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• Inherent hierarchical relationships in the UMLS are underutilized • We graphically assembled into the UMLS-Graph • The UMLS-Graph allowed for expansion of the Operative Stress Score by >400% • The powerful UMLS-Graph can be used to similarly accelerate other clinical research The Unified Medical Language System (UMLS) maps relationships between and within >100 biomedical vocabularies, including Current Procedural Terminology (CPT) codes, creating a powerful knowledge resource which can accelerate clinical research. We used synonymy and concepts relating hierarchical structure of CPT codes within the UMLS, (1) guiding surgical experts in expanding the Operative Stress Score (OSS) from 565 originally rated CPT codes to additional, 1,853 related procedures; (2) establishing validity of the association between the added OSS ratings and 30-day outcomes in VASQIP (2015-2018). The UMLS Metathesaurus and Semantic Network was converted into an interactive graph database (https://github.com/dbmi-pitt/UMLS-Graph) delineating ontology relatedness. From this UMLS-graph, the CPT hierarchy was queried obtaining all paths from each code to the hierarchical apex. Of 1,853 added ratings, 43% and 76% were siblings and cousins of original OSS CPT codes. Of 857,577 VASQIP cases (mean age, 64 ± 11years; 91% male; 75% white), 786,122 (92%) and 71,455 (8%) were rated in the original and added OSS. Compared to original, added OSS cases included more females (14% versus 9%) and frail patients (25% versus 19%) undergoing high stress procedures (11% versus 8%; all P <.001). Postoperative mortality consistently increased with OSS. Very low stress procedures had <0.5% (original, 0.4% [95%CI, 0.4%–0.5%] versus added, 0.9% [95%CI, 0.6%–1.2%]) and very high 3.8% (original, 3.5% [95%CI, 3.0%–4.0%] versus added, 5.8% [95%CI, 4.6–7.3%]) mortality rates. The synonymy and concepts relating biomedical data within the UMLS can be abstracted and efficiently used to expand the utility of existing clinical research tools. [ABSTRACT FROM AUTHOR]

From his perspective as a general surgeon, Episcopal priest and Medical Director for High Risk Populations and Outcomes at a large health-care system, the author identifies an unrecognized problem that clergy were banned from visiting parishioners in most hospitals across the country during the height of the Covid-19 pandemic—a situation that persists in many contexts. The author explains why pastoral visitation should be considered essential care—especially at a time of crisis—and encourages hospital administrators across the country to clarify policies to welcome community clergy as essential personnel, but to do so with prudent procedures that mitigate risk to the community and to the visiting clergy. Given the fact that most hospitals in this country were founded by religious organizations and still carry the imprint of that founding in their names, it would be tragic for these very same hospitals to cut patients off from their religious communities precisely at the time they need them most. [ABSTRACT FROM AUTHOR]

BACKGROUND: Surgical analyses often focus on single or binary outcomes; we developed an ordinal Desirability of Outcome Ranking (DOOR) for surgery to increase granularity and sensitivity of surgical outcome assessments. Many studies also combine elective and urgent procedures for risk adjustment. We used DOOR to examine complex associations of race/ethnicity and presentation acuity. STUDY DESIGN: NSQIP (2013 to 2019) cohort study assessing DOOR outcomes across race/ethnicity groups risk-adjusted for frailty, operative stress, preoperative acute serious conditions, and elective, urgent, and emergent cases. RESULTS: The cohort included 1,597,199 elective, 340,350 urgent, and 185,073 emergent cases with patient mean age of 60.0 ± 15.8, and 56.4% of the surgeries were performed on female patients. Minority race/ethnicity groups had increased odds of presenting with preoperative acute serious conditions (adjusted odds ratio [aORs] range 1.22 to 1.74), urgent (aOR range 1.04 to 2.21), and emergent (aOR range 1.15 to 2.18) surgeries vs the White group. Black (aOR range 1.23 to 1.34) and Native (aOR range 1.07 to 1.17) groups had increased odds of higher/worse DOOR outcomes; however, the Hispanic group had increased odds of higher/worse DOOR (aOR 1.11, CI 1.10 to 1.13), but decreased odds (aORs range 0.94 to 0.96) after adjusting for case status; the Asian group had better outcomes vs the White group. DOOR outcomes improved in minority groups when using elective vs elective/urgent cases as the reference group. CONCLUSIONS: NSQIP surgical DOOR is a new method to assess outcomes and reveals a complex interplay between race/ethnicity and presentation acuity. Combining elective and urgent cases in risk adjustment may penalize hospitals serving a higher proportion of minority populations. DOOR can be used to improve detection of health disparities and serves as a roadmap for the development of other ordinal surgical outcomes measures. Improving surgical outcomes should focus on decreasing preoperative acute serious conditions and urgent and emergent surgeries, possibly by improving access to care, especially for minority populations. [ABSTRACT FROM AUTHOR]

Background: Institutional review boards (IRBs) have been criticized for inconsistency, delay, and bias, suggesting an opportunity for quality improvement. To aid such quality improvement, this study aimed at determining IRB members’ and investigators’ priorities regarding IRB review at 10 Veterans Affairs (VA) IRBs.Methods: Six hundred and eighty anonymous Internet surveys were sent to 252 IRB members and staff, and to 428 principal investigators and project coordinators at 9 VA Medical Centers and the VA Central IRB. Surveys included 27 statements adapted from Koocher and Kieth-Spiegel's IRB-RAT describing IRB activities or functions (e.g., “An IRB that is open to reversing its earlier decisions”). Respondents indicated how each statement described both their “ideal” and “actual” IRBs. The difference between the ratings of the actual and ideal IRBs was calculated for each item, along with estimated 95% confidence intervals. Ratings outside those intervals indicated activities or functions with relatively good or poor performance compared to the ideal IRB.Results: Three hundred and ninety (57.4%) responses from 165 IRB members and staff (65.5%) and 225 investigators and project coordinators (52.6%) demonstrated that these IRBs were closest to the ideal when protecting human subjects, treating investigators with respect, and taking appropriate action for alleged scientific misconduct. The IRBs were furthest from the ideal regarding duplicative forms, timeliness of review, and provision of complete rationales for decisions. Although IRB members reported near-ideal willingness to reverse earlier decisions, investigators rated this capacity far from ideal. Investigators rated IRB members’ knowledge about procedures and policy as nearly ideal, but IRB members themselves rated this aspect far from ideal. Noteworthy site-level differences in the ratings of IRB functions and activities were also identified.Conclusions: Although these VA IRBs perform well in some areas, these data support the need for ongoing quality improvement. The described method of administering and analyzing the IRB-RAT may help identify and monitor site- and activity-specific initiatives for quality improvement. [ABSTRACT FROM PUBLISHER]

Institutional Review Boards (IRBs) are intended to protect those who participate in research. However, because there is no established measure of IRB quality, it is unclear whether these committees achieve their goal. The IRB Researcher Assessment Tool is a previously validated, internally normed, proxy measure of IRB quality that assesses 45 distinct IRB activities and functions. We administered this instrument to a sample of investigators and IRB members at a large urban VA Medical Center. We describe a systematic approach to analyze and interpret survey responses that can identify the IRB activities and functions most in need of quality improvement. The proposed approach to empirical data analysis and presentation could inform local initiatives to improve the quality of IRB review. [ABSTRACT FROM AUTHOR]

Background Previous studies of surgeon behavior report that surgeons rarely meet basic standards of informed consent, raising concerns that current practice requires urgent remediation. We wondered if the Veterans Affairs Healthcare System's recent implementation of standardized, procedure-specific consent forms might produce a better practice of informed consent than has been reported previously. Our goal was to determine how the discussions shared between surgeons and patients correspond to the VA's standardized consent forms. Methods We enrolled a prospective cohort of patients presenting for possible cholecystectomy or inguinal herniorrhaphy and the surgical providers for those patients. Audio recordings captured the clinical encounter(s) culminating in a decision to have surgery. Each patient's informed consent was documented using a standardized, computer-generated form. We abstracted and compared the information documented with the information discussed. Results Of 75 consecutively enrolled patients, 37 eventually decided to have surgery and signed the standardized consent form. Patients and providers discussed 37% (95% confidence interval, 0.07-0.67) and 33% (95% confidence interval, 0.21-0.43) of the information found on the cholecystectomy and herniorrhaphy consent forms, respectively. However, the patient-provider discussions frequently included relevant details nowhere documented on the standardized forms, culminating in discussions that included a median 27.5 information items for cholecystectomy and 20 items for herniorrhaphy. Fully, 80% of cholecystectomy discussions and 76% of herniorrhaphy discussions mentioned at least one risk, benefit or alternative, indication for, and description of the procedure. Conclusions The patients and providers observed here collaborated in a detailed process of informed consent that challenges the initial reports suggesting the need to remediate surgeon's practice of informed consent. However, because the discrepancy between the information documented and discussed exposes legal and ethical liability, there is an opportunity to improve the iMed system so that it better reflects what surgeons discuss and more frequently includes all the information patients need. [ABSTRACT FROM AUTHOR]

Yentl syndrome describing sex-related disparities has been extensively studied in medical conditions but not after surgery. This retrospective cohort study assessed the association of sex, frailty, presenting with preoperative acute serious conditions (PASC), and the expanded Operative Stress Score (OSS) with postoperative complications, mortality, and failure-to-rescue. The National Surgical Quality Improvement Program from 2015 to 2019 evaluating 30-d complications, mortality, and failure-to-rescue. Of 4,860,308 cases (43% were male; mean [standard deviation] age of 56 [17] y), 6.0 and 0.8% were frail and very frail, respectively. Frailty score distribution was higher in men versus women (P < 0.001). Most cases were low-stress OSS2 (44.9%) or moderate-stress OSS3 (44.5%) surgeries. While unadjusted 30-d mortality rates were higher (P < 0.001) in males (1.1%) versus females (0.8%), males had lower odds of mortality (adjusted odds ratio (aOR) = 0.92, 95% confidence interval [CI] = 0.90-0.94, P < 0.001) after adjusting for frailty, OSS, case status, PASC, and Clavien-Dindo IV (CDIV) complications. Males have higher odds of PASC (aOR = 1.33, CI = 1.31-1.35, P < 0.001) and CDIV complications (aOR = 1.13, CI = 1.12-1.15, P < 0.001). Male-PASC (aOR = 0.76, CI = 0.72-0.80, P < 0.001) and male-CDIV (aOR = 0.87, CI = 0.83-0.91, P < 0.001) interaction terms demonstrated that the increased odds of mortality associated with PASC or CDIV complications/failure-to-rescue were lower in males versus females. Our study provides a comprehensive analysis of sex-related surgical outcomes across a wide range of procedures and health care systems. Females presenting with PASC or experiencing CDIV complications had higher odds of mortality/failure to rescue suggesting sex-related care differences. Yentl syndrome may be present in surgical patients; possibly related to differences in presenting symptoms, patient care preferences, or less aggressive care in female patients and deserves further study. [ABSTRACT FROM AUTHOR]

Aim: To generate complete DNA profiles from blood and saliva samples deposited on FTA® and non-FTA® paper substrates following a direct amplification protocol. Methods: Saliva samples from living donors and blood samples from deceased individuals were deposited on ten different FTA® and non-FTA® substrates. These ten paper substrates containing body fluids were kept at room temperature for varying lengths of time ranging from one day to approximately one year. For all assays in this research, 1.2 mm punches were collected from each substrate containing one type of body fluid and amplified with reagents provided in the nine commercial polymerase chain reaction (PCR) amplification kits. The substrates were not subjected to purification reagent or extraction buffer prior to amplification. Results: Success rates were calculated for all nine amplification kits and all ten substrates based on their ability to yield complete DNA profiles following a direct amplification protocol. Six out of the nine amplification kits, and four out of the ten paper substrates had the highest success rates overall. Conclusion: The data show that it is possible to generate complete DNA profiles following a direct amplification protocol using both standard (non-direct) and direct PCR amplification kits. The generation of complete DNA profiles appears to depend more on the success of the amplification kit rather than the than the FTA®- or non-FTA®- based substrates. [ABSTRACT FROM AUTHOR]

Abstract: Background: We describe how patients perceive the process of informed consent and its influence on decision making for elective surgery. Methods: A cohort of 38 patients documented consent for cholecystectomy or inguinal herniorrhaphy using the Veterans Affair''s computer-based tool for documenting informed consent for clinical treatment. Participants completed semistructured telephone interviews exploring their attitudes about informed consent, iMed, and the decision-making process. We used qualitative methods to code and analyze the data. Results: Sixty-nine percent of patients decided to have surgery before meeting their surgeon, and 47% stated that the surgeon did not influence their decision. Although the surgeon was an important source of information for most patients (81%), patients frequently described using information gathered before meeting the surgeon, such as other health care providers (81%) or family members (58%). Most (68%) patients perceived iMed as a legal formality with little influence on decision making. Conclusions: Future research should examine whether patient decision making regarding elective surgery becomes better informed if nonsurgeon clinicians connect patients to educational resources such as iMed closer to the time of initial diagnosis and before meeting the surgeon. [Copyright &y& Elsevier]

Background: The Veterans Affairs Healthcare System implemented a computer-based tool (iMedConsent) to improve the quality of informed consent in 2004. The impact of this tool on the process of informed consent remains unknown. Our aim was to determine the impact of iMedConsent on patient information preference, anxiety, trust in the surgeon, ambivalence about the surgical decision, and comprehension of procedure-specific risk, benefits, and alternatives. Materials and Methods: We prospectively enrolled a consecutive cohort of patients presenting to a general surgery clinic for possible cholecystectomy or inguinal herniorrhaphy from October 2009 to August 2010. We administered questionnaires before and after the clinic visit. Results: Seventy-five patients completed pre-visit questionnaires. After evaluation by the surgeon, 42 patients were offered surgery and documented their informed consent using iMedConsent, of whom 38 (90%) also completed a post-visit questionnaire. Among the participants who completed both pre- and post-visit questionnaires, participant comprehension of procedure-specific risks benefits and alternatives improved from 50% at baseline to 60% after the clinic visit (P < 0.001). No differences were noted in ambivalence, trust, or anxiety. After the clinic visit, significantly more patients expressed a preference for participating in decision making with their surgeon (98% versus 71%, P = 0.008). However, significantly fewer expressed a preference for knowing all possible details about their illness (25% to 83%, P ≤ 0.001). Conclusions: The informed consent process using iMedConsent improves patient comprehension of procedure-specific risks, benefits, and alternatives. It also increases patient preferences for participating more actively in the decision-making process. However, the process may provide more detail than patients want regarding their illness. [ABSTRACT FROM AUTHOR]

The article offers information on the medical practice of informed consent for clinical treatment. It mentions that informed consent aims to guide the ethical practice of medicine and protect the legal rights of patients which can be used in legal, ethical, and administrative purposes. It says that the informed consent should be documented properly through the use of electronic medical record to ensure permanence of data and to provide evidence of their good faith efforts. INSET: Evidence used in this review.

Alisdair MacIntyre argues that the virtues necessary for good work are everywhere and always embodied by particular communities of practice. As a general surgeon, MacIntyre’s work has deeply influenced my own understanding of the practice of good surgery. The task of this essay is to describe how the guild of surgeons functions as a more-or-less coherent tradition of moral enquiry, embodying and transmitting the virtues necessary for the practice of good surgery. Beginning with an example of surgeons engaged in a process of moral discernment, I describe how the practice of surgery depends on the cultivation of a certain kind of practical wisdom (phronesis) that effectively orders the techniques of surgery toward particular notions of human flourishing within the limits of what is possible with the particular body on which the surgeon operates. I then argue that one reason why surgeons train in an apprenticeship model of “residency” is to cultivate not only the technical skill but also the practical wisdom to perform good surgery. I conclude by noting that the surgical profession is enduring necessary, but unprecedented, changes in the way it practices and transmits its art; and without deliberate and sustained attention to the character formation of surgeons, the profession runs the risk of creating excellent technicians who are nonetheless ill-equipped to practice wise and good surgery. [ABSTRACT FROM PUBLISHER]

We examined experiencing divine love as an indicator of affective spiritual growth in a prospective cohort of 200 patients surviving cardiac surgery. These patients previously completed two-wave preoperative interviews when standardized cardiac surgery data were also collected. The information included left ventricular ejection fraction, New York Heart Association Classification, baseline health (physical and mental), optimism, hope, religiousness, prayer coping, religious/spiritual coping, and demographics. We then measured divine love at 900 days postoperatively. Hierarchical linear regression indicated the direct effect of positive religious coping on experiences of divine love, controlling for other key variables. Postoperatively perceived spiritual support was entered at the final step as an explanatory factor, which appeared to mediate the coping effect. None of the other faith factors predicted divine love. Further research regarding divine love and spiritual support may eventually guide clinical attempts to support patients' spiritual growth as an independently relevant outcome of cardiac surgery. [ABSTRACT FROM AUTHOR]

Although existing measures of religiousness are sophisticated, no single approach has yet emerged as a standard. We review the measures of religiousness most commonly used in the religion and health literature with particular attention to their limitations, suggesting that vigilance is required to avoid over-generalization. After placing the development of these scales in historical context, we discuss measures of religious attendance, private religious practice, and intrinsic/extrinsic religious motivation. We also discuss measures of religious coping, wellbeing, belief, affiliation, maturity, history, and experience. We also address the current trend in favor of multi-dimensional and functional measures of religiousness. We conclude with a critique of the standard, “context-free” approach aimed at measuring “religiousness-in-general”, suggesting that future work might more fruitfully focus on developing ways to measure religiousness in specific, theologically relevant contexts. [ABSTRACT FROM AUTHOR]

We argue that debate regarding whether and how physicians should engage religious concerns has proceeded under inadequate terms. The prevailing paradigm approaches dialogue regarding religion as a form of therapeutic technique, engaged by one stranger, the physician, upon another stranger, the patient. This stranger-technique framework focuses the debate on questions of physicians' competence, threats to patients' autonomy, and neutrality regarding religion, and in so doing, it too greatly circumscribes the scope of physician-patient dialogue. In contrast, we argue that dialogue regarding religion is better approached as a form of philosophical discourse about ultimate human concerns. Such moral discourse is often essential to the patient-physician relationship, and rather than shrinking from such discourse, physicians might engage patients regarding religious concerns guided by an ethic of moral friendship that seeks the patient's good through wisdom, candor, and respect. [ABSTRACT FROM AUTHOR]

The traditional interpretation of"intrinsic"religiousness has fostered an unchallenged assumption that normative and substantive religious motivation is inherently individual and personal. Social motives for religiousness and structured practices have been characterized as"extrinsic"and as lacking in formative significance. We argue that this view is most applicable in American Protestant religions, and hence existing religious motivation scales reflect a distinctly American Protestant view. We then show that social motives and structured ritual practices are, in fact, as normative as individual motivations in several religious traditions. In particular, we describe the social practices and motives normative for Judaism and certain streams of Christianity. We then discuss the potential relevance of this analysis to emotion, collective identity, and moral judgment. [ABSTRACT FROM AUTHOR]

Presents an essay which aims to assist medical scientists in clarifying and advancing the concept of religion. Developments in philosophy which make the objectivity of the Enlightenment paradigm problematic; Study of religion and health fundamentally contingent on the specific languages and contexts in which particular religions find expression.

Strict coordination of proliferation and programmed cell death (apoptosis) is essential for normal physiology. An imbalance in these two opposing processes results in various diseases including AIDS, neurodegenerative disorders, myelodysplastic syndromes, ischemia/reperfusion injury, cancer, autoimmune disease, among others. Objective and quantitative noninvasive imaging of apoptosis would be a significant advance for rapid and dynamic screening as well as validation of experimental therapeutic agents. Here, we report the development of a recombinant luciferase reporter molecule that when expressed in mammalian cells has attenuated levels of reporter activity. In cells undergoing apoptosis, a caspase-3-specific cleavage of the recombinant product occurs, resulting in the restoration of luciferase activity that can be detected in living animals with bioluminescence imaging. The ability to image apoptosis noninvasively and dynamically over time provides an opportunity for high-throughput screening of proapoptotic and antiapoptotic compounds and for target validation in vivo in both cell lines and transgenic animals. [ABSTRACT FROM AUTHOR]

Cancer gene therapy is an active area of research relying upon the transfer and subsequent expression of a therapeutic transgene into tumor cells in order to provide for therapeutic selectivity. Noninvasive assessment of therapeutic response and correlation of the location, magnitude, and duration of transgene expression in vivo would be particularly useful in the development of cancer gene therapy protocols by facilitating optimization of gene transfer protocols, vector development, and prodrug dosing schedules. In this study, we developed an adenoviral vector containing both the therapeutic transgene yeast cytosine deaminase (yCD) along with an optical reporter gene (luciferase). Following intratumoral injection of the vector into orthotopic 9L gliomas, anatomical and diffusion-weighted MR images were obtained over time in order to provide for quantitative assessment of overall therapeutic efficacy and spatial heterogeneity of cell kill, respectively. In addition, bioluminescence images were acquired to assess the duration and magnitude of gene expression. MR images revealed significant reduction in tumor growth rates associated with yCD/5-fluorocytosine (5FC) gene therapy. Significant increases in mean tumor diffusion values were also observed during treatment with 5FC. Moreover, spatial heterogeneity in tumor diffusion changes were also observed revealing that diffusion magnetic resonance imaging could detect regional therapeutic effects due to the nonuniform delivery and/or expression of the therapeutic yCD transgene within the tumor mass. In addition, in vivo bioluminescence imaging detected luciferase gene expression, which was found to decrease over time during administration of the prodrug providing a noninvasive surrogate marker for monitoring gene expression. These results demonstrate the efficacy of the yCD/5FC strategy for the treatment of brain tumors and reveal the feasibility of using multimodality molecular and functional imaging for assessment of gene expression and therapeutic efficacy. [ABSTRACT FROM AUTHOR]

The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers. We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality. Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality. While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool. [ABSTRACT FROM AUTHOR]

Background Frailty is increasingly recognized as a useful measure of vulnerability in older adults. Multiple claims-based frailty indices (CFIs) can readily identify individuals with frailty, but whether 1 CFI improves prediction over another is unknown. We sought to assess the ability of 5 distinct CFIs to predict long-term institutionalization (LTI) and mortality in older Veterans. Methods Retrospective study conducted in U.S. Veterans ≥65 years without prior LTI or hospice use in 2014. Five CFIs were compared: Kim, Orkaby (Veteran Affairs Frailty Index [VAFI]), Segal, Figueroa, and the JEN-FI, grounded in different theories of frailty: Rockwood cumulative deficit (Kim and VAFI), Fried physical phenotype (Segal), or expert opinion (Figueroa and JFI). The prevalence of frailty according to each CFI was compared. CFI performance for the coprimary outcomes of any LTI or mortality from 2015 to 2017 was examined. Because Segal and Kim include age, sex, or prior utilization, these variables were added to regression models to compare all 5 CFIs. Logistic regression was used to calculate model discrimination and calibration for both outcomes. Results A total of 3 million Veterans were included (mean age 75, 98% male participants, 80% White, and 9% Black). Frailty was identified for between 6.8% and 25.7% of the cohort with 2.6% identified as frail by all 5 CFIs. There was no meaningful difference between CFIs in the area under the receiver operating characteristic curve for LTI (0.78–0.80) or mortality (0.77–0.79). Conclusions Based on different frailty constructs, and identifying different subsets of the population, all 5 CFIs similarly predicted LTI or death, suggesting each could be used for prediction or analytics. [ABSTRACT FROM AUTHOR]

Background: Few studies have evaluated frailty in the setting of aneurysmal subarachnoid hemorrhage (aSAH) using large-scale data. The risk analysis index (RAI) may be implemented at the bedside or assessed retrospectively, differentiating it from other indices used in administrative registry-based research. Methods: Adult aSAH hospitalizations were identified in the National Inpatient Sample (NIS) from 2015 to 2019. Complex samples statistical methods were performed to evaluate the comparative effect size and discriminative ability of the RAI, the modified frailty index (mFI), and the Hospital Frailty Risk Score (HFRS). Poor functional outcome was determined by the NIS-SAH Outcome Measure (NIS-SOM), shown to have high concordance with modified Rankin Scale scores > 2. Results: 42,300 aSAH hospitalizations were identified in the NIS during the study period. By both ordinal [adjusted odds ratio (aOR) 3.20, 95% confidence interval (CI) 3.05, 3.36, p < 0.001] and categorical stratification [frail aOR 3.59, 95% CI 3.39, 3.80, p < 0.001; severely frail aOR 6.67, 95% CI 5.78, 7.69, p < 0.001], the RAI achieved the largest effect sizes for NIS-SOM in comparison with the mFI and HFRS. Discrimination of the RAI for NIS-SOM in high-grade aSAH was significantly greater than that of the HFRS (c-statistic 0.651 vs. 0.615). The mFI demonstrated the lowest discrimination in both high-grade and normal-grade patients. A combined Hunt and Hess-RAI model (c-statistic 0.837, 95% CI 0.828, 0.845) for NIS-SOM achieved significantly greater discrimination than both the combined models for mFI and HFRS (p < 0.001). Conclusion: The RAI was robustly associated with poor functional outcomes in aSAH independent of established risk factors. [ABSTRACT FROM AUTHOR]

Background: Contemporary guidelines emphasize the value of incorporating frailty into clinical decision‐making regarding revascularization strategies for coronary artery disease. Yet, there are limited data describing the association between frailty and longer‐term mortality among coronary artery bypass grafting (CABG) patients. Methods: We conducted a retrospective cohort study (2016–2020, 40 VA medical centers) of US veterans nationwide that underwent coronary artery bypass grafting (CABG). Frailty was quantified by the Veterans Administration Frailty Index (VA‐FI), which applies the cumulative deficit method to render a proportion of 30 pertinent diagnosis codes. Patients were classified as non‐frail (VA‐FI ≤ 0.1), pre‐frail (0.1 < VA‐FI ≤ 0.2), or frail (VA‐FI > 0.2). We used Cox proportional hazards models to ascertain the association of frailty with all‐cause mortality. Our primary study outcome was 5‐year all‐cause mortality; the co‐primary outcome was days alive and out of the hospital within the first postoperative year. Results: There were 13,554 CABG patients (median 69 years, 79% White, 1.5% women). The mean pre‐operative VA‐FI was 0.21 (SD: 0.11); 31% were pre‐frail (VA‐FI: 0.17) and 47% were frail (VA‐FI: 0.31). Frail patients were older and had higher co‐morbidity burdens than pre‐frail and non‐frail patients. Compared with non‐frail patients (13.0% [11.4, 14.7]), there was a significant association between frail and pre‐frail patients and increased cumulative 5‐year all‐cause mortality (frail: 24.8% [23.3, 26.1]; HR: 1.75 [95% CI 1.54, 2.00]; pre‐frail 16.8% [95% CI 15.3, 18.4]; HR 1.2 [1.08,1.34]). Compared with non‐frail patients (mean 362[SD 12]), pre‐frail (mean 361 [SD 14]; p < 0.01) and frail patients (mean 358[SD 18]; p < 0.01) spent fewer days alive and out of the hospital in the first postoperative year. Conclusions: Pre‐frailty and frailty were prevalent among US veterans undergoing CABG and associated with worse mid‐term outcomes. Given the high prevalence of frailty with attendant adverse outcomes, there may be an opportunity to improve outcomes by identifying and mitigating frailty before surgery. [ABSTRACT FROM AUTHOR]

1. Utilizing a case-based approach, participants will self-report the ability to evaluate the merits and potential drawbacks of providing telepalliative care in the rural emergency department setting. 2. Utilizing an evidence-based approach, participants will self-report the ability to synthesize a rationale for clarifying goals of care in the emergency department prior to potential patient transfer to a higher level of care. Critically ill patients who present to rural emergency departments are often transferred far from home to quaternary medical centers for interventions that may or may not align with their goals of care. A telepalliative care consultation prior to potential transfer opens an alternative pathway to provide patient-centered goal-concordant care that positively impacts patients, families, clinicians, and health systems. Background: Specialty palliative care is prevalent in urban and academic settings, however in rural areas, access to this care is limited and the population faces a higher probability of serious illness. Disparities and misalignment between patient values, preferences, and plan of care often results in patient transfer from rural facilities to quaternary medical centers for low-value, goal-discordant care. Mr. J was a 90-year-old African American man with inclusion body myositis (bedbound), chronic respiratory failure, and increasingly frequent hospitalizations who presented to a rural hospital near his home critically ill from congestive heart failure. A goals of care (GOC) discussion between the emergency department clinician and family resulted in a request to "have everything done" to save his life. Triggered by a machine-learning algorithm (SafeNET), a "TeleGOC Pause" (clinician premeeting, telepalliative consultation, and recommendations) was performed. During the consultation, the patient's wife and daughter shared, "He wants to live, who doesn't?", and that he was afraid to die. The telepalliative clinician shared that Mr. J's body was dying, and that time may be short. Recalling his heart being shocked during a previous admission, his family wanted to avoid such interventions and hoped to get him back home. A recommendation was made for DNR/DNI and home hospice care. They agreed, the transfer was canceled, and he was admitted locally for diuresis overnight to improve symptoms before being discharged home with hospice the following day. Mr. J lived with his family for another 2 weeks. Telepalliative care in the emergency department aligns patient values and care preferences with a goal-concordant care plan, addresses disparities in care, and can avoid goal-discordant transfers away from a patient's home community. This service opens an alternative care pathway that positively impacts patients, families, and clinicians while providing substantial potential cost savings for health systems. Models of Palliative Care Delivery; Innovative Technologies [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about potential association between the serotonin system and the character trait of "self-transcendence."

Thousands of health systems are now recognized as "Age‐Friendly Health Systems," making this model one of the most widely disseminated – and most promising‐ models to redesign care delivery for older adults. Sustaining these gains will require demonstrating the impact on care delivery and outcomes of older adults. We propose a new measurement model to more tightly link Age‐Friendly Health System transformation to outcomes within each "M" (What Matters, Medications, Mobility, and Mentation). We evaluated measures based on the following characteristics: (1) conceptual responsiveness to changes brought about by practicing "4Ms" care; (2) degree to which they represent outcomes that matter to older adults; and (3) how they can be feasibly, reliably, and validly measured. We offer specific examples of how novel measures are currently being used where available. Finally, we present measures that could capture system‐level effects across "M"s. We tie these suggestions together into a conceptual measurement model for AFHS transformation, with the intent to spur discussion, debate, and iterative improvement in measures over time. [ABSTRACT FROM AUTHOR]

Unlike antibiotic and perfusion support, guidelines for sepsis source control lack high-quality evidence and are ungraded. Internally valid administrative data methods are needed to identify cases representing source control procedures to evaluate outcomes. Over five modified Delphi rounds, two independent reviewers identified Current Procedural Terminology (CPT) codes pertinent to source control. In each round, codes with perfect agreement were retained or excluded, whereas disagreements were reviewed by the panelists. Manual review of 400 patient records meeting Sepsis-3 criteria (2010-2017) clinically adjudicated which encounters included source control procedures (gold standard). The performance of consensus codes was compared with the gold standard to assess sensitivity, specificity, predictive values, and likelihood ratios. Of 5752 CPT codes, 609 consensus codes represented source control procedures. Of 400 hospitalizations for sepsis, 39 (9.8%; 95% confidence interval [CI] 7.0%-13.1%) underwent gold standard source control procedures and 29 (7.3%; 95% CI 4.9-10.3%) consensus code–defined source control procedures. Thirty consensus codes were identified (20.0% gastrointestinal/intraabdominal, 10.0% genitourinary, 13.3% hepatopancreatobiliary, 23.3% orthopedic/cranial, 23.3% soft tissue, and 10.0% intrathoracic), which had 61.5% (95% CI 44.6%-76.6%) sensitivity, 98.6% (95% CI 96.8%-99.6%) specificity, 83.2% (95% CI 66.6%-92.4%) positive, and 95.9% (95% CI 93.9%-97.2%) negative predictive values. With pretest probability at sample prevalence, an identified consensus code had a posttest probability of 83.0% (95% CI 66.0%-92.0%), whereas consensus code absence had a probability of 4.0% (95% CI 3.0-6.0) for undergoing a source control procedure. Using modified Delphi methodology, we created and validated CPT codes identifying source control procedures, providing a framework for evaluation of the surgical care of patients with sepsis. • Six hundred and nine CPT codes representing source control procedures were identified. • Consensus CPT codes had high specificity for source control procedures in sepsis. • Consensus CPT codes provide a universal definition to evaluate source control. [ABSTRACT FROM AUTHOR]

This article presents a letter to the editor regarding Larry Dossey and Andrew Weil as reported in the December 25, 2003, issue.

A letter to the editor is presented in response to the article "Should Physicians Prescribe Religious Activities?," by R.P. Sloan and colleagues, previously published in the June 22, 2000 issue of the "New England Journal of Medicine."

This study introduces an empirical approach for studying the role of prudence in physician treatment of end-of-life (EOL) decision making. A mixed-methods analysis of transcripts from 88 simulated patient encounters in a multicenter study on EOL decision making. Physicians in internal medicine, emergency medicine, and critical care medicine were asked to evaluate a decompensating, end-stage cancer patient. Transcripts of the encounters were coded for actor, action, and content to capture the concept of Aristotelian prudence, and then quantitatively and qualitatively analyzed to identify actions associated with preference-concordant treatment. Focusing on codes that describe characteristics of physician-patient interaction, the code for physicians restating patient preferences was associated with avoiding intubation. Multiple codes were associated with secondary measures of preference-concordant treatment. Prudent actions can be identified empirically, and research focused on the virtue of prudence may provide a new avenue for assessment and training in EOL care. [ABSTRACT FROM AUTHOR]

Many in academia believe that higher education leads to an increase in tolerance towards individuals who are different. There are some empirical findings to support this premise; however, the impact of higher education on acceptance of homosexuality has not been adequately explored. Gays and lesbians in society face many negative attitudes. Based upon the survey results of 364 students at a Midwestern university, juniors and seniors had statistically significant more positive attitudes towards gays and lesbians than did freshmen and sophomores. Even in multi-variate analysis, upper-level students had more positive views on many of the attitudinal measures. [ABSTRACT FROM AUTHOR]

Background: Processes for transferring patients to higher acuity facilities lack a standardized approach to prognostication, increasing the risk for low value care that imposes significant burdens on patients and their families with unclear benefits. We sought to develop a rapid and feasible tool for predicting mortality using variables readily available at the time of hospital transfer. Methods and findings: All work was carried out at a single, large, multi-hospital integrated healthcare system. We used a retrospective cohort for model development consisting of patients aged 18 years or older transferred into the healthcare system from another hospital, hospice, skilled nursing or other healthcare facility with an admission priority of direct emergency admit. The cohort was randomly divided into training and test sets to develop first a 54-variable, and then a 14-variable gradient boosting model to predict the primary outcome of all cause in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and transition to comfort measures only or hospice care. For model validation, we used a prospective cohort consisting of all patients transferred to a single, tertiary care hospital from one of the 3 referring hospitals, excluding patients transferred for myocardial infarction or maternal labor and delivery. Prospective validation was performed by using a web-based tool to calculate the risk of mortality at the time of transfer. Observed outcomes were compared to predicted outcomes to assess model performance. The development cohort included 20,985 patients with 1,937 (9.2%) in-hospital mortalities, 2,884 (13.7%) 30-day mortalities, and 3,899 (18.6%) 90-day mortalities. The 14-variable gradient boosting model effectively predicted in-hospital, 30-day and 90-day mortality (c = 0.903 [95% CI:0.891–0.916]), c = 0.877 [95% CI:0.864–0.890]), and c = 0.869 [95% CI:0.857–0.881], respectively). The tool was proven feasible and valid for bedside implementation in a prospective cohort of 679 sequentially transferred patients for whom the bedside nurse calculated a SafeNET score at the time of transfer, taking only 4–5 minutes per patient with discrimination consistent with the development sample for in-hospital, 30-day and 90-day mortality (c = 0.836 [95%CI: 0.751–0.921], 0.815 [95% CI: 0.730–0.900], and 0.794 [95% CI: 0.725–0.864], respectively). Conclusions: The SafeNET algorithm is feasible and valid for real-time, bedside mortality risk prediction at the time of hospital transfer. Work is ongoing to build pathways triggered by this score that direct needed resources to the patients at greatest risk of poor outcomes. [ABSTRACT FROM AUTHOR]

How well institutional review boards (IRBs) follow Common Rule criteria for levels of initial protocol review has not been systematically evaluated. We compared levels of review as determined using the Office for Human Research Protections (OHRP) human subject regulations decision charts of 313 protocols that had been approved by IRBs. There was a 97.8% agreement between 140 protocols that were reviewed by full board and the levels of review according to OHRP criteria. Likewise, there was a 93.8% agreement between 113 protocols that were reviewed using an expedited review procedure and OHRP criteria. However, there was only 75% agreement for exempt protocols. Specifically, 10 (16.7%) of the 60 exempt protocols were found to require IRB review, that is, six protocols requiring expedited review and four protocols requiring full board review. Conducting non-exempt research without prior IRB approval constitutes serious noncompliance. Our data suggest that exempt protocols need more scrutiny. [ABSTRACT FROM AUTHOR]

Little is known about pediatric caregivers' perceptions of religious or spiritual (R/S) care provided by physicians. We conducted a qualitative, semistructured interview study to understand perceptions of pediatric caregivers toward physician-led R/S care. Participants were 20 primary caregivers whose children were hospitalized and receiving palliative care services. Interviews were audio recorded, transcribed verbatim, and analyzed using constant comparative methods. Three recurrent themes emerged regarding physician-led R/S care: (1) Most caregivers view providing R/S care as a positive sign of physician empathy, while a minority (3/20) prefer to keep R/S and medical care separate, (2) many caregivers prefer R/S care from a physician with whom they have a close relationship and/or share a faith background, and (3) physicians should open the door, but allow families to lead conversations about R/S care. Caregivers have mixed perceptions on physicians engaging in R/S care; most prefer that families set the direction of R/S care for themselves and their loved ones. Physicians should be trained to evaluate families' spiritual backgrounds and needs in ways that respectfully open the door to these conversations. [ABSTRACT FROM AUTHOR]

1. Define the process by which a telepalliative care program can be developed and implemented in the emergency department. 2. Evaluate the successes and challenges as well as mitigate the barriers to providing telepalliative care in the emergency department. Patients with rapid decompensation are frequently transferred to referral centers far from the patient's home and community without first clarifying whether such a transfer is consistent with the patient's goals. This quality improvement project describes whether a novel palliative care telehealth intervention, a Tele-Goals of Care (TeleGOC) Pause, increased goal-concordant care delivery and decreased goal-discordant transfers. We formed a workgroup including physician, nursing, and administrative leaders from emergency medicine, palliative medicine, critical care medicine, and hospital medicine to understand workflows and telehealth access in the emergency department at UPMC medical centers. The SafeNET score, a validated tool for risk-stratifying acutely ill patients at time of transfer from emergency departments to intensive care units, was used to identify patients for a TeleGOC Pause. For each TeleGOC Pause, emergency, palliative, and critical care physicians discussed the patient prognosis followed by a virtual patient and family meeting. The primary outcome was goal-concordant plans, and the secondary outcome was goal-discordant transfers avoided. Between November 2020 and May 2022, we completed 50 TeleGOC Pauses, and all TeleGOC patients (100%) received a virtual patient and family meeting resulting in goal-concordant treatment plans. One-third of TeleGOC patients (N=17) decided to be transferred and two-thirds elected against transfer to continue medical care at their local hospital (N=33). Seven-day mortality for TeleGOC patients was 56% overall, with higher mortality (70%) among patients who chose to stay at their local hospital and lower (29%) among those who chose to transfer. Providing timely bedside specialty-level palliative care in the emergency department via a Tele-Goals of Care Pause is feasible and highly effective in aligning both patient and family goals of care. The TeleGoC Pause affords an opportunity to provide goal-concordant care and results in a significant reduction in goal-discordant transfers. [ABSTRACT FROM AUTHOR]

BACKGROUND Frailty is a marker of dependency, disability, hospitalization, and mortality in community‐dwelling older adults. However, existing tools for measuring frailty are too cumbersome for rapid point‐of‐care assessment. The Risk Analysis Index (RAI) of frailty is validated in surgical populations, but its performance outside surgical populations is unknown. OBJECTIVE Validate the RAI in ambulatory patients. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of outpatient surgical clinics within the University of Pittsburgh Medical Center Healthcare System between July 1, 2016, and December 31, 2016. Frailty was assessed using the RAI. Current Procedural Terminology codes following RAI assessment identified patients with and without minor office‐based procedures (eg, joint injection, laryngoscopy). MAIN OUTCOMES AND MEASURES All‐cause 1‐year mortality, assessed by stratified Cox proportional hazard models. RESULTS: Of 28,059 patients, 13,861 were matched to a minor, office‐based procedure and 14,198 did not undergo any procedure. The mean (SD) age was 56.7 (17.2) years; women constituted 15,797 (56.3%) of the cohort. Median time (interquartile range 25th‐75th percentile) to measure RAI was 30 (22–47) seconds. Mortality among the frail was two to five times that of patients with normal RAI scores. For example, the hazard ratio for frail ambulatory patients without a minor procedure was 3.69 (95% confidence interval [CI] = 2.51‐5.41), corresponding to 30‐, 180‐, and 365‐day mortality rates of 2.9%, 11.2%, and 17.4%, respectively, compared to 0.3%, 2.3%, and 4.0% among patients with normal RAI scores. Discrimination of mortality (overall, and censored at 30, 180, and 365 days) was excellent, ranging from c = 0.838 (95% CI = 0.773‐0.902) for 30‐day mortality after minor procedures to c = 0.909 (95% CI = 0.855‐0.964) without a procedure. CONCLUSION: RAI is a valid, easily administered tool for point‐of‐care frailty assessment in ambulatory populations that may help clinicians and patients make better informed decisions about care choices—especially among patients considered high risk with a potentially limited life span. J Am Geriatr Soc 68:1818‐1824, 2020. [ABSTRACT FROM AUTHOR]

Background Despite perceptions that institutional review boards (IRBs) delay research, little is known about how long it takes to secure IRB approval. We retrospectively quantified IRB review times at 10 large Veterans Affairs (VA) IRBs. Methods We collected IRB records pertaining to a stratified random sample of research protocols drawn from 10 of the 26 largest VA IRBs. Two independent analysts abstracted dates from the IRB records, from which we calculated overall and incremental review times. We used multivariable linear regression to assess variation in total and incremental review times by IRB and review level (i.e., exempt, expedited, or full board) and to identify potential targets for efforts to improve the efficiency and uniformity of the IRB review process. Results In a sample of 277 protocols, the mean review time was 112 d (95% confidence interval [CI]: 105-120). Compared with full-board reviews at IRB 1, average review times at IRBs 3, 8, 9, and 10 were 27 (95% CI: 6-48), 37 (95% CI: 11-63), 45 (95% CI: 20-69), and 24 (95% CI: 2-45) d shorter, and at IRB 6, times were 56 (95% CI: 28-84) d longer. Across all IRBs, expedited reviews were 44 (95% CI: 30-58) d shorter on average than were full-board reviews, with no significant difference between exempt and full-board reviews. However, after subtracting the time required for Research and Development Committee review, exempt reviews were 21 (95% CI: 1-41) d shorter on average than were full-board reviews. Conclusions IRB review times differ significantly by IRB and review level. Few VA IRBs approach a consensus panel goal of 60 d for IRB review. The unexpectedly longer review times for exempt protocols in the VA can be attributed to time required for Research and Development Committee review. Prospective, routine collection of key time points in the IRB review process could inform IRB-specific initiatives for reducing VA IRB review times. [ABSTRACT FROM AUTHOR]

The article discusses functional status and physiological reserve associated with increased vulnerability to adverse medical outcomes. Topics include the phenotypic model has based on lean body mass, grip strength, endurance, walking gait speed, and activity level; and validated screening, allows clinicians to devote attention to palliative care domains and thus improve quality of life.