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Many patients with advanced serious illness or at the end of life experience delirium, a potentially reversible form of acute brain dysfunction, which may impair ability to participate in medical decision-making and to engage with their loved ones. Screening for delirium provides an opportunity to address modifiable causes. Unfortunately, delirium remains underrecognized. The main objective of this pilot was to validate the brief Confusion Assessment Method (bCAM), a two-minute delirium-screening tool, in a veteran palliative care sample.
This was a pilot prospective, observational study that included hospitalized patients evaluated by the palliative care service at a single Veterans’ Administration Medical Center. The bCAM was compared against the reference standard, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Both assessments were blinded and conducted within 30 minutes of each other.
We enrolled 36 patients who were a median of 67 years (interquartile range 63–73). The primary reasons for admission to the hospital were sepsis or severe infection (33%), severe cardiac disease (including heart failure, cardiogenic shock, and myocardial infarction) (17%), or gastrointestinal/liver disease (17%). The bCAM performed well against the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, for detecting delirium, with a sensitivity (95% confidence interval) of 0.80 (0.4, 0.96) and specificity of 0.87 (0.67, 0.96).
Significance of Results
Delirium was present in 27% of patients enrolled and never recognized by the palliative care service in routine clinical care. The bCAM provided good sensitivity and specificity in a pilot of palliative care patients, providing a method for nonpsychiatrically trained personnel to detect delirium.
Agetolites is a problematic Late Ordovician genus possessing traits of both tabulate and rugose corals. The presence of numerous mural pores has often been considered to indicate a relation to tabulates, although an affinity to rugosans has also been proposed, based mainly on well-developed septa that alternate in length. To further consider the taxonomic position of Agetolites, growth characteristics of coralla representing three species from the Xiazhen Formation in South China are documented and assessed, focusing on modes of corallite increase. Three major modes of increase are recognized. By far the most common mode involves the development of an offset from a connective mural pore, without a clear relationship to a particular parent corallite. This mode of increase is usually associated with corner pores, but in one case occurs at a wall pore. The lateral mode of increase, which is relatively uncommon, is a typical feature in corallites along the boundary of intergrowths with stromatoporoids. The axial mode of increase is rare, occurring during rejuvenation of a damaged corallite or during regeneration following termination of a corallite. The mode of corallite increase that is characteristic of Agetolites, involving a connective mural pore and occurring without evidence of a particular parent, supports the interpretation that this genus is not a rugosan or a typical favositid tabulate. Mural pores are unknown in rugosans, and offsets arise from distinct parent corallites in favositids. The Ordovician genus Lichenaria, considered a representative of the most primitive stock of tabulate corals, shows the closest similarities with types of increase in Agetolites. Certain aspects of lateral and axial increase in Agetolites are comparable to features in a few more genera of Ordovician tabulates, further supporting a tabulate affinity. The phylogenetic relation of Agetolites to those and other tabulate genera, however, remains unresolved.
National policies target healthcare-associated infections using medical claims and National Healthcare Safety Network surveillance data. We found low concordance between the 2 data sources in rates and rankings for surgical site infection following colon surgery in 155 hospitals, underscoring the limitations in evaluating hospital quality by claims data.
Based on multivariate morphometric analysis, Halysites catenularius is identified from the Rumba Formation (Telychian) and Jaagarahu Formation (Sheinwoodian) of Estonia; H. priscus is confirmed as a junior synonym. Halysites catenularius, H. junior, and H. senior are shown to be closely related; H. catenularius is morphologically intermediate. Cyclomorphism in H. catenularius, recorded by fluctuations of corallite tabularial area, indicates an average annual growth rate of 6.0 mm, which is typical for halysitids. Tubules in H. catenularius, generated from small intramural openings between adjacent corallites, were involved in two types of interstitial increase. The intramural openings, three types of lateral increase, temporary agglutinated patches of corallites, and axial increase documented in H. catenularius resemble features in some species of Catenipora. These similarities are consistent with the interpretation that Halysites evolved from Catenipora. Evaluation of the possibility that both genera are polyphyletic will require further detailed analysis of additional species.
Hill (Twin Research and Human Genetics, Vol. 21, 2018, 84–88) presented a critique of our recently published paper in Cell Reports entitled ‘Large-Scale Cognitive GWAS Meta-Analysis Reveals Tissue-Specific Neural Expression and Potential Nootropic Drug Targets’ (Lam et al., Cell Reports, Vol. 21, 2017, 2597–2613). Specifically, Hill offered several interrelated comments suggesting potential problems with our use of a new analytic method called Multi-Trait Analysis of GWAS (MTAG) (Turley et al., Nature Genetics, Vol. 50, 2018, 229–237). In this brief article, we respond to each of these concerns. Using empirical data, we conclude that our MTAG results do not suffer from ‘inflation in the FDR [false discovery rate]’, as suggested by Hill (Twin Research and Human Genetics, Vol. 21, 2018, 84–88), and are not ‘more relevant to the genetic contributions to education than they are to the genetic contributions to intelligence’.
In 2008, the Centers for Medicare and Medicaid Services (CMS) stopped reimbursing for hospital-acquired conditions (HACs) not present on admission (POA). We sought to understand why this policy did not impact central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) trends.
Retrospective cohort study.
Acute-care hospitals in the United States.
Fee-for-service Medicare patients discharged January 1, 2007, through December 31, 2011.
Using inpatient Medicare claims data, we analyzed billing practices before and after the HAC policy was implemented, including the use and POA designation of codes for CLABSI or CAUTI. For the 3-year period following policy implementation, we determined the impact on diagnosis-related groups (DRG) determining reimbursement as well as hospital characteristics associated with the reimbursement impact.
During the study period, 65,205,607 Medicare fee-for-service hospitalizations occurred at 3,291 acute-care, nonfederal US hospitals. Based on coding, CLABSI and CAUTI affected 0.23% and 0.06% of these hospitalizations, respectively. In addition, following the HAC policy, 82% of the CLABSI codes and 91% of the CAUTI codes were marked POA, which represented a large increase in the use of this designation. Finally, for the small numbers of CLABSI and CAUTI coded as not POA, financial impacts were detected on only 0.4% of the hospitalizations with a CLABSI code and 5.7% with a CAUTI code.
Part of the reason the HAC policy did not have its intended impact is that billing codes for CLABSI and CAUTI were rarely used, were commonly listed as POA in the postpolicy period, and infrequently impacted hospital reimbursement.
In 2012, the Centers for Medicare and Medicaid Services expanded a 2008 program that eliminated additional Medicare payment for mediastinitis following coronary artery bypass graft (CABG) to include Medicaid. We aimed to evaluate the impact of this Medicaid program on mediastinitis rates reported by the National Healthcare Safety Network (NHSN) compared with the rates of a condition not targeted by the program, deep-space surgical site infection (SSI) after knee replacement.
Interrupted time series with comparison group.
We included surveillance data from nonfederal acute-care hospitals participating in the NHSN and reporting CABG or knee replacement outcomes from January 2009 through June 2017. We examined the Medicaid program’s impact on NHSN-reported infection rates, adjusting for secular trends. The data analysis used generalized estimating equations with robust sandwich variance estimators.
During the study period, 196 study hospitals reported 273,984 CABGs to the NHSN, resulting in 970 mediastinitis cases (0.35%), and 294 hospitals reported 555,395 knee replacements, with 1,751 resultant deep-space SSIs (0.32%). There was no significant change in incidence of either condition during the study. Mediastinitis models showed no effect of the 2012 Medicaid program on either secular trend during the postprogram versus preprogram periods (P=.70) or an immediate program effect (P=.83). Results were similar in sensitivity analyses when adjusting for hospital characteristics, restricting to hospitals with consistent NHSN reporting or incorporating a program implementation roll-in period. Knee replacement models also showed no program effect.
The 2012 Medicaid program to eliminate additional payments for mediastinitis following CABG had no impact on reported mediastinitis rates.
Catenipora is one of the most common tabulate coral genera occurring in various lithofacies in the Upper Ordovician Xiazhen Formation at Zhuzhai in South China. A combination of traditional multivariate analysis and geometric morphometrics is applied to a large number of specimens to distinguish and identify species. Based on three major principal components extracted from 11 morphological characters, three major groups as determined by the cluster-analysis dendrogram are considered to be morphospecies. Their validity and distinctiveness are confirmed by discriminant analysis, descriptive statistics, and bivariate plots. Tabularium area and common wall thickness are the most meaningful characters to distinguish the three morphospecies. Geometric morphometrics is adopted to compare the morphospecies with types and/or figured specimens of species previously reported from the vicinity of Zhuzhai. Despite discrepancies in corallite size, principal component analysis and discriminant analysis, as well as consideration of overall morphological characteristics, indicate that the morphospecies represent C. zhejiangensis Yu in Yu et al., 1963, C. shiyangensis Lin and Chow, 1977, and C. dianbiancunensis Lin and Chow, 1977.
Catenipora occurs in seven stratigraphic intervals in the Xiazhen Formation at Zhuzhai, representing a variety of heterogeneous environments. The coralla preservation is variable due to differential compaction; coralla preserved in limestones are commonly intact and in growth position, whereas those in shales are mostly crushed or fragmentary. The size and shape of corallites are considered primarily to be species-specific characters, but are also related to the depositional environments. In all species, morphological characters, including corallite size, septal development, and shape and size of lacunae, show high variability in accordance with lithofacies and stratigraphic position. The intraspecific differences in corallite size at various localities in the Zhuzhai area may indicate responses to local environmental factors, but may also reflect genetic differences if there was limited connection among populations.
In October 2008, Medicare ceased additional payment for hospital-acquired conditions not present on admission. We evaluated the policy’s differential impact in hospitals with high vs low operating margins. Medicare’s payment policy may have had an impact on reducing central line–associated bloodstream infections in hospitals with low operating margins.
Infect. Control Hosp. Epidemiol. 2015;37(1):100–103
This triennium has seen progress in a number of directions related to Commission 20 objectives. Foremost, the growth in the number of astrometric observations of small solar system bodies continues to accelerate and the total number of measurements recorded by the Minor Planet Center now exceeds 135 million. Currently the Pan-STARRS project and the Catalina Sky Survey (CSS) dominate detection and discovery efforts, while the NEO-WISE space mission contributes infrared detections valuable for understanding the size distribution of populations. Looking forward, the Large Synoptic Survey Telescope (LSST) is now funded and in construction on Cerro Pachon in Chile. LSST has the potential to revolutionize the field by conducting a multi-color, ten-year, all-sky survey with a limiting magnitude ~24.5 in the r-band. Survey operations are set to begin in 2022.
The 2008 Centers for Medicare & Medicaid Services hospital-acquired conditions policy limited additional payment for conditions deemed reasonably preventable.
To examine whether this policy was associated with decreases in billing rates for 2 targeted conditions, vascular catheter-associated infections (VCAI) and catheter-associated urinary tract infections (CAUTI).
Adult Medicare patients admitted to 569 acute care hospitals in California, Massachusetts, or New York and subject to the policy.
We used an interrupted times series design to assess whether the hospital-acquired conditions policy was associated with changes in billing rates for VCAI and CAUTI.
Before the policy, billing rates for VCAI and CAUTI were increasing (prepolicy odds ratio per quarter for VCAI, 1.17 [95% CI, 1.11–1.23]; for CAUTI, 1.19 [1.16–1.23]). The policy was associated with an immediate drop in billing rates for VCAI and CAUTI (odds ratio for change at policy implementation for VCAI, 0.75 [95% CI, 0.69–0.81]; for CAUTI, 0.87 [0.79–0.96]). In the postpolicy period, we observed a decreasing trend in the billing rate for VCAI and a leveling-off in the billing rate for CAUTI (postpolicy odds ratio per quarter for VCAI, 0.98 [95% CI, 0.97–0.99]; for CAUTI, 0.99 [0.97–1.00]).
The Centers for Medicare & Medicaid Services hospital-acquired conditions policy appears to have been associated with immediate reductions in billing rates for VCAI and CAUTI, followed by a slight decreasing trend or leveling-off in rates. These billing rates, however, may not correlate with changes in clinically meaningful patient outcomes and may reflect changes in coding practices.
Infect. Control Hosp. Epidemiol. 2015;36(8):871–877
Policymakers may wish to align healthcare payment and quality of care while minimizing unintended consequences, particularly for safety net hospitals.
To determine whether the 2008 Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy had a differential impact on targeted healthcare-associated infection rates in safety net compared with non–safety net hospitals.
Interrupted time-series design.
SETTING AND PARTICIPANTS
Nonfederal acute care hospitals that reported central line–associated bloodstream infection and ventilator-associated pneumonia rates to the Centers for Disease Control and Prevention’s National Health Safety Network from July 1, 2007, through December 31, 2013.
We did not observe changes in the slope of targeted infection rates in the postpolicy period compared with the prepolicy period for either safety net (postpolicy vs prepolicy ratio, 0.96 [95% CI, 0.84–1.09]) or non–safety net (0.99 [0.90–1.10]) hospitals. Controlling for prepolicy secular trends, we did not detect differences in an immediate change at the time of the policy between safety net and non–safety net hospitals (P for 2-way interaction, .87).
The Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy did not have an impact, either positive or negative, on already declining rates of central line–associated bloodstream infection in safety net or non–safety net hospitals. Continued evaluations of the broad impact of payment policies on safety net hospitals will remain important as the use of financial incentives and penalties continues to expand in the United States.
Long-acting injectable formulations of antipsychotics are treatment alternatives to oral agents.
To assess the efficacy of aripiprazole once-monthly compared with oral aripiprazole for maintenance treatment of schizophrenia.
A 38-week, double-blind, active-controlled, non-inferiority study; randomisation (2:2:1) to aripiprazole once-monthly 400 mg, oral aripiprazole (10–30 mg/day) or aripiprazole once-monthly 50mg (a dose below the therapeutic threshold for assay sensitivity). (Trial registration: clinicaltrials.gov, NCT00706654.)
A total of 1118 patients were screened, and 662 responders to oral aripiprazole were randomised. Kaplan–Meier estimated impending relapse rates at week 26 were 7.12% for aripiprazole once-monthly 400mg and 7.76% for oral aripiprazole. This difference (−0.64%, 95% CI −5.26 to 3.99) excluded the predefined non-inferiority margin of 11.5%. Treatments were superior to aripiprazole once-monthly 50mg (21.80%, P⩽0.001).
Aripiprazole once-monthly 400mg was non-inferior to oral aripiprazole, and the reduction in Kaplan–Meier estimated impending relapse rate at week 26 was statistically significant v. aripiprazole once-monthly 50 mg.
The objective of this study is to evaluate the construct validity of the NIH Neurobehavioral Toolbox Cognitive Health Battery (NIHTB-CHB) in adults. Confirmatory factor analysis was used to evaluate the dimensional structure underlying the NIHTB-CHB and Gold Standard tests chosen to serve as concurrent validity criteria for the NIHTB-CHB. These results were used to evaluate the convergent and discriminant validity of the NIHTB-CHB in adults ranging from 20 to 85 years of age. Five dimensions were found to explain the correlations among NIHTB-CHB and Gold Standard tests: Vocabulary, Reading, Episodic Memory, Working Memory and Executive Function/Processing Speed. NIHTB-CHB measures and their Gold Standard analogues defined factors in a pattern that broadly supported the convergent and discriminant validity of the NIHTB-CHB tests. This 5-factor structure was found to be invariant across 20–60 year old (N=159) and 65–85 year old (N=109) age groups that were included in the current validity study. Second order Crystallized Abilities (Vocabulary and Reading) and Fluid Abilities (Episodic Memory, Working Memory, Executive/Speed) factors parsimoniously explained correlations among the five first order factors. These results suggest that the NIHTB-CHB will provide both fine-grained and broad characterization of cognition across the adult age span. (JINS, 2014, 20, 1–9)