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Background: Delivery of palliative care in neurointensive care units (neuro-ICUs) can be inconsistent, often due to absence of formal care triggers. The Care and Communication Bundle (CCB) of Quali...

Introduction Postdischarge patient calls are an effective intervention to decrease unplanned readmissions. Despite its efficacy, calls are time consuming and compete with other clinical obligations. The purpose of this study was to evaluate the viability of intern-led quality improvement (QI) on conducting initial postdischarge calls to filter patients who require clinical or nurse follow-up. Methods QI interns from an academic medical center's QI program completed postdischarge patient calls within 72 hours of patient discharge from a neurosurgery service between June 2018 and July 2019. QI interns filtered patients who required follow-up calls from a clinical service or nurse department. The departments called patients within 48 hours of requests. Unplanned readmission rate was compared between the cohort of patients who requested and received a follow-up call versus a cohort of patients who requested and did not receive a follow-up call (control). Results QI interns completed 83.8% postdischarge patient calls within 72 hours of discharge. Reasons for unsuccessful calls included patient unresponsiveness (74.6%), wrong phone number on file (13.9%), and request to be called at a different time (11.5%). Nurses completed 57.2% follow-up requests within the targeted 48 hours and completed remaining requests within 7 days. QI intern postdischarge follow-up calls, in conjunction with nurse follow-up intervention, showed a significant (risk ratio = −3.31, p = 0.012) preventive effect on unplanned readmission rate. Conclusions QI interns are a viable alternative to nurses to conduct the first contact of postdischarge patient follow-up calls. This system of QI interns filtering calls to the correct clinical service or nurse department increased postdischarge patient follow-up calls success rate and decreased readmission rates.

Background: End-of-life (EOL) supportive care, including palliative and hospice services, is an area of increasing importance in critical care. Neurointensivists face unique challenges in providing timely supportive care to terminally ill patients expected to expire in the NeuroICU. Objective: This study explored the extent of effective utilization of, and recorded barriers to, palliative and hospice services in a dedicated 30-bed NeuroICU at a large academic medical center. Design: A retrospective chart review of patients who expired in the NeuroICU was conducted. The timeline from patient admission to arrival of palliative care services was traced. Qualitative review of chart notes was used to identify barriers to provision of palliative services. Setting: A total of 330 patients expired in the NeuroICU during the study period, including 176 from the neurology and 154 from the neurosurgical service. Results: Across services, 146 expired patients were never referred to palliative care or hospice services. Of those referred, over one-third were referred more than 4 days past admission to the NeuroICU. On average, patients were referred with less than 1 day before expiration. Common barriers to referral for supportive services were documented (e.g., patient expected to expire, family declined service). Conclusions: Despite benefits of palliative care and an in-hospital hospice opportunity, we identified lack of referral, and particularly delays in referral to services as significant barriers. Our study highlights these as missed opportunities for patients and families to receive maximum benefits from these services. Future research should solidify triggers for EOL services in this setting.

Catheter-associated urinary tract infections (CAUTIs) account for 25% of all hospital-acquired infections. Neuro-critically ill patients are at 2–5 times greater risk of developing CAUTI because of increased use of indwelling urinary catheters due to neurogenic urinary retention. Despite the heightened risk of CAUTI occurrence for the neuro-critically ill, there is little data on specific characteristics of CAUTIs and risk factors among this population. The aim of this study was to identify characteristics and risk factors associated with CAUTI development in the neuro-critical patient population. In this retrospective single-center case–control study in a tertiary care dedicated 30-bed neuroICU, approximately 3 controls (exact ratio—3.2) were randomly selected for each CAUTI case between January 1st, 2016 and December 31st, 2018. Demographic, clinical and laboratory data were collected, including prospectively collected data pertaining to urinary and bowel function. Descriptive and multivariate logistic regression analysis was conducted to identify common patient characteristics, CAUTI risk factors and duration from catheterization to developing a CAUTI (Time-to-CAUTI). Of 3045 admissions during the study period, 1045 (34.30%) had a urinary catheter at some point during their admission. Of those, 45 developed a CAUTI, yielding a CAUTI incidence rate of 1.50%, corresponding to 4.49 infections/1000 catheter days. On average, CAUTI patients were older as compared to controls (66.44 years of age vs 58.09 years; p

Background: Patient-centered care includes delineation of patient treatment values (ie, advance care planning [ACP]). Advance care planning often includes advance directive (AD) completion and is underutilized, particularly among neurology and neurosurgery patients. Implementation of a supportive care team (SCT) in outpatient clinic settings may offer opportunities for AD education and completion. Objective: This study assesses the effectiveness of an integrative SCT composed of hospice volunteers and undergraduate quality improvement interns in their efforts to provide ACP education in neurological and neurosurgical outpatient clinics. Assessment includes a description of different types of SCT-patient encounters, as well as patient interest in and completion of ADs after interacting with the SCT. Results: Across the data collection period, 2770 encounters were initiated. The majority of encounters resulted in patient ACP education. Some patients completed ADs during their SCT encounter (3.45%) or after their SCT encounter (10.18%). Conclusion: The SCT effectively enhances ACP education in this patient population. The utilization of trained interns to assist with ACP is beneficial and practical in clinic workflow.

To assess variability in interpretation of electroencephalogram (EEG) background activity and qualitative grading of cerebral dysfunction based on EEG findings, including which EEG features are deemed most important in this determination.A web-based survey (Qualtrics) was disseminated to electroencephalographers practicing in institutions participating in the Critical Care EEG Monitoring Research Consortium between May 2017 and August 2018. Respondents answered 12 questions pertaining to their training and EEG interpretation practices and graded 40 EEG segments (15-second epochs depicting patients' most stimulated state) using a 6-grade scale. Fleiss' Kappa statistic evaluated interrater agreement.Of 110 respondents, 78.2% were attending electroencephalographers with a mean of 8.3 years of experience beyond training. Despite 83% supporting the need for a standardized approach to interpreting the degree of dysfunction on EEG, only 13.6% used a previously published or an institutional grading scale. The overall interrater agreement was fair (k = 0.35). Having Critical Care EEG Monitoring Research Consortium nomenclature certification (40.9%) or EEG board certification (70%) did not improve interrater agreement (k = 0.26). Predominant awake frequencies and posterior dominant rhythm were ranked as the most important variables in grading background dysfunction, followed by continuity and reactivity.Despite the preference for a standardized grading scale for background EEG interpretation, the lack of interrater agreement on levels of dysfunction even among experienced academic electroencephalographers unveils a barrier to the widespread use of EEG as a clinical and research neuromonitoring tool. There was reasonable agreement on the features that are most important in this determination. A standardized approach to grading cerebral dysfunction, currently used by the authors, and based on this work, is proposed.

ObjectiveBystander cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest (OHCA) improves survival and neurological outcomes. Nonetheless, many OHCA patients do not receive bystander CPR during a witnessed arrest. Our aim was to identify potential barriers to bystander CPR.MethodsParticipants at CPR training events conducted in the USA between February and May 2018 answered a 14-question survey prior to training. Respondents were asked about their overall comfort level performing CPR, and about potential concerns specific to performing CPR on a middle-aged female, a geriatric male, and male and female adolescent patients. Open-ended responses were analysed qualitatively by categorising responses into themes.ResultsOf the 677 participants, 582 (86.0%) completed the survey, with 509 (88.1%) between 18 and 29 years of age, 341 (58.6%) without prior CPR training and 556 (96.0%) without prior CPR experience. Across all four scenarios of patients in cardiac arrest, less than 65% of respondents reported that they would be ‘Extremely Likely’ (20.6%–29.1%) or ‘Moderately Likely’ (26.9%–34.8%) to initiate CPR. The leading concerns were ‘causing injury to patient’ for geriatric (n=193, 63.1%), female (n=51, 20.5%) and adolescent (n=148, 50.9%) patients. Lack of appropriate skills was the second leading concern when the victim was a geriatric (n=41, 13.4%) or adolescent (n=68, 23.4%) patient, whereas for female patients, 35 (14.1%) were concerned about exposing the patient or the patient’s breasts interfering with performance of CPR and 15 (6.0%) were concerned about being accused of sexual assault. Significant differences were observed in race, ethnicity and age regarding the likelihood of starting to perform CPR on female and adolescent patients.ConclusionsParticipants at CPR training events have multiple concerns and fears related to performing bystander CPR. Causing additional harm and lack of skills were among the leading reservations reported. These findings should be considered for improved CPR training and public education.

Background: Hospital readmissions that occur within 30 days of the initial hospital stay are costly and potentially avoidable. Studies have shown that in addition to patients’ discharge instructions and education, follow-up calls post-discharge can significantly reduce readmission that occurs within 30 days of the initial hospital stay. Objective: To evaluate the effectiveness of nurse follow-up calls conducted in the neurosurgery service for discharged patients between October 2017 and February 2018 in reducing readmissions that occur within 30 days of initial hospital stay. Methods: An audit was initially conducted to assess compliance with conducting follow-up calls. Weekly discharge reports were used to check if patients received a follow-up call within 24–48 h post-discharge. To capture the nurses’ feedback on follow-up calls, an anonymous survey was administered. Medical insurance claims data, also known as claims-based data in the American health care system, were reviewed and analyzed to assess whether there was any difference in number of days from initial discharge to readmission between patients who received a follow-up call and those who did not. Results: Results based on a multivariable regression model indicated that patients who received a follow-up call after they were discharged from initial admission stayed out of hospital longer (incidence-rate ratio = 1.54, 95% CI = [1.13, 2.10], p = 0.006) compared to those that did not receive a follow-up call. Conclusion: Readmitted patients who received post-discharge follow-up calls had significant improvements in the length of time out of the hospital. Future development could include developing additional call strategies.

Patient and caregiver awareness of multidisciplinary rounds (MDR) times, and their subsequent involvement in MDR, aids in decreasing adverse health outcomes, reducing average length of stay, and increasing satisfaction. The objective of this study was to increase patient and caregiver awareness of MDR times using signage interventions and to assess the state of rounding processes with patient and caregiver satisfaction pre- and post-intervention. We administered survey questions to assess MDR interaction and awareness regarding MDR times. Patient and caregiver awareness of rounding times increased significantly by 25.87% ( P = .0043) post-intervention. Although patients’ confidence in the physician remained largely unchanged after the intervention due to high initial confidence levels, MDR satisfaction metrics increased slightly post-intervention. Thus, our signage intervention increased rounding time awareness in the MDR process.

Existing literature on electronic patient portals demonstrates mixed findings for portal user demographic patterns and relationships between portal usage and clinical outcomes. This study sought to determine characteristics of portal users specific to a neurology patient population and examine whether usage predicted decreased clinic visits and risk of hospitalization. A cross-sectional analysis on 13,483 patients seen at a tertiary neurology outpatient clinic over a 1-year period found significant associations between demographics, and interactions between age, sex, and race. Black and Hispanic patients were less likely to be portal users. While females had higher odds of portal usage overall, their probability decreased with increasing age. Portal users had higher rates of clinic utilization but no difference in hospitalization risk. These results highlight demographics that may need strategic targeting to increase portal uptake and the need for other interventions for populations more likely to experience health events resulting in hospitalization.

BackgroundPatient experience and clinical outcomes are improved when patients know what to expect. Providing valuable, appropriate information proves challenging considering variation in patient education, literacy, and limitations specific to patients with neurologic disease. Scaffolding of what to expect, care team members, needed materials, procedures, directions to facilities, and methods of communication are core aspects of improving patient readiness.MethodsThis study employed standard quality improvement methods. An existing (original) patient welcome letter was first analyzed to assess its literacy levels. Surveys were then administered to patients with neurologic disease assessing perception of readiness for ambulatory appointments and the overall value of the welcome letter. In addition to Likert-type scales, patients also provided open feedback on what should be included in the letter. A revised letter was then created with added content, improving literacy levels. The letter was further assessed through clinical and nonclinical groups including our neuromedicine Patient and Family Advisory Council. Response data were analyzed comparing the original vs the revised score using a t test assuming equal variances.ResultsThe “overall value” score of the original welcome letter (3.79 of 5.0) improved to the revised score (4.63 of 5.0). Patients perceived the revised welcome letter as improving their readiness significantly as ambulatory patients with neurologic disease.ConclusionsPreparing patients for their neurology visits is important and affects visits' value. Sensitivity to literacy levels is an essential component of person-centered care among neurologic patients. Carefully created and assessed welcome letters help to achieve these goals by improving readiness for outpatient appointments and increases perceived overall value significantly.

Although the Patient Centered Medical Home is a considered an optimal model for care, some children still do not receive care in this model. Beyond the clinical and practitioner factors known to affect having a medical home, family and environmental risks [referred to as adverse childhood experiences (ACE)] may also be associated with having a medical home. This study’s purpose was to examine whether family and environment risks are associated with children having a medical home. Data from the nationally representative, cross-sectional 2011–2012 National Survey of Children’s Health telephone survey were used (N = 95,677). Analyses were conducted to describe the sample characteristics and determine the association between family and environmental risks and whether a child has a medical home. A subset of risks were modeled from the seminal study of ACEs. Nearly one-quarter of parents reported that their children experienced at-least one ACE. Compared to children who experienced no ACEs, children who experienced at least one ACE, or other family and environmental risks, had lower odds of having a medical home than those whom did not. Logistic regressions showed that cumulative ACEs (odds ratio (OR) 0.76; 95 % confidence interval (CI) 0.65–0.90) as well as other family and environmental risks (OR 0.36, 95 % CI 0.26–0.51) were related to lower odds of having a medical home. This study suggests that family and environmental risks, including ACEs, impact parental report of a child having a medical home and that a dosage effect may exist. ACEs and other risk factors must be considered when providers care for children at-risk of experiencing negative events, particularly multiple negative events.

The Patient-Centered Medical Home (PCMH) is a model of care that has been promoted as a way to transform a broken primary care system in the US. However, in order to convince more practices to make the transformation and to properly reimburse practices who are PCMHs, valid and reliable data are needed. Data that capture patient experiences in a PCMH is valuable, but which instrument should be used remains unclear. Our study aims to compare the validity and reliability of two national PCMH instruments. Telephone surveys were conducted with children who receive care from 20 pediatric practices across Florida (n = 990). All of the children are eligible for Medicaid or the Children's Health Insurance Program. Analyses were conducted to compare the Consumer Assessment of Health Plan Survey-Patient-Centered Medical Home (CAHPS-PCMH) and the National Survey of Children with Special Health Care Needs (NS-CSHCN) medical home domain. Respondents were mainly White non-Hispanic, female, under 35 years old, and from a two-parent household. The NS-CSHCN outperformed the CAHPS-PCMH in regard to scale reliability (Cronbach's alpha coefficients all ≥0.81 vs. 0.56-0.85, respectively). In regard to item-domain convergence and discriminant validity the CAHPS-PCMH fared better than the NS-CSHCN (range of convergence 0.66-0.93 vs. 0.32-1.00). The CAHPS-PCMH did not correspond to the scale structure in construct validity testing. Neither instrument performed well in the known-groups validity tests. No clear best instrument was determined. Further revision and calibration may be needed to accurately assess patient experiences in the PCMH.

At some point in their lives, nearly one-half of all American children will have a behavioral health con- dition. Many will not receive the care they need from a fragmented health delivery system. The patient-centered medical home is a promising model to improve their care; however, little evidence exists. Our study aim was to examine the association between several behavioral health indicators and having a patient-centered medical home. 91,642 children's parents or guardians completed the 2007 National Survey of Children's Health. An indicator for patient-centered medical home was included in the dataset. Descriptive statistics, bivariate tests, and multivariate regression models were used in the analyses. Children in the sample were mostly Male (52 %), White (78 %), non- Hispanic (87 %), and did not have a special health care need (80 %). 6.2 % of the sample had at least one behav- ioral health condition. Conditions ranged from ADHD (6 %) to Autism Spectrum Disorder (ASD) (1 %). Fre- quency of having a patient-centered medical home also varied for children with a behavioral health condition (49 % of children with ADHD and 33 % of children with ASD). Frequency of having a patient-centered medical home decreased with multiple behavioral health conditions. Higher severity of depression, anxiety, and conduct disor- der were associated with a decreased likelihood of a patient-centered medical home. Results from our study can be used to target patient-centered medical home interven- tions toward children with one or more behavioral health conditions and consider that children with depression, anxiety, and conduct disorder are more vulnerable to these disparities.

Providing a medical home to children with Attention-Deficit Hyperactivity Disorder (ADHD) is challenging. Little is known about the factors associated with having a medical home for these children, or how comorbidities affect having a medical home. Our study aims are: (1) identify factors associated with having a medical home and five sub-components of a medical home and (2) determine the effect of medical home on several outcomes for children with ADHD. The sample included 5,495 children with ADHD from the 2007 National Survey of Children’s Health. Descriptive and multivariate analyses were conducted. Children with ADHD alone and children with ADHD plus a physical diagnosis had greater frequencies of having a medical home, or meeting the five sub-components, than children with ADHD plus a mental diagnosis. Multivariate results show that children with ADHD plus a physical and/or mental comorbidity were 24–63% more likely to be without a medical home compared to children with only ADHD. Having a medical home also had a bearing on several child health outcomes. Having a medical home was significantly associated with being less likely to have an unmet health need and having fewer missed school days; but also being less likely to have received needed mental health care (P < .05). Our results suggest that there are differences in parent’s perceptions of receiving care among children with ADHD. Pediatric medical home projects and policies should acknowledge that children with ADHD often have comorbidities making their care more complex. These complexities should be addressed during practice transformation and setting reimbursement policies.

Older adults sometimes exhibit higher levels of off-target verbosity during story recall than do young adults. This appears as the inclusion of extraneous information not directly relevant to the topic. Some production of such material has been clearly related to cognitive decline, particularly older adults’ inability to inhibit production of irrelevant information. In tandem, however, research also suggests that some extraneous information is indirectly related to the topic and may reflect age differences in communicative styles. To further elucidate the social cognitive aspect of this issue, the question of import is: What is the content of the additional information provided by participants during story recall? The present study answers this question. Grounded in the autobiographical memory and life story literatures, we introduce the construct, story asides, and a reliable content-analytic scheme for its assessment. Young and older adults (N = 129) recalled one of two types of stories: a personal autobiographical memory or an experimenter-generated fictional story. Narratives were reliably coded for story asides. As expected, older adults produced more story asides than young adults only for autobiographical stories. The discussion focuses on the role of story asides in everyday communication including the possibility that they may be a sign of communicative expertise.

Bortezomib, a clinical drug for multiple myeloma (MM) and mantle cell lymphoma, exhibits complex mechanisms of action, which vary depending on the cancer type and the critical genetic alterations of each cancer. Here we investigated the signaling mechanisms of bortezomib in mouse B lymphoma and human MM cells deficient in a new tumor suppressor gene, TRAF3. We found that bortezomib consistently induced up-regulation of the cell cycle inhibitor p21(WAF1) and the pro-apoptotic protein Noxa as well as cleavage of the anti-apoptotic protein Mcl-1. Interestingly, bortezomib induced the activation of NF-κB1 and the accumulation of the oncoprotein c-Myc, but inhibited the activation of NF-κB2. Furthermore, we demonstrated that oridonin (an inhibitor of NF-κB1 and NF-κB2) or AD 198 (a drug targeting c-Myc) drastically potentiated the anti-cancer effects of bortezomib in TRAF3-deficient malignant B cells. Taken together, our findings increase the understanding of the mechanisms of action of bortezomib, which would aid the design of novel bortezomib-based combination therapies. Our results also provide a rationale for clinical evaluation of the combinations of bortezomib and oridonin (or other inhibitors of NF-κB1/2) or AD 198 (or other drugs targeting c-Myc) in the treatment of lymphoma and MM, especially in patients containing TRAF3 deletions or relevant mutations.

Family feedback is an essential component of family-centered care. Both encouraging and facilitating a process that promotes honest feedback from the family's perspectives are crucial. A large body of literature supports the value of the patient− and family-centered medical home and the integral role of physician/family/patient communication within its context. Moreover, the Pediatric Milestones Project identifies the need to assess residents on incorporating family feedback as a critical skill (within the competencies of interpersonal and communication skills, and systems-based practice). We attempted to address this need through the development of these multirater tools that can be used to provide residents with feedback on how well they incorporate family feedback in their clinical practice. We developed a Resident Self-Assessment Tool (RSA), which allows residents to assess how well they feel they elicit family feedback. Residents rate themselves on how well they perceive they performed behaviors deemed necessary to elicit family feedback. We also developed a Family/Caregiver Perception Tool (FP). The intent of the FP is to provide residents with feedback on observable behaviors as perceived by families/caregivers during individual encounters. The perception of the family/caregiver is critical in helping residents learn how well they elicit family feedback. The intent is to capture family/caregiver perception in a given clinical encounter. Using the RSA and the FP together will help provide residents with feedback on their skills in eliciting family feedback—an important step towards providing patient− and family-centered care. We conducted a qualitative pilot study of the tools through a multicenter study in the continuity clinic setting. Ten programs were enrolled, with one program unable to participate due to incompatible study time lines. A total of nine Pediatric Residency Training Programs used the FP and RSA in the period of May-September 2012. A total of 143 PGY 2 residents participated, with a total of 377 FPs and 143 RSAs completed. Overall, programs reported that the assessment tools were useful and reasonable to implement. Specifically, data from the qualitative study showed that the tools were a reasonable length and literacy level for families/caregivers, as well as a reasonable effort for residents. Additionally, administration of the tools was reasonable to faculty members and not burdensome in terms of time or effort. Programs also reported being able to incorporate the tools into their already-busy programs and found them to be a beneficial addition.

This study assesses palliative care implementation in the Neuro ICU of a large medical center. The expectation of death at admission is high, making comprehensive palliative care vital. The aim was to examine how providers’ views of palliative care are related to their end-of-life (EOL) expertise. Forty-one providers responded to 25 questions (Likert-type scales) concerning their views of palliative care delivery. EOL expertise (e.g., ethical issues, clear definition of palliative care, avoiding futile care) was also assessed. Exploratory factor analysis of views of care delivery (Varimax rotation, 44.26% variance explained) resulted in three factors reflective of increasing levels of palliative care provision: initiating the process, providing basic comfort-care, and delivering holistic care. Linear regression analyses used these three factors to predict EOL expertise. Endorsing Delivery of Holistic Care predicts the use of ethics consults to aid complex care decisions (B = .96, p = .001) and avoidance of administering futile care (B = .68, p = .05). Endorsing Provision of Basic Comfort Care predicts greater previous palliative care involvement (B = 1.23, p = .008). Endorsing Initiation of the Process predicts having a more comprehensive definition of palliative care (B = 2.34, p = .005) and of Advance Directives (B = 1.23, p = .013). Results suggest that different ways of viewing palliative care exist even within a single unit and that these views are related to providers’ expertise in dealing with ethical issues, end of life planning, and delivery of care.

Background Identification of novel genetic risk factors is imperative for a better understanding of B lymphomagenesis and for the development of novel therapeutic strategies. TRAF3, a critical regulator of B cell survival, was recently recognized as a tumor suppressor gene in B lymphocytes. The present study aimed to identify novel oncogenes involved in malignant transformation of TRAF3-deficient B cells. Methods We used microarray analysis to identify genes differentially expressed in TRAF3−/− mouse splenic B lymphomas. We employed lentiviral vector-mediated knockdown or overexpression to manipulate gene expression in human multiple myeloma (MM) cell lines. We analyzed cell apoptosis and proliferation using flow cytometry, and performed biochemical studies to investigate signaling mechanisms. To delineate protein-protein interactions, we applied affinity purification followed by mass spectrometry-based sequencing. Results We identified mutated in colorectal cancer (MCC) as a gene strikingly up-regulated in TRAF3-deficient mouse B lymphomas and human MM cell lines. Aberrant up-regulation of MCC also occurs in a variety of primary human B cell malignancies, including non-Hodgkin lymphoma (NHL) and MM. In contrast, MCC expression was not detected in normal or premalignant TRAF3−/− B cells even after treatment with B cell stimuli, suggesting that aberrant up-regulation of MCC is specifically associated with malignant transformation of B cells. In elucidating the functional roles of MCC in malignant B cells, we found that lentiviral shRNA vector-mediated knockdown of MCC induced apoptosis and inhibited proliferation in human MM cells. Experiments of knockdown and overexpression of MCC allowed us to identify several downstream targets of MCC in human MM cells, including phospho-ERK, c-Myc, p27, cyclin B1, Mcl-1, caspases 8 and 3. Furthermore, we identified 365 proteins (including 326 novel MCC-interactors) in the MCC interactome, among which PARP1 and PHB2 were two hubs of MCC signaling pathways in human MM cells. Conclusions Our results indicate that in sharp contrast to its tumor suppressive role in colorectal cancer, MCC functions as an oncogene in B cells. Our findings suggest that MCC may serve as a diagnostic marker and therapeutic target in B cell malignancies, including NHL and MM. Electronic supplementary material The online version of this article (doi:10.1186/s13045-014-0056-6) contains supplementary material, which is available to authorized users.

Children with life-threatening illnesses and their families may face a myriad of medical decisions in their lifetimes. Oftentimes these complicated medical decisions cause disagreements among patients, families, and providers about what is the best course of action. Although no evidence exists, it is possible that conflict may affect subgroups of the population differently. This study aims to investigate how decisional conflict varies among racial and ethnic subgroups.Two hundred sixty-six surveys were completed with parents whose children have a life-threatening illness. All children lived in Florida and were enrolled in the Medicaid program. The Decisional Conflict Scale, overall and broken down into its five distinct subscales, was used to assess parental decision-making. Descriptive, bivariate, and multivariate analyses were conducted. Subgroup analyses were conducted on Latino respondents.Our bivariate results suggest that minority parents report less Effective Decision Making (p0.05) and report less Support in Decision Making (p0.05) compared to white, non-Hispanic parents. For the subgroup analysis, we found that those who identify as Mexican American and Central/South American report having greater Uncertainty in Choosing Options (p0.05) and less Values Clarity (p0.05) as compared to Puerto Rican or Cuban Americans. Results from the multivariate analyses suggest that those whose primary language is not English are associated with greater Uncertainty in Choosing Options (p0.05). Values Clarity was lower for children who were diagnosed with their life-threatening condition at birth (p0.05) as compared to children diagnosed at a later time.Our study is the first to describe racial and ethnic differences in decisional conflict of parents of children with life-threatening illnesses. Significant differences exist by race, ethnicity, language spoken, and diagnosis time across several subdomains of decisional conflict. These differences are important to address when creating clinical care plans, engaging in shared decision-making, and creating interventions to alleviate decisional conflict.

Background The patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature. Methods Eligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware’s seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice’s medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%. Results Staff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b = 0.75) and community outreach is negatively associated (b = -0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR = 1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR = 0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout. Conclusions Staff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale. Electronic supplementary material The online version of this article (doi:10.1186/2049-3258-72-36) contains supplementary material, which is available to authorized users.

We recently reported that specific deletion of a novel tumor suppressor gene, TRAF3, in B lymphocytes leads to B lymphoma development in mice. Interestingly, B lymphoma development in B-TRAF3-/- mice exhibits a long latency (about 9 months), indicating that additional oncogenic alterations are required for B lymphomagenesis. To delineate such oncogenic alterations in TRAF3-/- B lymphomas, we performed microarray analyses and identified mutated in colorectal cancer (MCC) as a gene consistently up-regulated in B lymphomas spontaneously developed in different individual B-TRAF3-/- mice. We verified the striking up-regulation of MCC expression in TRAF3-/- B lymphomas at both the mRNA and protein levels by quantitative real time PCR and Western blot analyses, respectively. We further found that the MCC transcript and protein were aberrantly elevated in 6 human patient-derived multiple myeloma cell lines with TRAF3 deletions or relevant mutations. In contrast, MCC expression was not detected in normal mouse splenic B cells or premalignant TRAF3-/- B cells. Furthermore, MCC expression was not induced in normal splenic B cells or premalignant TRAF3-/- B cells by a variety of B cell stimuli, including CD40, BCR, LPS, and CpG. Taken together, our findings indicate that aberrant MCC expression is associated with B cell tumorigenesis. Our ongoing study will further elucidate the roles and mechanisms of MCC in TRAF3 deficiency-initiated B cell malignant transformation.