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Patients with receding or high hairlines have traditionally been considered unfavorable candidates for endoscopic brow lift as this can further lengthen the hairline. We analyzed outcomes in patients that underwent a novel endoscopic brow lift technique with placement of incisions and anchoring Endotine Forehead Devices (CoApt Systems Inc, Palo Alto, CA, USA) directly at the natural forehead crease lines, in an effort to minimize elevation of the hairline, whereas providing well-hidden scars. We retrospectively reviewed all patients who underwent this new Endotine and incision placement between 2016 and 2020. Preoperative and postoperative photographs of all patients were analyzed to determine the postoperative changes in brow elevation and forehead length proportion (defined as length from cranium to chin).The forehead length proportion was unchanged pre- and post-operatively, with no statistically significant differences noted (P = 0.48). The average brow position elevation ranged from 2.78 mm in the medial location to 5.05 mm in the lateral location. All patients were happy with their appearance and had improved visual fields postoperatively. The forehead scars healed well and were well hidden in forehead rhytids at long term follow-up.This novel endoscopic brow lift technique provides an option to utilize a minimally invasive approach in patients with receding hairline. With this technique, visible scars were minimized, whereas still being able to achieve reasonable brow elevation. Thus, our approach enables long term maintenance of brow elevation with inconspicuous scars in the forehead.

Periorbital hemorrhage is a potentially sight threatening surgical complication. The effect of new oral anticoagulants (NOACs) on hemorrhagic events after periorbital surgery has not been investigated. We describe four cases of severe delayed postoperative hemorrhage associated with NOACs, in addition to three cases in patients on traditional antithrombotic agents. Time of delayed hemorrhage ranged from postoperative day 2 to 6. Six patients required surgical intervention to achieve control of bleeding, and two patients required transfusion of blood products. Risk factors and management of this rare complication are discussed.

Prior work demonstrated that Phlpp1 deficiency alters trabecular bone mass and enhances M-CSF responsiveness, but the cell types and requirement of Phlpp1 for this effect were unclear. To understand the function of Phlpp1 within myeloid lineage cells, we crossed Phlpp1 floxed mice with mice harboring LysM-Cre. Micro-computed tomography of the distal femur of 12-week-old mice revealed a 30% increase in bone volume per total volume of Phlpp1 female conditional knockouts, but we did not observe significant changes within male Phlpp1 cKOLysM mice. Bone histomorphmetry of the proximal tibia further revealed that Phlpp1 cKOLysM females exhibited elevated osteoclast numbers, but conversely had reduced levels of serum markers of bone resorption as compared to littermate controls. Osteoblast number and serum markers of bone formation were unchanged. In vitro assays confirmed that Phlpp1 ablation enhanced osteoclast number and area, but limited bone resorption. Additionally, reconstitution with exogenous Phlpp1 suppressed osteoclast numbers. Dose response assays demonstrated that Phlpp1−/− cells are more responsive to M-CSF, but reconstitution with Phlpp1 abrogated this effect. Furthermore, small molecule-mediated Phlpp inhibition enhanced osteoclast numbers and size. Enhanced phosphorylation of Phlpp substrates—including Akt, ERK1/2, and PKCζ—accompanied these observations. In contrast, actin cytoskeleton disruption occurred within Phlpp inhibitor treated osteoclasts. Moreover, Phlpp inhibition reduced resorption of cells cultured on bovine bone slices in vitro. Our results demonstrate that Phlpp1 deficiency within myeloid lineage cells enhances bone mass by limiting bone resorption while leaving osteoclast numbers intact, moreover, we show that Phlpp1 represses osteoclastogenesis and controls responses to M-CSF.

Case-control analysis and systematic literature review.To illustrate the prognosis and perioperative risk factors associated with this condition.Ischemic optic neuropathy (ION) is the most common pathological diagnosis underlying postoperative vision loss. It comes in two primary forms-anterior (AION)-affecting the optic disc or posterior (PION) affecting the optic nerve proximal to the disc. Spine surgery remains one of the largest sources of acute perioperative visual loss.We performed a 1:4 case-control analysis (by age and year of surgery) for patients with ION and those who didn't develop ION following spine surgery at our institution. A systematic literature search of Medline, Embase, Scopus from inception to September 2017 as also performed.We identified 12 cases from our institution. Comparison to 48 matched controls revealed fusion, higher number of operative levels, blood loss, and change in hemoglobin, hematocrit to be significantly associated with ION. Majority were diagnosed with PION (83%, 10/12) and had bilateral presentation (75%, 9/12). Only 30% patients (3/10) demonstrated improvement in visual acuity while the rest remained either unchanged (40%, 4/10) or worsened (20%, 2/10) at last follow-up. Literature review identified 182 cases from 42 studies. Posterior ischemic optic neuropathy (PION) was found in 58.7% (114/194) of cases, anterior ischemic optic neuropathy (AION) in 17% (33/19) and unspecified ION in 24% (47/194). PION was associated with higher odds of severe visual deficit at immediate presentation (odds ratio [OR]: 6.45, confidence interval [CI]: 1.04-54.3, P = 0.04) and last follow-up.PION is the most common cause of vision loss following spine surgery and causes more severe visual deficits compared with AION. Prone spine surgery especially multi-level fusions with longer operative time, higher blood loss, and intraoperative hypotension are most associated with the development of this devastating complication.3.

Suicide is a major public health issue and is the second leading cause of death among adolescents. Teachers are in an ideal position to screen and refer at-risk students, but most teachers have not received adequate training in this area. The purpose of this study was to assess the effectiveness of a computer simulation on training teachers in effective identification and referral practices for middle school students at-risk for bullying and suicidal ideation. Students in a Masters of Arts in Teaching (MAT) program in New York State completed At-Risk for Middle School Educators, a computer simulation created by Kognito Interactive that is intended to effectively train teachers in effective identification and referral practices for middle school students at-risk for bullying and suicidal ideation. Participants completed pre- and post-intervention surveys and participated in an online discussion of the simulation training. Results of a paired-samples t test indicated that At-Risk for Middle School Educators significantly improved the likelihood that teachers will recommend a student in distress for psychological services. It also significantly improved teacher confidence and competence in approaching and referring at-risk students to mental health services. Although the sample size was small and further research is warranted, results suggest that At-Risk for Middle School Educators is an effective training tool for educators in the area of the identification and referral of at-risk students.

Patients with syphilis can present with optic disc oedema (ODE) without visual compromise, which has been primarily attributed to papilloedema from raised intracranial pressure or optic perineuritis from optic nerve sheath inflammation. We report four cases of ODE in the setting of syphilis with preserved visual function, normal intracranial pressure, and no enhancement of the optic nerve or sheath on magnetic resonance imaging. We propose the term “incipient syphilitic papillitis” for cases presenting with ODE, preserved vision and absence of optic nerve sheath enhancement, which is likely a more common presentation than syphilitic optic perineuritis.

Background There is robust preclinical literature and preliminary clinical findings supporting the use of N-Acetylcysteine (NAC) to treat substance use disorders, including tobacco use disorder (TUD). However, randomized controlled trials have yielded mixed results and NAC’s efficacy for TUD has not been established. The goals of this study were to assess the efficacy of NAC in promoting early and end-of-treatment abstinence and preventing relapse among adult smokers. Methods This randomized, double-blinded clinical trial enrolled adult, daily smokers (N = 114; ages 23–64; 51 % female; 65 % White; 29 % Black/African American; 7% Hispanic/Latinx), who were randomized 1:1 to receive NAC (n = 59) or placebo (n = 55) (1200 mg b.i.d.) for eight weeks. Participants received brief cessation counseling and incentives for abstinence during the first three days of the quit attempt. Primary outcomes: (i) carbon monoxide (CO)-confirmed abstinence during the first three days of the quit attempt. Secondary outcomes: (ii) time to relapse; (iii) biologically confirmed abstinence at Week 8. Results No differences were found between NAC and placebo groups on measures of early abstinence (3-day quit attempt; 11 % for NAC vs. 15 % for placebo; all p > 0.11), time to relapse (p = 0.19), and end-of-treatment abstinence (7% for NAC vs. 11 % for placebo; all p > 0.40]. Conclusions Results indicate that NAC is a well-tolerated pharmacotherapy but is unlikely to be efficacious as a monotherapy for TUD in adults. Considered in the collective context of other research, NAC may potentially be more useful in a younger population, as a combination pharmacotherapy, or in the presence of more intensive psychosocial treatment.

Prior studies demonstrated that deletion of the protein phosphatase Phlpp1 in Ctsk-Cre expressing cells enhances bone mass, characterized by diminished osteoclast activity and increased coupling to bone formation. Due to non-specific expression of Ctsk-Cre, the definitive mechanism for this observation was unclear. To further define the role of bone resorbing osteoclasts, we performed ovariectomy (Ovx) and Sham surgeries on Phlpp1 cKOCtsk and WT mice. Micro-CT analyses confirmed enhanced bone mass of Phlpp1 cKOCtsk Sham females. In contrast, Ovx induced bone loss in both groups, with no difference between Phlpp1 cKOCtsk and WT mice. Histomorphometry demonstrated that Ovx mice lacked differences in osteoclasts per bone surface, suggesting that estradiol (E2) is required for Phlpp1 deficiency to have an effect. We performed high throughput unbiased transcriptional profiling of Phlpp1 cKOCtsk osteoclasts and identified 290 differentially expressed genes. By cross-referencing these differentially expressed genes with all estrogen response element (ERE) containing genes, we identified IGFBP4 as potential estrogen-dependent target of Phlpp1. E2 induced PHLPP1 expression, but reduced IGFBP4 levels. Moreover, genetic deletion or chemical inhibition of Phlpp1 was correlated with IGFBP4 levels. We then assessed IGFBP4 expression by osteoclasts in vivo within intact 12-week-old females. Modest IGFBP4 immunohistochemical staining of TRAP+ osteoclasts within WT females was observed. In contrast, TRAP+ bone lining cells within intact Phlpp1 cKOCtsk females robustly expressed IGFBP4, but levels were diminished within TRAP+ bone lining cells following Ovx. These results demonstrate that effects of Phlpp1 conditional deficiency are lost following Ovx, potentially due to estrogen-dependent regulation of IGFBP4.

Musculoskeletal pain contributes significantly to chronic pain experienced by adults and to health care use. This chapter details several methods to evaluate pain and physical activity in mice that can be applied to preclinical orthopedic models. These methods include the von Frey filament assay that measures mechanical allodynia, open-field activity assays for evaluation of ambulation, and incapacitance measurements to determine static weight bearing.

Background: This study aims to compare the prevalence of dry eye symptoms following blepharoptosis surgery and surgical outcomes in patients ≥80 years old when compared to younger, case-matched con...

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.

Phlpp protein phosphatases are abnormally abundant within human osteoarthritic articular chondrocytes and may contribute to the development of osteoarthritis. Mice lacking Phlpp1 were previously shown to be resistant to post-traumatic osteoarthritis. Here a small molecule with therapeutic properties that inhibits Phlpp1 and Phlpp2 was tested for its ability to slow post-traumatic OA in mice and to stimulate anabolic pathways in human articular cartilage from OA joints. PTOA was induced in male C57Bl/6 mice by surgically destabilizing the meniscus. Seven weeks after surgery, mice received a single intra-articular injection of the Phlpp inhibitor NSC117079 or saline. Mechanical allodynia was measured with von Frey assays, mobility was tracked in an open field system, and cartilage damage was assessed histologically. A single intra-articular injection of the Phlpp inhibitor NSC117079 attenuated mechanical allodynia and slowed articular cartilage degradation in joints with a destabilized meniscus. Animals treated with the Phlpp inhibitor 7 weeks after injury maintained normal activity levels, while those in the control group traveled shorter distances and were less active 3 months after the joint injury. NSC117079 also increased production of cartilage extracellular matrix components (glycosaminoglycans and aggrecan) in over 90% of human articular cartilage explants from OA patients and increased phosphorylation of Phlpp1 substrates (AKT2, ERK1/2, and PKC) in human articular chondrocytes. Our results indicate that Phlpp inhibitor NSC117079 is a novel osteoarthritis disease modifying drug candidate that may have palliative affects. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1487-1497, 2018.

BackgroundHospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced.MethodsThis is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services.ResultsWe observed significant changes (pConclusionsInvesting in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.

Type 2 diabetes is an emerging global health epidemic. Foundations for new therapies are arising from understanding interactions between body systems. Bone-derived factors that reduce RANKL (receptor activator of NF-kappa B ligand) signaling in the liver may prevent insulin resistance and the onset of type 2 diabetes. Here we demonstrate that deletion of the epigenetic regulator, Hdac3, in Osx1-expressing osteoprogenitors prevents insulin resistance induced by high fat diet by increasing serum and skeletal gene expression levels of osteoprotegerin (Opg), a natural inhibitor of RANKL signaling. Removal of one Opg allele in mice lacking Hdac3 in Osx1+ osteoprogenitors increases the insulin resistance of the Hdac3-deficient mice on a high fat diet. Thus, Hdac3-depletion in osteoblasts increases expression of Opg, subsequently preserving insulin sensitivity. The Hdac inhibitor vorinostat also increased Opg transcription and histone acetylation of the Opg locus. These results define a new mechanism by which bone regulates systemic insulin sensitivity.

In 2015 an estimated 2.7 million people in the United States (1 percent of the population) died. Although decedents' illness experience varies substantially, important trends in care at the end of life are evident. To identify the most pressing health care policy issues related to end-of-life care, we present a comprehensive picture of the epidemiology and care patterns of people in the last stage of life. We identify three key trends in end-of-life care: increasing diversity in the primary diagnoses of decedents, increases in multimorbidity and illness complexity among people with terminal illnesses, and shifts in patterns of care at the end of life and in sites of death. This changing epidemiology of those in the last phase of life puts new pressures on the Medicare hospice benefit to ensure the availability of high-quality end-of-life care. In addition, health care policy makers must grapple with the fact that even with increasing use of hospice care, care intensity increases at the end of life. We highlight and discuss tensions that must be managed to ensure that high-quality care is accessible for people at the end of life.

Background Face transplantation can offer functional and aesthetic restoration to patients who have exhausted their reconstructive options, improving quality of life and psychosocial integration. Ethical issues in face transplantation abound, including questions of patient selection and evaluation before transplantation. To date, there has been no study of ethicists' opinions regarding face transplantation. Methods An online survey of attendees of the 2015 International Conference on Clinical Ethics Consultation (n = 401) assessed ethicists' opinions about face transplantation. Questions examined the risk-to-benefit ratio of immunosuppression; permissibility of face transplantation in subpopulations (including children and blind patients); donor-recipient age, sex, and ethnicity mismatches; and ethical oversight. Results Most ethicists (84 percent) agreed that it is permissible to perform a face transplantation on an adult in the absence of clear medical contraindications. Most respondents also agreed that it is permissible to perform a face transplantation on a child (62 percent) or a blind patient (61 percent), yet demonstrated less consensus regarding the permissibility of performing a face transplantation on patients with an increased risk of immune rejection. Respondents were generally supportive of age, sex, and ethnicity mismatches, with 43 percent indicating that it is permissible to have a sex mismatch. The majority answered that face transplantation should be covered by federal insurance (74 percent). Conclusions This study provides insight into clinical ethicists' views regarding face transplantation. Most ethicists support the ethical permissibility of face transplantation, and did not have concerns about age, sex, and ethnicity mismatches. These findings highlight emerging areas of consensus regarding the ethical permissibility of face transplantation.

Background There is no consensus exists regarding which reconstructive approach, if any, should be used after performing transcranial lateral orbital wall resections. Rigid reconstruction is often done to prevent enophthalmos; however, it is not clear if this is a risk with extensive orbital wall resections for transcranial surgery. Objective To assess globe position dynamics in patients that underwent transcranial lateral and superior orbital wall resections without rigid reconstruction to determine if enophthalmos is a significant risk. Methods Preoperative (PO) and postoperative data were retrospectively collected from the electronic medical records of 55 adult patients undergoing lateral and superior orbital wall resections as part of a skull base approach. The globe positions were assessed radiologically at all available time points and used to track relative globe displacements over time. Results An evaluation of PO variables identified a relationship between maximum lesion diameters and globe positions dynamics. The composition of globe position presentations in the population remained relatively stable over time, with only 1 out of 55 patients (1.81%) developing postoperative enophthalmos. An assessment of mean globe displacements revealed improvements in the patients presenting with PO exophthalmos, and stability in the patients presenting with normal PO globe positions. Conclusions Excellent results in long-term postoperative globe position dynamics can be achieved without the use of rigid reconstruction after transcranial lateral and superior orbital wall resections, regardless of the PO globe positioning.

Mental disorders are disabling and economically costly health conditions. Given limited resources, mental health systems in low- and middle-income countries (LMICs) tend to focus on patients with the most severe conditions, for whom treatment usually relies on use of psychoactive medications; however, inconsistent patterns of use can be ineffective, wasteful, and potentially harmful. Therefore, a greater understanding of prescription practices and medication availability in LMIC is needed. We estimated associations between prescription practices and hospitals and medication availability for patients diagnosed with schizophrenia or delusional disorders (n = 7,296) and patients diagnosed with epilepsy (n = 1,807), the two most common mental and neurological disorders seen at Ghana’s psychiatric hospitals. Among patients with a primary diagnosis of schizophrenia or delusional disorders, 43% were prescribed an anti-psychotic or combination of anti-psychotics and anti-cholinergics. Among patients with...

Osteoarthritis (OA) is the leading form of arthritis in the elderly, causing pain, disability, and immobility. OA has been associated with accumulation of senescent cells in or near joints. However, evidence for a causal link between OA and cellular senescence is lacking. Here, we present a novel senescent cell transplantation model involving injection of small numbers of senescent or nonsenescent cells from the ear cartilage of luciferase-expressing mice into the knee joint area of wild-type mice. By using bioluminescence and 18FDG PET imaging, we could track the injected cells in vivo for more than 10 days. Transplanting senescent cells into the knee region caused leg pain, impaired mobility, and radiographic and histological changes suggestive of OA. Transplanting nonsenescent cells had less of these effects. Thus, senescent cells can induce an OA-like state and targeting senescent cells could be a promising strategy for treating OA.

Background: Despite evidence that enrollment with hospice services has the potential to reduce hospital readmission rates, previous research has not examined exactly how hospitals may promote the appropriate use of hospice and palliative care for their discharged patients. Therefore, we sought to explore the strategies used by hospitals to increase the use of hospice and palliative care for patients at risk of readmission. Methods: We conducted a secondary analysis of qualitative data from a study of hospitals that were participating in the State Action on Avoidable Readmissions (STAAR) initiative, a quality improvement collaborative. We used data attained from 46 in-depth interviews conducted during 10 hospital site visits using a standard discussion guide and protocol. We used a grounded theory approach using the constant comparative method to generate recurrent and unifying themes. Results: We found that a positive effect for hospitals participating in the STAAR initiative was enhanced engagement in efforts to promote greater use of hospice and palliative care as a possible method of reducing unplanned readmissions, the central goal of the STAAR initiative. Hospital staff described strategies to increase the use of hospice and palliative care that included (1) designing and implementing tracking systems to identify patients most at risk of being readmitted, (2) providing education about hospice and palliative care to family, internal and external clinical groups, and (3) establishing closer links to posthospital settings. Conclusion: National efforts to reduce rehospitalizations may result in improved integration of hospice and palliative care for patients who are at risk of readmission.

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.

Purpose The authors aimed to determine key features of IgG4-related ophthalmic disease (IgG4-ROD) and Graves orbitopathy (GO) to aid in diagnosis. Methods The authors retrospectively identified ophthalmology patients seen between June 2009 and November 2013 with clinical overlap of GO and IgG4-ROD. Patient findings were reviewed to characterize the 2 conditions. Results Among 8 patients (7 male and 1 female), the mean age was 45.8 years. Time between diagnoses of GO and IgG4-ROD ranged from 1 month to 8 years. Imaging showed enlarged extraocular muscles in all patients. Enlarged infraorbital nerves were seen in 4 patients. Tissue biopsy showed CD20+ lymphocytes with a large proportion of IgG4 plasma cells in 7 of 8 orbital specimens. Six patients had a ratio of IgG4:IgG cells >40%. Discussion No pathognomonic clinical findings for GO or IgG4-ROD have been reported, but some key features can help distinguish the conditions. GO is likely if findings include increased thyrotropin receptor antibodies, lid retraction/lid lag, and enlarged extraocular muscles with typical tendon-sparing morphology. Findings suggestive of IgG4-ROD include history of asthma and progressive orbital disease in patients with previous diagnosis of GO, disproportionately large lateral rectus muscle, and enlarged infraorbital nerves. Increased serum IgG4 level and biopsy showing >10 IgG4+ plasma cells/high-power field and IgG4:IgG ratio >40% will support the diagnosis of IgG4-ROD. Conclusions GO and IgG4-ROD are complicated inflammatory processes affecting the orbit and present diagnostic challenges. The authors recommend biopsy for patients who do not follow the usual clinical course of GO or have clinical characteristics of IgG4-ROD.

The authors describe three children who developed excess overhanging upper eyelid tissue following unilateral levator resection for congenital ptosis. This was thought to be pre-aponeurotic fat herniation. A second procedure, a variation of sulcoplasty, was performed at a mean 4.3 months later and all three children showed improved sulcus and crease symmetry. [ J Pediatr Ophthalmol Strabismus . 2019;56:e1–e4.]

Histone deacetylases (Hdacs) are conserved enzymes that remove acetyl groups from lysine side chains in histones and other proteins. Eleven of the 18 Hdacs encoded by the human and mouse genomes depend on Zn2+for enzymatic activity, while the other 7, the sirtuins (Sirts), require NAD2+. Collectively, Hdacs and Sirts regulate numerous cellular and mitochondrial processes including gene transcription, DNA repair, protein stability, cytoskeletal dynamics, and signaling pathways to affect both development and aging. Of clinical relevance, Hdacs inhibitors are United States Food and Drug Administration-approved cancer therapeutics and are candidate therapies for other common diseases including arthritis, diabetes, epilepsy, heart disease, HIV infection, neurodegeneration, and numerous aging-related disorders. Hdacs and Sirts influence skeletal development, maintenance of mineral density and bone strength by affecting intramembranous and endochondral ossification, as well as bone resorption. With few exceptions, inhibition of Hdac or Sirt activity though either loss-of-function mutations or prolonged chemical inhibition has negative and/or toxic effects on skeletal development and bone mineral density. Specifically, Hdac/Sirt suppression causes abnormalities in physiological development such as craniofacial dimorphisms, short stature, and bone fragility that are associated with several human syndromes or diseases. In contrast, activation of Sirts may protect the skeleton from aging and immobilization-related bone loss. This knowledge may prolong healthspan and prevent adverse events caused by epigenetic therapies that are entering the clinical realm at an unprecedented rate. In this review, we summarize the general properties of Hdacs/Sirts and the research that has revealed their essential functions in bone forming cells (e.g., osteoblasts and chondrocytes) and bone resorbing osteoclasts. Finally, we offer predictions on future research in this area and the utility of this knowledge for orthopedic applications and bone tissue engineering.

In 2011, 1.65 million individuals with terminal illnesses received hospice services, and 44.6% of all decedents in the United States had been under the care of a hospice.1 Hospice users and their primary caregivers are typically older adults. In 2013, an estimated 84% of hospice users were aged 65 and older and 41% were aged 85 and older.2 Primary caregivers, who help make decisions for terminally ill individuals, are most often their spouses or adult children who are aged 60 and older.3 Although most family members of individuals in hospice who die recover from initial reactions of acute grief and return to preloss functioning,4 an estimated 11% develop the mental health disorders of complicated grief (CG) and depression, with prevalence increasing slightly with increasing age.5–7 CG is characterized by symptoms of reactive distress to the death (e.g., disbelief or bitterness) and disruption in social relationships or identity.8 Criteria for major depressive disorder (depression) are well established,8 but diagnosis of depression after bereavement has recently undergone a significant change. The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, allows diagnosis of depression within 2 weeks of bereavement, replacing the DSM, Fourth Edition, requirement that depression not be diagnosed until 2 months after bereavement.8 This change expands the population of individuals who might benefit from screening and treatment. In older adults, depression and CG are associated with greater risk of morbidity for most of the common diseases of later life, including chronic functional impairment, hypertension, sleep impairment, and suicidal ideation.9–18 For example, the risk of hypertension is 10 times as high in older widowed adults who meet consensus criteria for CG as in those who do not.19 As the U.S. population continues to age, it is likely that the impairment associated with depression and CG will create an even greater societal burden. Well-validated measures and effective individual and group psychotherapeutic treatments for CG and depression in older adults have been developed,20–22 yet older adults are less likely to seek bereavement support than younger adults,23 in part because of a cohort-specific stigma about the acceptability of using mental health care.24 Because hospices care for people before and during death, they are uniquely positioned to offer screening and referral services for CG and bereavement-related depression in older family caregivers. Receiving bereavement support in a setting to which older adults are already connected may make it use more likely.25 Moreover, Medicare, the primary payer for hospice care (providing coverage to 84% of people in hospice)1 requires that hospices offer bereavement services to family members for at least a year after the person in hospice dies in order to receive reimbursement under the Medicare Hospice Benefit.1 Although hospice provision of bereavement services has been described in detail,26–29 previous publications have not focused specifically on screening and referral practices for CG or depression. Accordingly, the current study used data from the National Hospice Survey to estimate the extent to which hospices nationally provide screening and referral services that address the mental health needs of family members of individuals who die in hospice. The associations between organizational and staff factors and the likelihood of offering screening and referral for CG and depression were also examined. Organizational theory posits that organizational structure can affect the type and quality of care provided.30 In this analysis, organizational factors considered included hospice profit status, chain affiliation, size, and geographical region. In keeping with previous work, it was hypothesized that larger hospice size would be associated with higher likelihood of conducting screening and referral.29 Because previous analyses did not find consistent associations between profit status, chain affiliation, region, and bereavement service intensity more generally,29 it was not expected to that any association would be found with these variables in the analyses. It was also hypothesized that the extent to which hospices provide screening and referral or bereavement-related mental health conditions would be associated with provider- level factors, such as level of provider training, volunteer availability, and interdisciplinary team meeting involvement. Consistent with theories that participation of and interactions among providers of a variety of backgrounds can enhance care,31–33 research has demonstrated that social worker and volunteer involvement, and interdisciplinary collaboration more broadly, are associated with better quality of care for people in hospice.22,34,35 Training requirements have also been associated with quality of bereavement care provision specifically,36 but these associations have not been adequately studied for hospice bereavement care. As previous findings and existing theory predicted, it was hypothesized that lengthier training requirements, interdisciplinary team attendance from a large range of providers, and a lower ratio of volunteer hours to number of individuals in hospice would be associated with higher likelihood of conducting CG and depression screening and referral. Findings from this study can provide a more-complete picture of how hospices may be screening for important bereavement-related mental health problems and helping family caregivers connect to appropriate care after the death. This information can inform future work to identify strategies to improve mental health screening or therapy in hospices, as well as in other settings with a large bereaved population.

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.

Graves' orbitopathy (GO) is a potentially sight-threatening disease for which available medical therapy is not uniformly successful. Multiple case series suggest that rituximab (RTX) may be effective therapy for GO patients.To determine the efficacy of RTX in GO.It is a prospective, randomized, double-masked, placebo-controlled trial.The study was conducted at a large academic private practice.Twenty five patients with active moderate to severe GO were enrolled, and 21 completed the study to the primary endpoint.Two RTX infusions (1000 mg each) or two saline infusions were given 2 weeks apart.The primary endpoint was a reduction in clinical activity score (CAS) assessed as a continuum and separately as improvement by ≥ 2 points at 24 weeks. Secondary endpoints included success and failure rates, proportions showing clinically significant improvement in proptosis, lid fissure width, diplopia score, lagophthalmos and disease severity, and changes in those parameters, orbital fat/ muscle volume and quality-of-life.The treatment groups were similar in all parameters at baseline. The last observation was carried forward if the patient discontinued prematurely. No differences were found in the proportions of patients showing CAS improvement at 24 weeks (25% placebo; 31% RTX, P = .75) or in CAS decrease from baseline to 24 or 52 weeks [mean 1.5 points (1.8 SD) placebo; 1.2 (2 SD) RTX at 24 weeks, P = .73]. Similarly, there were no differences between groups in any of the secondary endpoints at either 24 or 52 weeks. There were four adverse events (AE) in 3/12 placebo patients and 11 AE in 8/13 RTX-treated patients; 5/6 moderate or severe AE occurred in the RTX group.RTX offered no additional benefit over placebo to our patients with active and moderate to severe GO and carried with it non-negligible adverse effects.

Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice.To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees.Longitudinal, observational cohort study (2008-2010).Medicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355).We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures.Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices.Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.

Hospice use has increased substantially during the past decade by an increasingly diverse patient population; however, little is known about patterns of hospice use and how these patterns have changed during the past decade.To characterize Medicare hospice users in 2000 and 2010 and estimate the prevalence of (1) very short (≤1 wk) hospice enrollment; (2) very long (6 mo) hospice enrollment; and (3) hospice disenrollment and how these utilization patterns have varied over time and by patient and hospice characteristics.Cross-sectional analysis of Medicare hospice claims data from 2000 and 2010.All US Medicare Hospice Benefit enrollees in 2000 (N=529,573) and 2010 (N=1,150,194).As of 2010, more than half (53.4%) of all Medicare decedents who used hospice had either very short (≤1 wk, 32.4%) or very long (6 mo, 13.9%) hospice enrollment or disenrolled from hospice before death (10.6%). This represents an increase of 4.9 percentage points from 2000. In multivariable analysis, patients with noncancer diagnoses, the fastest growing group of hospice users, were approximately twice as likely as those with cancer to have very short or long enrollment periods and to disenroll from hospice.The substantial proportion of hospice users with very short or long enrollment, or enrollments that end before death, underscores the potential for interventions to improve the timing and appropriateness of hospice referral so that the full benefits of hospice are received by patients and families.

ObjectiveTo examine whether state-level spending on social and public health services is associated with lower rates of homicide in the USA.DesignEcological study.SettingUSA.ParticipantsAll states in the USA and the District of Columbia for which data were available (n=42).Primary outcome measureHomicide rates for each state were abstracted from the US Department of Justice Federal Bureau of Investigation’s Uniform Crime Reporting.ResultsAfter adjusting for potential confounding variables, we found that every $10 000 increase in spending per person living in poverty was associated with 0.87 fewer homicides per 100 000 population or approximately a 16% decrease in the average homicide rate (estimate=−0.87, SE=0.15, pConclusionsBased on our findings, spending on social and public health services is associated with significantly lower homicide rates at the state level. Although we cannot infer causality from this research, such spending may provide promising avenues for homicide reduction in the USA, particularly among states with lower levels of poverty.

Objectives To examine rates of hospice disenrollment and posthospice hospitalization among patients who are enrolled in hospices that provide continuous home care (CHC) (CHC hospices) compared with patients who are enrolled in hospices that do not offer CHC (non-CHC hospices). Methods We performed a retrospective cohort study among Medicare fee-for-service decedents between July and December 2011, who were 66 years and older and had used hospice in their last 6 months of life. We used propensity score matching to account for potential confounding characteristics of hospices. Generalized estimating equation models were applied to estimate between CHC hospices and non-CHC hospices the associations of hospice disenrollment/hospitalization, adjusted for patient characteristics. We also conducted subgroup analyses to examine how the association might have differed by hospice size, and by the percentage of enrollees who received CHC. Results After matching, we identified 936 pairs of CHC and non-CHC hospices, well balanced in terms of organizational characteristics. In fully adjusted models, compared with non-CHC hospices, CHC hospices had significantly lower disenrollment rates (adjusted rate ratio, 0.73; 95% confidence interval, 0.60-0.87), and lower hospitalization rates (adjusted rate ratio, 0.79; 95% confidence interval, 0.66-0.95). These associations were significantly more pronounced among larger hospices (those with >175 enrollees during study period), and among hospices in which at least 7.3% of enrollees used CHC. Conclusions CHC hospices had significantly lower rates of hospice disenrollment and posthospice hospitalization, suggesting CHC service available may enable higher quality of end-of-life care.

Background To determine the patterns of alcohol use among households in Trinidad and Tobago (T&T) and to estimate the association between alcohol use and negative psychological, social, or physical events experienced by the household. Methods A convenience sample of 1837 households across T&T. We identified bivariate correlates of alcohol use, and heavy episodic drinking using chi-square and t-test analyses and used multivariable logistic regression to estimate adjusted associations between household alcohol use and experiences within the past 12 months adjusted for sociodemographic covariates. Results One thousand five hundred two households had complete data for all variables (82% response rate). Nearly two thirds (64%) of households included alcohol users; 57% of household that consumed alcohol also reported heavy episodic drinking. Households that reported alcohol consumption were significantly more likely to report illnesses within the households, relationship problems, and behavioral and antisocial problems with children. Among households where a member was employed, those who consumed alcohol were nearly twice as likely (OR = 1.98; 95% confidence interval (CI) 1.03, 3.82) to have a household member call in sick to work and 2.9 times as likely (OR = 2.9; CI 1.19, 7.04) to have a household member suffer work related problems compared with households who reported not consuming alcohol. Conclusions Approximately two thirds of households in T&T reported using alcohol. These households were more likely to report psychological, physical, and social problems. These findings would support efforts to enforce current policies, laws, and regulations as well as new strategies to reduce the impact of harmful alcohol consumption on households in T&T. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4266-z) contains supplementary material, which is available to authorized users.

Purpose To determine if tangent visual fields gathered during assessment of superior visual field deficits caused by blepharoptosis and dermatochalasis offer good correlation to clinical exam in a time and cost efficient manner. Methods Prospective, observational case series. Subjects included all patients referred to a single surgeon (CCN) who underwent surgical correction of blepharoptosis and/or dermatochalasis. Preoperatively and postoperatively, upper margin-to-reflex distances were assessed. Tangent visual fields were performed in a timed fashion and analyzed for degrees of intact vision in the vertical meridian and degrees squared of area under the curve. Data were compared by Student t-tests and Pearson correlation coefficients. Results Mean preoperative superior visual fields with the eyelid in the natural position measured 8° in the vertical meridian. Measurements in the vertical meridian and area under the curve showed excellent correlation (r = 0.87). Patients with ptosis showed strong correlation between margin-to-reflex distance and superior visual fields. Patients completed field testing faster than reported times for automated or Goldmann testing. Finally, tangent screens were the least expensive type of equipment to purchase. Conclusions Tangent visual fields are a rapid and inexpensive way to test for functional loss of superior visual field in patients with upper eyelid malposition. Our data revealed potential differences between tangent screen results and published results for automated or Goldmann visual field testing which warrants further studies.

BACKGROUND Despite recent reductions in national unplanned readmission rates, we have relatively little understanding of which hospital strategies are most associated with changes in risk-standardized readmission rates (RSRR). OBJECTIVE We examined associations between the change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies over 12–18 months in a national sample of hospitals. DESIGN We conducted a prospective study of hospitals using a Web-based survey at baseline (November 2010–May 2011, n = 599, 91.0 % response rate) and 12–18 months later (November 2011–October 2012, n = 501, 83.6 % response rate), with RSRR measured at the same time points. The final analytic sample included 478 hospitals. PARTICIPANTS The study included hospitals participating in the Hospital-to-Home (H2H) and State Action on Avoidable Rehospitalizations (STAAR) initiatives. MAIN MEASURES We examined associations between change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies previously demonstrated to have increased between baseline and follow-up, using unadjusted and adjusted linear regression. KEY RESULTS The average number of strategies taken up from baseline to follow-up was 1.6 (SE = 0.06); approximately one-quarter (25.3 %) of hospitals took up at least three new strategies. Hospitals that adopted the strategy of routinely discharging patients with a follow-up appointment already scheduled experienced significant reductions in RSRR (reduction of 0.63 percentage point, p value < 0.05). Hospitals that took up three or more strategies had significantly greater reductions in RSRR compared to hospitals that took up only zero to two strategies (reduction of 1.29 versus 0.57 percentage point, p value < 0.05). Among the 117 hospitals that took up three or more strategies, 93 unique combinations of strategies were used. CONCLUSIONS Although most individual strategies were not associated with RSRR reduction, hospitals that took up any three or more strategies showed significantly greater reduction in RSRR compared to hospitals that took up fewer than three strategies. Electronic supplementary material The online version of this article (doi:10.1007/s11606-014-3105-5) contains supplementary material, which is available to authorized users.

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

Foreign-educated and foreign-born health workers constitute a sizable and important portion of the US health care workforce. We review the distribution of these workers and their countries of origin, and we summarize the literature concerning their contributions to US health care. We also report on these workers' experiences in the United States and the impact their migration has on their home countries. Finally, we present policy strategies to increase the benefits of health care worker migration to the United States while mitigating its negative effects on the workers' home countries. These strategies include attracting more people with legal permanent residency status into the health workforce, reimbursing home countries for the cost of educating health workers who subsequently migrate to the United States, improving policies to facilitate the entry of direct care workers into the country, advancing efforts to promote and monitor ethical migration and recruitment practices, and encouraging the implementation of programs by US employers to improve the experience of immigrating health workers.

Reducing readmissions is a national priority, but many hospitals lack practical tools to identify patients at increased risk of unplanned readmission.To estimate the association between a composite measure of patient condition at discharge, the Rothman Index (RI), and unplanned readmission within 30 days of discharge.Adult medical and surgical patients in a major teaching hospital in 2011.The RI is a composite measure updated regularly from the electronic medical record based on changes in vital signs, nursing assessments, Braden score, cardiac rhythms, and laboratory test results. We developed 4 categories of RI and tested its association with readmission within 30 days, using logistic regression, adjusted for patient age, sex, insurance status, service assignment (medical or surgical), and primary discharge diagnosis.Sixteen percent of the sample patients (N=2730) had an unplanned readmission within 30 days of discharge. The risk of readmission for a patient in the highest risk category (RI70) was1 in 5 while the risk of readmission for patients in the lowest risk category was about 1 in 10. In multivariable analysis, patients with an RI70 (the highest risk category) or 70-79 (medium risk category) had 2.65 (95% confidence interval, 1.72-4.07) and 2.40 (95% confidence interval, 1.57-3.67) times higher odds of unplanned readmission, respectively, compared with patients in the lowest risk category.Clinicians can use the RI to help target hospital programs and supports to patients at highest risk of readmission.

Objectives. We sought to provide a systematic review of the determinants of success in scaling up and sustaining community health worker (CHW) programs in low- and middle-income countries (LMICs). Methods. We searched 11 electronic databases for academic literature published through December 2010 (n = 603 articles). Two independent reviewers applied exclusion criteria to identify articles that provided empirical evidence about the scale-up or sustainability of CHW programs in LMICs, then extracted data from each article by using a standardized form. We analyzed the resulting data for determinants and themes through iterated categorization. Results. The final sample of articles (n = 19) present data on CHW programs in 16 countries. We identified 23 enabling factors and 15 barriers to scale-up and sustainability, which were grouped into 3 thematic categories: program design and management, community fit, and integration with the broader environment. Conclusions. Scaling up and sustaining CHW programs in LMICs requires effective program design and management, including adequate training, supervision, motivation, and funding; acceptability of the program to the communities served; and securing support for the program from political leaders and other health care providers.

Objective To describe patient experiences with hospital inpatient care among participants living in rural China and to examine their associations with sociodemographic characteristics, hospital type and province. Design Cross-sectional study using data from questionnaires administered to members of randomly selected households in 2010. We used linear and logistic regression to determine associations between patient ratings of care and key components of their experience and between patient ratings of care and sociodemographic characteristics, hospital type and province. Setting Households located in seven provinces in rural China. Participants Household members >15 years who reported being admitted to the hospital within the last 365 days with valid data on our outcome measures ( n = 443). Main Outcome Measures Patient evaluations of health care experiences. Results Approximately 31% of participants rated their experiences 5.0 out of 5.0 (best), but 22% rated their experiences ≤3.0. Fifteen percent would not recommend the facility to family and friends. Five factors emerged, of which, ‘communication with nurses’ was most strongly and consistently associated with overall patient ratings. Multivariable models showed that ratings for township and county-level hospitals were significantly lower than above county-level hospitals. Variation also existed across the seven provinces. Conclusions Findings suggest that patients on average have high ratings of hospital care, but a notable proportion of participants, particularly those receiving care in county-level hospitals, continue to be less than fully satisfied. As China further develops its health system, establishing routine monitoring of patients' experiences will be important to ensure the system is responsive to the population needs.

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.

Background Adult obesity rates in the United States have reached epidemic proportions, yet vary considerably across states and counties. We sought to explore community-level factors that may be associated with reduced adult obesity rates at the county level. Methods We identified six U.S. counties that were positive deviants for adult obesity and conducted semi-structured interviews with community leaders and government officials involved in efforts to promote healthier lifestyles. Using site visits and in-depth qualitative interviews, we identified several recurrent themes and strategies. Results Participants: 1) developed a nuanced understanding of their communities; 2) recognized the complex nature of obesity, and 3) implemented a county-wide strategic approach for promoting healthy living. This county-wide approachwas used to a) break down silos and build partnerships, b) access community resources and connections, and c) transfer ownership to community members. Conclusions We found that county leaders focused on establishing a county-wide structure to connect and support community-led initiatives to promote healthy living, reduce obesity, and foster sustainability. Findings from this study can help inform county-level efforts to improve healthy living and combat the multi-faceted challenges of adult obesity across the U.S.

Among the four levels of hospice care, continuous home care (CHC) is the most expensive care, and infrequently provided in practice.To identify hospice and patient characteristics associated with the use of CHC and to examine the associations between CHC utilization and hospice disenrollment or hospitalization after hospice enrollment.Using 100% fee-for-service Medicare claims data for beneficiaries aged 66 years or older who died between July and December 2011, we identified the percentage of hospice agencies in which patients used CHC in 2011 and determined hospice and patient characteristics associated with the use of CHC. Using multivariable analyses, we examined the associations between CHC utilization and hospice disenrollment and hospitalization after hospice enrollment, adjusted for hospice and patient characteristics.Only 42.7% of hospices (1533 of 3592 hospices studied) provided CHC to at least one patient during the study period. Patients enrolled with for-profit, larger, and urban located hospices were more likely to use CHC (P 0.001). Within these 1533 hospices, only 11.4% of patients used CHC. Patients who were white, had cancer, and had more comorbidities were more likely to use CHC. In multivariable models, compared with patients who did not use CHC, patients who used CHC were less likely to have hospice disenrollment (adjusted odds ratio 0.21; 95% CI 0.19, 0.23) and less likely to be hospitalized after hospice enrollment (adjusted odds ratio 0.37; 95% CI 0.34, 0.40).Although a minority of patients uses CHC, such services may be protective against hospice disenrollment and hospitalization after hospice enrollment.

Ethiopia implemented an innovative community-based health program, called the health extension program, to enhance access to basic health promotion, disease prevention and selected curative services by establishing health posts in every village, also called kebeles, with average of 5000 people, staffed with two health extension workers (HEWs). This time and motion study was done to estimate the amount of time that HEWs spend on various work duties and to explore differences in urban compared with rural settings and among regions. A total of 44 HEWs were observed for 21 consecutive days, and time and motion data were collected using tablet computers. On average, HEWs were on duty for 15.5 days out of the 21 days of observation period, and on average, they stayed on duty for about 6 hours per day. Out of the total observed work time, the percentages of total time spent on various activities were as follows: providing health education or services (12.8%); participating in meetings and giving trainings (9.3%); conducting community mapping and mobilization (0.8%); recordkeeping, reporting, managing family folders (13.2%); managing commodities and supplies (1.3%); receiving supervision (3.2%); receiving training (1.6%); travel between work activities (15.5%); waiting for clients in the health post (or health centre in urban settings) (24.9%); building relationships in the community (13.3%); and other activities that could not be meaningfully categorized (4%). The proportion of time spent on different activities and the total time worked varied significantly between rural and urban areas and among the regions (at P < 0.05). Findings of this study indicate that only a minority of HEW time is spent on providing health education and services, and substantial time is spent waiting for clients. The efficiency of the HEW model may be improved by creating more demand for services or by redesigning service delivery modalities.