term fractal α parameter were associated with vasopressor independence. Conclusions Loss of complexity in HRV is associated with worse outcome early in severe sepsis and septic shock. Further work should evaluate whether complexity of HRV could guide treatment in sepsis.

Introduction Many clinicians perceive that peritoneal dialysis (PD) should be reserved for younger, healthier, more affluent patients. Our aim was to examine outcomes for PD patients in a managed care setting and to identify predictors of adverse outcomes. Methods We identified all patients who initiated PD at our institution between 1 January 2001 and 31 December 2010. Predictor variables studied included age, sex, race, PD modality, cause of end-stage renal disease (ESRD), dialysis vintage, Charlson comorbidity index (CCI) score, education, and income level. Poisson models were used to determine the relative risk (RR) of peritonitis and the number of hospital days per patient-year. The log-rank test was used to compare technique survival by patient strata. Results Among the 1378 patients who met the inclusion criteria, only female sex [RR: 0.85; 95% confidence interval (CI): 0.74 to 0.98; p = 0.02] and higher education (RR: 0.77; 95% CI: 0.60 to 0.98; p = 0.04) were associated with peritonitis. For hospital days, dialysis vintage (RR: 1.11; 95% CI: 1.04 to 1.18; p = 0.002), CCI score (RR: 1.06; 95% CI: 1.02 to 1.20; p = 0.002), and cause of ESRD (RR for glomerulonephritis: 0.59; 95% CI: 0.43 to 0.80; p = 0.0006; and RR for hypertension: 0.69; 95% CI: 0.55 to 0.88; p = 0.002) were associated with 1 extra hospital day per patient-year. The 2-year technique survival was 61% for patients who experienced at least 1 episode of peritonitis and 72% for those experiencing no peritonitis (p = 0.0001). Baseline patient age, primary cause of ESRD, and PD modality were the only other variables associated with technique survival in the study. Conclusions Neither race nor socio-economic status predicted technique survival or hospital days in our study. Female sex and higher education were the only two variables studied that had an association with peritonitis.

Study objective We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes. Methods We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined "low severity" as PaO 2 /FiO 2 ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics. Results Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions. Conclusion We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.

The objectives of this study were to assess the reactions of adult patients and parents of children with metabolic conditions to receipt of an "information prescription" (IP) to visit Genetics Home Reference (GHR), a National Institutes of Health/National Library of Medicine online resource, and evaluate the perceived utility of information found on the site.Patients seen at the University of Utah Metabolic Service Clinic were invited to participate in the study and asked to complete an initial survey to gather demographic data and an online survey six weeks later to obtain information about user experience.Fifty-three of 82 individuals completed both surveys, for an overall response rate of 64.6%. Most respondents (88.7%) agreed that receiving the IP was a "good idea," and nearly all used the IP to visit GHR. More than three-quarters (79.6%) agreed that information on GHR supplemented a physician's advice; 60.4% reported an improved understanding of a health condition; and 41.5% either looked for or would consider looking for additional information. Eighty-six percent of respondents were satisfied with the information found on GHR, and 80% would recommend the site.Use of an IP to direct patients to GHR was well received, and retrieved information was perceived as useful in key areas. The high level of satisfaction with GHR argues for expanded use of the IP approach in this patient population.

Purpose To describe adherence to glaucoma medications. Patients and methods Medication adherence was investigated using the computerized records of Kaiser Permanente Southern California, a group model health maintenance organization that provides care to 3.4 million residents of Southern California. Eligible glaucoma patients were diagnosed between 2005 and 2009 and had medical and prescription drug coverage between 2005 and 2009. Utilization and adherence parameters were calculated for each of the 5 years from the incident date. Results A total of 17,943 newly diagnosed glaucoma patients were identified between the years 2005 and 2009. Of patients diagnosed with glaucoma in 2005, 71% were continuously eligible for 5 years. Medication adherence was calculated using a medication possession ratio. Adherence was bimodal and not normal in distribution. Overall, the mean age of the entire group was 66 years, with 56% being 65 years of age or older. The high adherence group tended to be older, more likely to be female, and more likely to be white. The low adherent group (younger) tended to have more and worse diabetes, renal disease, myocardial infarction, and stroke. Conclusions The shape of the adherence distribution appears bimodal, so analysis based on parametric measures may not be appropriate. Investigations of adherence should probably be performed separately for the low, mid, and high groups.

Background Patients’ perceptions of the quality of their hospitalization have become important to the American healthcare system. Standard surveys of perceived quality of healthcare do not focus on the Intensive Care Unit (ICU) portion of the stay. Our objective was to evaluate the construct validity and internal consistency of the Intermountain Patient Perception of Quality (PPQ) survey among patients discharged from the ICU. Methods We analyzed prospectively collected results from the ICU PPQ survey of all inpatients at Intermountain Medical Center whose hospitalization included an ICU stay. We employed principal components analysis to determine the constructs present in the PPQ survey, and Cronbach’s alpha to evaluate the internal consistency (reliability) of the items representing each construct. Results We identified 5,680 patients who had completed the PPQ survey. There were three basic domains measured: nursing care, physician care, and overall perception of quality. Most of the variability was explained with the first two principal components. Constructs did not vary by type of respondent. Conclusions The Intermountain ICU PPQ survey demonstrated excellent construct validity across three distinct constructs. This, in addition to its previously established content validity, suggests the utility of the PPQ survey as an assay of the perceived quality of the ICU experience. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0828-x) contains supplementary material, which is available to authorized users.

Background We evaluated our previously derived admission criteria for agreement with physician decisions and outpatient failure among patients presenting to emergency departments (EDs) with pneumonia. Methods Among patients presenting to seven Intermountain EDs in the urban region of Utah with pneumonia December 1 2009-December 1 2010, we measured hospital admission rates and outpatient failure, defined as either 7-day secondary hospitalization or death in 30 days for patients initially discharged home from the ED. We measured our admission criteria’s ability to predict hospital admission and its hypothetical rates of admission and outpatient failure with strict adherence to the criteria. We compared our admission criteria to other electronically calculable criteria, CURB-65 and A-DROP. Results In 2,308 patients, admission rate was 57%, 30-day mortality 6.1%, 7-day secondary hospitalization 5.8%, and outpatient failure rate 6.4%. Our admission criteria predicted hospital admission with an AUC of 0.77, compared to 0.73 for CURB-65 ≥ 2 and 0.78 for A-DROP≥ 2. Hypothetical 100% concordance with our admission criteria decreased the hospitalization rate to 52% and reduced the outpatient failure rate to 3.9%, slightly better than A-DROP ≥ 2 (54% and 4.3%) and CURB-65 ≥ 2 (49% and 5.1%). Conclusions Our admission criteria agreed acceptably with overall observed admission decisions for patients presenting to EDs with pneumonia, but may safely reduce hospital admission rates and increase recognition of patients at risk for outpatient failure compared to CURB-65 ≥ 2 or A-DROP ≥ 2.

Objective The Sequential Organ Failure Assessment (SOFA) score, a measure of multiple-organ dysfunction syndrome, is used to predict mortality in critically ill patients by assigning equally weighted scores across 6 different organ systems. We hypothesized that specific organ systems would have a greater association with mortality than others. Design We retrospectively studied patients admitted over a period of 4.2 years to a mixed-profile intensive care unit (ICU). We recorded age and comorbidities, and calculated SOFA organ scores. The primary outcome was 30-day all-cause mortality. We determined which organ subscores of the SOFA score were most associated with mortality using multiple analytic methods: random forests, conditional inference trees, distanced-based clustering techniques, and logistic regression. Setting A 24-bed mixed-profile adult ICU that cares for medical, surgical, and trauma (level 1) patients at an academic referral center. Patients All patients' first admission to the study ICU during the study period. Measurements and Main Results We identified 9120 first admissions during the study period. Overall 30-day mortality was 12%. Multiple analytical methods all demonstrated that the best initial prediction variables were age and the central nervous system SOFA subscore, which is determined solely by Glasgow Coma Scale score. Conclusions In a mixed population of critically ill patients, the Glasgow Coma Scale score dominates the association between admission SOFA score and 30-day mortality. Future research into outcomes from multiple-organ dysfunction may benefit from new models for measuring organ dysfunction with special attention to neurologic dysfunction.

In 2011, Kaiser Permanente Northwest Region (KPNW) won the Lawrence Patient Safety Award for its innovative work in reducing hospital readmission rates. In 2012, Kaiser Permanente Southern California (KPSC) won the Transfer Projects Lawrence Safety Award for the successful implementation of the KPNW Region's "transitional care" bundle to a Region that was almost 8 times the size of KPNW. The KPSC Transition in Care Program consists of 6 KPNW bundle elements and 2 additional bundle elements added by the KPSC team. The 6 KPNW bundle elements were risk stratification, standardized discharge summary, medication reconciliation, a postdischarge phone call, timely follow-up with a primary care physician, and a special transition phone number on discharge instructions. The 2 additional bundle elements added by KPSC were palliative care consult if indicated and a complex-case conference. KPSC has implemented most of the KPNW and KPSC bundle elements during the first quarter of 2012 for our Medicare risk population at all of our 13 medical centers. Each year, KPSC discharges approximately 40,000 Medicare risk patients. After implementation of bundle elements, KPSC Medicare risk all-cause 30-day Healthcare Effectiveness Data and Information Set readmissions observed-over-expected ratio and readmission rates from December 2010 to November 2012 decreased from approximately 1.0 to 0.80 and 12.8% to 11%, respectively.

Objectives. We compared admission rates, outcomes, and performance of the CURB-65 mortality prediction score of homeless patients and nonhomeless patients with community-acquired pneumonia (CAP). Methods. We compared homeless (n = 172) and nonhomeless (n = 1897) patients presenting to a Salt Lake City, Utah, emergency department with CAP from 1996 to 2006. In the homeless cohort, we measured referral from and follow-up with the local homeless health care clinic and arrangement of medical housing. Results. Homeless patients were younger (44 vs 59 years; P Conclusions. A large cohort of homeless patients with CAP demonstrated higher hospitalization risk than but similar length of stay and costs as nonhomeless patients. The strong relationship between the hospital and homeless health care clinic may have contributed to this finding.

Purpose: To determine whether variability of coarsely sampled heart rate and blood pressure early in the course of severe sepsis and septic shock predicts successful resuscitation, defined as vasopressor independence at 24 hours after admission. Methods: In an observational study of patients admitted with severe sepsis or septic shock from 2009 to 2011 to either of 2 intensive care units (ICUs) at a tertiary-care hospital, in whom blood pressure was measured via an arterial catheter, we sampled heart rate and blood pressure every 30 seconds over the first 6 hours of ICU admission and calculated the coefficient of variability of those measurements. Primary outcome was vasopressor independence at 24 hours; and secondary outcome was 28-day mortality. Results: We studied 165 patients, of which 97 (59%) achieved vasopressor independence at 24 hours. Overall, 28-day mortality was 15%. Significant predictors of vasopressor independence at 24 hours included the coefficient of variation of heart rate, age, Acute Physiology and Chronic Health Evaluation II, the number of increases in vasopressor dose, mean vasopressin dose, mean blood pressure, and time–pressure integral of mean blood pressure less than 60 mm Hg. Lower sampling frequencies (up to once every 5 minutes) did not affect the findings. Conclusions: Increased variability of coarsely sampled heart rate was associated with vasopressor independence at 24 hours after controlling for possible confounders. Sampling frequencies of once in 5 minutes may be similar to once in 30 seconds.

Volume expansion is a mainstay of therapy in septic shock, although its effect is difficult to predict using conventional measurements. Dynamic parameters, which vary with respiratory changes, appear to predict hemodynamic response to fluid challenge in mechanically ventilated, paralyzed patients. Whether they predict response in patients who are free from mechanical ventilation is unknown. We hypothesized that dynamic parameters would be predictive in patients not receiving mechanical ventilation. This is a prospective, observational, pilot study. Patients with early septic shock and who were not receiving mechanical ventilation received 10-mL/kg volume expansion (VE) at their treating physician's discretion after initial resuscitation in the emergency department. We used transthoracic echocardiography to measure vena cava collapsibility index and aortic velocity variation before VE. We used a pulse contour analysis device to measure stroke volume variation (SVV). Cardiac index was measured immediately before and after VE using transthoracic echocardiography. Hemodynamic response was defined as an increase in cardiac index 15% or greater. Fourteen patients received VE, five of whom demonstrated a hemodynamic response. Vena cava collapsibility index and SVV were predictive (area under the curve = 0.83, 0.92, respectively). Optimal thresholds were calculated: vena cava collapsibility index, 15% or greater (positive predictive value, 62%; negative predictive value, 100%; P = 0.03); SVV, 17% or greater (positive predictive value 100%, negative predictive value 82%, P = 0.03). Aortic velocity variation was not predictive. Vena cava collapsibility index and SVV predict hemodynamic response to fluid challenge patients with septic shock who are not mechanically ventilated. Optimal thresholds differ from those described in mechanically ventilated patients.

Background Some patients with hypotensive shock do not respond to usual doses of vasopressor therapy. Very little is known about outcomes after high-dose vasopressor therapy (HDV). We sought to characterize survival among patients with shock requiring HDV. We also evaluated the possible utility of stress-dose corticosteroid therapy in these patients. Methods We conducted a retrospective study of patients with shock requiring HDV in the ICUs of five hospitals from 2005 through 2010. We defined HDV as receipt at any point of ≥ 1 μg/kg/min of norepinephrine equivalent (calculated by summing norepinephrine-equivalent infusion rates of all vasopressors). We report survival 90 days after hospital admission. We evaluated receipt of stress-dose corticosteroids, cause of shock, receipt of CPR, and withdrawal or withholding of life support therapy. Results We identified 443 patients meeting inclusion criteria. Seventy-six (17%) survived. Survival was similar (20%) among the 241 patients with septic shock. Among the 367 nonsurvivors, 254 (69%) experienced withholding/withdrawal of care, and 115 (31%) underwent CPR. Stress-dose corticosteroid therapy was associated with increased survival (P = .01). Conclusions One in six patients with shock survived to 90 days after HDV. The majority of nonsurvivors died after withdrawal or withholding of life support therapy. A minority of patients underwent CPR. Additionally, stress-dose corticosteroid therapy appears reasonable in patients with shock requiring HDV.

Volume expansion is a common therapeutic intervention in septic shock, although patient response to the intervention is difficult to predict. Central venous pressure (CVP) and shock index have been used independently to guide volume expansion, although their use is questionable. We hypothesize that a combination of these measurements will be useful.In a prospective, observational study, patients with early septic shock received 10-mL/kg volume expansion at their treating physician's discretion after brief initial resuscitation in the emergency department. Central venous pressure and shock index were measured before volume expansion interventions. Cardiac index was measured immediately before and after the volume expansion using transthoracic echocardiography. Hemodynamic response was defined as an increase in a cardiac index of 15% or greater.Thirty-four volume expansions were observed in 25 patients. A CVP of 8 mm Hg or greater and a shock index of 1 beat min(-1) mm Hg(-1) or less individually had a good negative predictive value (83% and 88%, respectively). Of 34 volume expansions, the combination of both a high CVP and a low shock index was extremely unlikely to elicit hemodynamic response (negative predictive value, 93%; P = .02).Volume expansion in patients with early septic shock with a CVP of 8 mm Hg or greater and a shock index of 1 beat min(-1) mm Hg(-1) or less is unlikely to lead to an increase in cardiac index.

Background Patients with severe sepsis or septic shock often exhibit significant cardiovascular dysfunction. We sought to determine whether severity of diastolic dysfunction assessed by transthoracic echocardiography (TTE) predicts 28-day mortality. Methods In this prospective, observational study conducted in two intensive care units at a tertiary care hospital, 78 patients (age 53.2 ± 17.1 years; 51% females; mean APACHE II score 23.3 ± 7.4) with severe sepsis or septic shock underwent TTE within 6 h of ICU admission, after 18 to 32 h, and after resolution of shock. Left ventricular (LV) diastolic dysfunction was defined according to modified American Society of Echocardiography 2009 guidelines using E, A, and e’ velocities; E/A and E/e’; and E deceleration time. Systolic dysfunction was defined as an ejection fraction

Background Fewer than half of eligible hospitalized medical patients receive appropriate venous thromboembolism (VTE) prophylaxis. One reason for this low rate is the complexity of existing risk assessment models. A simple set of easily identifiable risk factors that are highly predictive of VTE among hospitalized medical patients may enhance appropriate thromboprophylaxis. Methods Electronic medical record interrogation was performed to identify medical admissions from January 1, 2000-December 31, 2007 (n=143,000), and those patients with objectively confirmed VTE during hospitalization or within 90 days following discharge. Putative risk factors most predictive of VTE were identified, and a risk assessment model (RAM) was derived; 46,000 medicine admissions from January 1, 2008-December 31, 2009 served as a validation cohort to test the predictive ability of the RAM. The newly derived RAM was compared with a published VTE assessment tool (Kucher Score). Results Four risk factors: previous VTE; an order for bed rest; peripherally inserted central venous catheterization line; and a cancer diagnosis, were the minimal set most predictive of hospital-associated VTE (area under the receiver operating characteristic curve [AUC]=0.874; 95% confidence interval [CI], 0.869-0.880). These risk factors upon validation in a separate population (validation cohort) retained an AUC=0.843; 95% CI, 0.833-0.852. The ability of the 4-element RAM to identify patients at risk of developing VTE within 90 days was superior to the Kucher Score. Conclusions The 4-element RAM identified in this study may be used to identify patients at risk for VTE and improve rates of thromboprophylaxis. This simple and accurate RAM is an alternative to more complicated published VTE risk assessment tools that currently exist.