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In 2008, Kaiser Permanente Northwest identified the transition from hospital to home as a pivotal quality improvement opportunity and used multiple patient-centered data collection methods to identify unmet needs contributing to preventable readmissions. A transitional care bundle that crosses care settings and organizational functions was developed to meet needs expressed by patients. It comprises 5 elements: risk stratification, a specialized phone number for discharged patients, timely postdischarge follow-up, standardized patient discharge instructions and same-day discharge summaries, and pharmacist-supported medication reconciliation. The transitional care bundle has been in place for 6 years. Readmission rates decreased from 12.1% to 10.6%, Hospital Consumer Assessment of Healthcare Providers and Systems scores for the discharge instruction composite moved from below the 50(th) to above the 90(th) national percentile, average time to the first postdischarge appointment decreased from 9.7 days to 5.3 days, and error rates on the discharge medication list decreased from 57% to 21% (P.0001 for all). The program, which continues to evolve to address sustainability challenges and organizational initiatives, suggests the potential of a multicomponent, patient-centered care bundle to address the complex, interrelated drivers of preventable readmissions.

Temporomandibular disorders remain a common cause of visits to primary care physicians, internists, pediatricians, and emergency departments. Advances in the clinical diagnosis, radiographic imaging, and classification of these disorders have improved long-term management. There are several types of disorders of the masticatory muscles and the temporomandibular joint as well as associated structures and each may have a complex cause, clinical course, and response to therapy. Host susceptibility plays a role at several stages of these disorders. Future research offers greater possibility in defining this heterogeneous group of disorders and providing more focused and effective treatment strategies.

This is a unique case of bilateral metachronous testicular mesothelioma of the tunica vaginalis. Testicular mesothelioma is a rare entity found in patients with or without asbestos occupational exposure. The tumor most commonly presents as a unilateral testicular mass. More rare presentations include bilateral synchronous or metachronous tumors. Treatment is with surgical resection and prognosis is not generally favorable. The benefits of adjuvant therapy with radiation or chemotherapy remain unknown and further studies are needed.

The objective of this series was to assess sonographic and clinical findings in patients with hyperreactio luteinalis (HL; enlarged ovaries). We retrospectively identified 31 patients with HL and collected data including gestational age, maximum ovarian size, and pregnancy outcomes. Hyperreactio luteinalis was detected at a mean gestational age of 21.6 weeks, reaching average maximum ovarian volumes of 417 and 359 mL on the right and left, respectively. After the first trimester, HL appears to be associated with multiple gestations, twin-twin transfusion syndrome, gestational trophoblastic disease, and Beckwith-Wiedemann syndrome. When HL is present, maternal complications such as preeclampsia are common, and preterm delivery often results.

To evaluate percutaneous brush cytology, forceps biopsy and a tandem procedure consisting of both, in the diagnosis of malignant biliary obstruction. A retrospective review of consecutive patients who underwent biliary brush cytology and/or forceps biopsy between 01/2010 and 09/2014 was performed. The cytology and pathology results were compared to the composite outcome (including radiological, pathological and clinical data). Cost for tandem procedure compared to brush cytology and forceps biopsy alone was calculated. A total of 232 interventions in 129 patients (70.8 ± 11.0 years) were included. Composite outcome showed malignancy in 94/129 (72.9%) patients. Sensitivity for brush cytology, forceps biopsy and tandem procedure was 40.6% (95% CI 32.6–48.7%), 42.7% (32.4–53.0%) and 55.8% (44.7–66.9%) with 100% specificity, respectively. There were 9/43 (20.9%) additional cancers diagnosed when forceps biopsy was performed in addition to brush cytology, while there were 13/43 (30.2%) more cancers diagnosed when brush cytology was performed in addition to forceps biopsy. Additional costs per additionally diagnosed malignancy if tandem approach is to be utilised in all cases was $704.96. Using brush cytology and forceps biopsy in tandem improves sensitivity compared to brush cytology and forceps biopsy alone in the diagnosis of malignant biliary obstruction. • Tandem procedure improves sensitivity compared to brush cytology and forceps biopsy. • Brush cytology may help to overcome “crush artefacts” from forceps biopsy. • The cost per diagnosed malignancy may warrant tandem procedure in all patients.

Radiation exposure increases cancer risk in children with Crohn disease (CD). Magnetic resonance enterography (MRE) can image the gastrointestinal tract without exposure to radiation. The aim of the present study was to determine whether our MRE protocol could diagnose terminal ileitis and the degree of inflammatory activity in children with CD.Retrospective review of patients 18 years of age or younger who underwent MRE for known or suspected CD from June 15, 2007 to April 1, 2010. MRE was performed with Volumen and water as oral contrast and gadolinium-based intravenous contrast. No antiperistaltic agent was used. Each MRE was compared with ileal biopsies obtained within 90 days. Severity of inflammation on MRE was scored and compared with the Pediatric Crohn Disease Activity Index (PCDAI).Seventy-two patients underwent 80 MREs during the study period. Forty-two of the 72 patients (58.3%) underwent colonoscopy within 90 days of MRE, and the terminal ileum was intubated in 33. Compared with histology, MRE had a sensitivity of 71.4% and a specificity of 100% for terminal ileitis. The positive and negative predictive values were 100% and 70%, respectively. PCDAI was calculated in 39 of the 72 patients (54.2%) and had a statistically significant positive correlation with MRE score of 0.37 (P = 0.020426).In children with known or suspected CD, our MRE protocol has a high specificity and positive predictive value for terminal ileitis. Severity of inflammation on MRE had a statistically significant positive correlation with PCDAI.

The ultrasound findings involving the gravid uterus will be described with a focus on differentiating normal from pathologic conditions. Topics pertaining to the gravid uterus include uterine fibroids, müllerian anomalies, cervical shortening, the normal and pathologic appearance of cesarean delivery scars, and uterine rupture. Clinical management and therapeutic implications based on sonographic findings will be emphasized.

Imaging plays a key role in the diagnostic evaluation of women for infertility. The pelvic causes of female infertility are varied and range from tubal and peritubal abnormalities to uterine, cervical, and ovarian disorders. In most cases, the imaging work-up begins with hysterosalpingography to evaluate fallopian tube patency. Uterine filling defects and contour abnormalities may be discovered at hysterosalpingography but typically require further characterization with hysterographic or pelvic ultrasonography (US) or pelvic magnetic resonance (MR) imaging. Hysterographic US helps differentiate among uterine synechiae, endometrial polyps, and submucosal leiomyomas. Pelvic US and MR imaging help further differentiate among uterine leiomyomas, adenomyosis, and the various müllerian duct anomalies, with MR imaging being the most sensitive modality for detecting endometriosis. The presence of cervical disease may be inferred initially on the basis of difficulty or failure of cervical cannulation at hysterosalpingography. Ovarian abnormalities are usually detected at US. The appropriate selection of imaging modalities and accurate characterization of the various pelvic causes of infertility are essential because the imaging findings help direct subsequent patient care.

Temporomandibular disorders remain a common cause of visits to primary care physicians, internists, pediatricians, and emergency departments. Advances in the clinical diagnosis, radiographic imaging, and classification of these disorders have improved long-term management. There are several types of disorders of the masticatory muscles and the temporomandibular joint as well as associated structures and each may have a complex cause, clinical course, and response to therapy. Host susceptibility plays a role at several stages of these disorders. Future research offers greater possibility in defining this heterogeneous group of disorders and providing more focused and effective treatment strategies.

The OX-40 molecule is expressed on the surface of recently activated T lymphocytes. The presence of OX-40 on CD4+ T cells was analyzed in a rat haplo-identical (parental → F1) bone marrow transplant model of acute graft-versus-host disease (aGVHD). Increased numbers of activated CD4+ T cells that expressed the OX-40 antigen were detected in peripheral blood soon after transplantation before the earliest sign of disease. The peak of OX-40 expression occurred 12 days posttransplantation with a range of 18% to 36% of circulating T cells and remained 10-fold above background, never returning to baseline. A slight increase in OX-40 expression (range, 1% to 6%) was also detected on peripheral blood lymphocytes from control syngeneic F1 → F1 recipients. OX-40+ T cells were isolated from spleen, skin, lymph node, and liver tissue of rats undergoing aGVHD, but not in syngeneic transplants. OX-40+ T cells isolated from these tissues were of donor origin and were shown to be allo-reactive. These data raise the possibility of using the OX-40 antibody to detect and deplete selectively the T cells that cause aGVHD.

The ultrasound findings in the postpartum uterus will be described with a focus on differentiating normal from pathologic conditions. Imaging of the postpartum uterus will include a discussion of the normal postpartum uterus, postpartum hematomas, and retained products of conception. Clinical management and therapeutic implications based on sonographic findings will be emphasized.

The OX-40 molecule is expressed on the surface of recently activated T lymphocytes. The presence of OX-40 on CD4+ T cells was analyzed in a rat haplo-identical (parental --F1) bone marrow transplant model of acute graft-versus-host disease (aGVHD). Increased numbers of activated CD4+ T cells that expressed the OX-40 antigen were detected in peripheral blood soon after transplantation before the earliest sign of disease. The peak of OX-40 expression occurred 12 days posttransplantation with a range of 18% to 36% of circulating T cells and remained 10-fold above background, never returning to baseline. A slight increase in OX-40 expression (range, 1% to 6%) was also detected on peripheral blood lymphocytes from control syngeneic F1 --F1 recipients. OX-40+ T cells were isolated from spleen, skin, lymph node, and liver tissue of rats undergoing aGVHD, but not in syngeneic transplants. OX-40+ T cells isolated from these tissues were of donor origin and were shown to be alloreactive. These data raise the possibility of using the OX-40 antibody to detect and deplete selectively the T cells that cause aGVHD.

We report the case of an invasive thymoma presenting as an aortic dissection in a 49-year-old woman with hypertension and a marfanoid appearance. The patient presented to the emergency department with "tearing" substernal chest pain. A chest radiograph revealed a right para-aortic bulge consistent with a dissecting aorta, but an aortogram was normal. Other disease states, including various types of mediastinal masses, have been reported to mimic aortic dissection.

In Saccharomyces cerevisiae the mitochondrial gene responsible for the specification of apocytochrome b (cob-box) is believed to consist of both coding and intervening sequences. Mutations in the latter give rise to pleiotropic phenotypes in vivo, lacking not only cytochrome b but also subunit I of cytochrome oxidase, and producing sets of novel polypeptides. The experiments described here have examined 15 different mit− mutants in this region and demonstrate that these results are faithfully reproduced by isolated mitochondria in vitro. This inference also applies to other types of mutational lesions in coding segments of the cob-box gene and of the gene oxi3, responsible for the specification of subunit I.