Using geographic variation in unplanned ambulatory care sensitive condition admission rates to identify commissioning priorities:an analysis of routine data from England

Objectives To use geographic variation in unplanned ambulatory care sensitive condition admission rates to identify the clinical areas and patient subgroups where there is greatest potential to prevent admissions and improve the quality and efficiency of care. Methods We used English Hospital Episode Statistics data from 2011/2012 to describe the characteristics of patients admitted for ambulatory care sensitive condition care and estimated geographic variation in unplanned admission rates. We contrasted geographic variation across admissions with different lengths of stay which we used as a proxy for clinical severity. We estimated the number of bed days that could be saved under several scenarios. Results There were 1.8 million ambulatory care sensitive condition admissions during 2011/2012. Substantial geographic variation in ambulatory care sensitive condition admission rates was commonplace but mental health care and short-stay (&lt;2 days) admissions were particularly variable. Reducing rates in the highest use areas could lead to savings of between 0.4 and 2.8 million bed days annually. Conclusions Widespread geographic variations in admission rates for conditions where admission is potentially avoidable should concern commissioners and could be symptomatic of inefficient care. Further work to explore the causes of these differences is required and should focus on mental health and short-stay admissions. </jats:sec

Economics of Increased Beef Grader Accuracy

Carcass data from more than 38,000 cattle was used to compare the called and measured yield grade in two different periods: before and after the slaughter plant incorporated another grader in the line to improve grading accuracy. The study shows that the graders accuracy significantly increased. The higher accuracy affected all yield grades, but most notably resulted in more called yield grade 4 and 5 carcasses. This analysis will develop insight of what will be the effect of instrument grading that will be more accurate than previously called grades.The results are expressed as the conditional distribution of the called yield grade for a given value of the measured yield grade. The pricing grid currently used by the industry was used to analyze the effect of the graders errors on the expected values of the premiums on both periods and by yield grade. The results show that the company has an incentive to improve accuracy of grading. Simulating the results of measured vs. called yield grade over prices at the time and a standard industry grid showed that the plant can benefit by $1.32 per head by increasing grading accuracy.cattle, carcass grading, accuracy, economics of grading,

Ultrasound Guided Placement of Single-Lumen Peripheral Intravenous Catheters in the Internal Jugular Vein

Introduction: The peripheral internal jugular (IJ), also called the “easy IJ,” is an alternative to peripheral venous access reserved for patients with difficult intravenous (IV) access. The procedure involves placing a single-lumen catheter in the IJ vein under ultrasound (US) guidance. As this technique is relatively new, the details regarding the ease of the procedure, how exactly it should be performed, and the safety of the procedure are uncertain. Our primary objective was to determine the success rate for peripheral IJ placement. Secondarily, we evaluated the time needed to complete the procedure and assessed for complications. Methods: This was a prospective, single-center study of US-guided peripheral IJ placement using a 2.5-inch, 18-gauge catheter on a convenience sample of patients with at least two unsuccessful attempts at peripheral IV placement by nursing staff. Peripheral IJ lines were placed by emergency medicine (EM) attending physicians and EM residents who had completed at least five IJ central lines. All physicians who placed lines for the study watched a 15-minute lecture about peripheral IJ technique. A research assistant monitored each line to assess for complications until the patient was discharged. Results: We successfully placed a peripheral IJ in 34 of 35 enrolled patients (97.1%). The median number of attempts required for successful cannulation was one (interquartile range (IQR): 1 to 2). The median time to successful line placement was 3 minutes and 6 seconds (IQR: 59 seconds to 4 minutes and 14 seconds). Two lines failed after placement, and one of the 34 successfully placed peripheral IJ lines (2.9%) had a complication – a local hematoma. There were, however, no arterial punctures or pneumothoraces. Although only eight of 34 lines were placed using sterile attire, there were no line infections. Conclusion: Our research adds to the growing body of evidence supporting US-guided peripheral internal jugular access as a safe and convenient procedure alternative for patients who have difficult IV access

Calculating hospital length of stay using the Hospital Episode Statistics; a comparison of methodologies

Abstract Background Accurate calculation of hospital length of stay (LOS) from the English Hospital Episode Statistics (HES) is important for a wide range of audit and research purposes. The two methodologies which are commonly used to achieve this differ in their accuracy and complexity. We compare these methods and make recommendations on when each is most appropriate. Methods We calculated LOS using continuous inpatient spells (CIPS), which link care spanning across multiple hospitals, and spells, which do not, for six conditions with short (dyspepsia or other stomach function, ENT infection), medium (dehydration and gastroenteritis, perforated or bleeding ulcer), and long (stroke, fractured proximal femur) average LOS. We examined how inter-area comparisons (i.e. benchmarking) and temporal trends differed. We defined a classification system for spells and explored the causes of differences. Results Stroke LOS was 16.5 days using CIPS but 24% (95% CI: 23, 24) lower, at 12.6 days, using spells. Smaller differences existed for shorter-LOS conditions including dehydration and gastroenteritis (4.5 vs. 4.2 days) and ENT infection (0.9 vs. 0.8 days). Typical patient pathways differed markedly between areas and have evolved over time. One area had the third shortest stroke LOS (out of 151) using spells but the fourth longest using CIPS. These issues were most profound for stroke and fractured proximal femur, as patients were frequently transferred to a separate hospital for rehabilitation, however important disparities also existed for conditions with simpler secondary care pathways (e.g. ENT infections, dehydration and gastroenteritis). Conclusions Spell-based LOS is widely used by researchers and national reporting organisations, including the Health and Social Care Information Centre, however it can substantially underestimate the time patients spend in hospital. A widespread shift to a CIPS methodology is required to improve the quality of LOS estimates and the robustness of research and benchmarking findings. This is vital when investigating clinical areas with typically long, complex patient pathways. Researchers should ensure that their LOS calculation methodology is fully described and explicitly acknowledge weaknesses when appropriate

Direct Interaction between AR and PAK6 in Androgen-Stimulated PAK6 Activation

A p21-activated kinase 6 (PAK6) was previously identified to be an androgen receptor (AR) interacting protein through a yeast two-hybrid screening. We used hormone responsive prostate cancer LAPC4 and LNCap cell lines as models to study the signaling events associated with androgen stimulation and PAK6. An androgen-stimulated PAK6 kinase activation was observed in LAPC4 cells expressing endogenous PAK6 and in LNCap cells ectopically expressing a wild type PAK6. This activation was likely mediated through a direct interaction between AR and PAK6 since siRNA knock-down of AR in LAPC4 cells downregulated androgen-stimulated PAK6 activation. In addition, LNCap cells expressing a non-AR-interacting PAK6 mutant exhibited dampened androgen-stimulated kinase activation. As a consequence of androgen-stimulated activation, PAK6 was phosphorylated at multiple serine/threonine residues including the AR-interacting domain of PAK6. Furthermore, androgen-stimulation promoted prostate cancer cell motility and invasion were demonstrated in LNCap cells ectopically expressing PAK6-WT. In contrast, LNCap expressing non-AR-interacting mutant PAK6 did not respond to androgen stimulation with increased cell motility and invasion. Our results demonstrate that androgen-stimulated PAK6 activation is mediated through a direct interaction between AR and PAK6 and PAK6 activation promotes prostate cancer cells motility and invasion

Patient flow within UK emergency departments:a systematic review of the use of computer simulation modelling methods

Objectives Overcrowding in the emergency department (ED) is common in the UK as in other countries worldwide. Computer simulation is one approach used for understanding the causes of ED overcrowding and assessing the likely impact of changes to the delivery of emergency care. However, little is known about the usefulness of computer simulation for analysis of ED patient flow. We undertook a systematic review to investigate the different computer simulation methods and their contribution for analysis of patient flow within EDs in the UK.Methods We searched eight bibliographic databases (MEDLINE, EMBASE, COCHRANE, WEB OF SCIENCE, CINAHL, INSPEC, MATHSCINET and ACM DIGITAL LIBRARY) from date of inception until 31 March 2016. Studies were included if they used a computer simulation method to capture patient progression within the ED of an established UK National Health Service hospital. Studies were summarised in terms of simulation method, key assumptions, input and output data, conclusions drawn and implementation of results.Results Twenty-one studies met the inclusion criteria. Of these, 19 used discrete event simulation and 2 used system dynamics models. The purpose of many of these studies (n=16; 76%) centred on service redesign. Seven studies (33%) provided no details about the ED being investigated. Most studies (n=18; 86%) used specific hospital models of ED patient flow. Overall, the reporting of underlying modelling assumptions was poor. Nineteen studies (90%) considered patient waiting or throughput times as the key outcome measure. Twelve studies (57%) reported some involvement of stakeholders in the simulation study. However, only three studies (14%) reported on the implementation of changes supported by the simulation.Conclusions We found that computer simulation can provide a means to pretest changes to ED care delivery before implementation in a safe and efficient manner. However, the evidence base is small and poorly developed. There are some methodological, data, stakeholder, implementation and reporting issues, which must be addressed by future studies

Does the Graders Accuracy Explain the Increase in Called Yield Grades 4’s and 5’s?

Carcass data from more than 38 thousand cattle was used to compare the called and measured yield grade in two different periods: before and after the slaughter plant incorporated another grader in the line to improve grading accuracy. The study shows that the graders accuracy significantly increased. The higher accuracy effected all yield grades, but most notably resulted in more called yield grade 4 and 5 carcasses. This analysis may be a forecast of the impact of instrument grading that will be more accurate than previously called grades

Partner behavioral responses to pain mediate the relationship between partner pain cognitions and pain outcomes in women with provoked vestibulodynia

Partner behavioral responses to pain can have a significant impact on patient pain and depression, but little is known about why partners respond in specific ways. Using a cognitive-behavioral model, the present study examined whether partner cognitions were associated with partner behavioral responses, which prior work has found to predict patient pain and depressive symptoms. Participants were 354 women with provoked vestibulodynia and their partners. Partner pain-related cognitions were assessed using the partner versions of the Pain Catastrophizing Scale and Extended Attributional Style Questionnaire, whereas their behavioral responses to pain were assessed with the Multidimensional Pain Inventory. Patient pain was measured using a numeric rating scale, and depressive symptoms were assessed using the Beck Depression Inventory–II. Path analysis was used to examine the proposed model. Partner catastrophizing and negative attributions were associated with negative partner responses, which were associated with higher patient pain. It was also found that partner pain catastrophizing was associated with solicitous partner responses, which in turn were associated with higher patient pain and depressive symptoms. The effect of partner cognitions on patient outcomes was partially mediated by partner behavioral responses. Findings highlight the importance of assessing partner cognitions, both in research and as a target for intervention. Perspective The present study presents a cognitive-behavioral model to partially explain how significant others' thoughts about pain have an effect on patient pain and depressive symptoms. Findings may inform cognitive-behavioral therapy for couples coping with PVD

Search for gravitational wave bursts in LIGO's third science run

We report on a search for gravitational wave bursts in data from the three LIGO interferometric detectors during their third science run. The search targets subsecond bursts in the frequency range 100-1100 Hz for which no waveform model is assumed, and has a sensitivity in terms of the root-sum-square (rss) strain amplitude of hrss ~ 10^{-20} / sqrt(Hz). No gravitational wave signals were detected in the 8 days of analyzed data.Comment: 12 pages, 6 figures. Amaldi-6 conference proceedings to be published in Classical and Quantum Gravit