Methods: Rates of disease and outcomes were derived from a review of the literature. Using TreeAge-Pro software, a decision model was created to simulate expected health outcomes for populations with high GBC incidence, following 3 treatment strategies: no early intervention, one-time screening ultrasound (US), or PCCY. Lifetime cancer-specific survival was the outcome of interest. Sensitivity analyses were performed to determine threshold values.

Results: Based on our model, populations where lifetime risk of GBC exceeds 0.4% may benefit from early intervention by US or PCCY. Two-way sensitivity analysis shows that over a relatively narrow range of disease incidence, US may be favored if sensitivity exceeds 50%. In many cases where lifetime risk exceeds 1%, PCCY may improve survival.

Conclusions: GBC varies in incidence, but affects many individuals in some populations in the Americas. The lethality of GBC may justify aggressive public health intervention including screening or prophylactic cholecystectomy. Decision analysis models using best-available evidence may help determine the optimal treatment of individuals at risk for GBC.

In this study, Ru(bpy)₃²⁺-doped silica nanoparticles (RuSNP) were used to target nucleic acid sequences in a lateral flow fluorescent assay. This assay was developed to improve the sensitivity and lower the limit of detection as compared to the traditional lateral flow assay. The assay targeted both the spliced leader sequence as well as the polyA tail of the mRNA. The surface of spherical RuSNP was modified by glycidoxypropyl trimethoxysilane (GOPTMS). Amine-terminated oligonucleotides as a bioreceptor were immobilized onto the RuSNP via the interaction between the NH₂ and the epoxy group of the GOPTMS. The conjugate complexes formed were immobilized on the conjugate pad, and the capture oligonucleotides used for test and control lines were immobilized on the nitrocellulose membrane. The effects of the amount of RuSNP, GOPTMS, amine-capped oligonucleotides, and capture oligonucleotides on the test line on the performance of the test strips were investigated and optimized. The fluorescence intensity was evaluated by using a fluorescent microplate reader.

The experimental results showed that the nucleic acid sequence-based and RuSNP-labeled lateral flow assay was very sensitive compared with the gold-labeled test strips and the chemiluminescent test strips we developed previously, and that the limit of detection (LOD) of the test strips developed is 0.4 fmol. The LOD can further be reduced about one order of magnitude when dipstick format was used.

Objective: To describe the types of errors occurring in the home medication management of children with cancer.

Design: In a prospective observational study at three pediatric oncology clinics in the Northeast and Southeast US, patients undergoing chemotherapy and their parents were recruited from 11/2007-4/2011. We reviewed medical records and checked prescription doses. A trained nurse visited the home, reviewed medication bottles and directly observed administration. Two physicians independently made judgments regarding whether an error occurred and its severity. Overall rates of errors were weighted to account for clustering within sites.

Results: For 92 patients, we reviewed 963 medications and observed 242 medication administrations. We found 72 medication errors. Four errors led to significant patient injury. An additional 40 errors had potential for injury: 2 were life-threatening, 13 serious and 25 significant. Error rates varied between study sites (40 -121 errors per 100 patients); the weighted overall rate was 70.2 errors per 100 patients (95%CI: 58.9-81.6). The weighted rate of errors with injury was 3.6 (1.7-5.5) per 100 patients and with potential to injure the patient was 36.3 (29.3-43.3) per 100 patients. Errors occurred most often in medication administration (e.g.: failure to change doses as instructed), prescribing, and labeling (e.g.: 2 wrong frequency). Errors less often involved chemotherapy than other medications. Clinicians were unaware of 82% of the errors in their patients’ homes.

Conclusions: In a multisite study of outpatient pediatric cancer care, medication errors were common. Rates of preventable medication-related injuries in this outpatient population were comparable or higher than that found in studies of hospitalized patients.

Study Design: A decision analysis model was created to compare non-surgical and surgical treatment options for healthy women with stress urinary incontinence. Decision paths included conservative management, pelvic floor physical therapy, pelvic floor physical therapy with electrical stimulation, incontinence pessary and surgical treatment with a midurethral sling. A Markov model cohort analysis was performed with a cycle length of one year starting at age 45 with a lifetime horizon. Probabilities, success rates and utilities for health outcomes were obtained from the literature or, when unavailable, by expert opinion. A cost utility analysis was performed using US recommendations from a societal perspective. This includes cost to the patient and the health plan. Cost data was obtained from Medicare reimbursement in 2012 US dollars. Cost and quality adjusted life years were discounted at 3% per year. Sensitivity analysis was performed to test the validity of our model.

Results: Analysis of the model showed that incontinence pessary was the most cost-effective treatment option with a cost of $11,411 for 18.9 quality adjusted life years. At a willingness to pay threshold of $50,000, incontinence pessary remained the most cost-effective treatment option. At a willingness to pay threshold of $60,000, surgery became the most cost-effective treatment option. Pelvic floor physical therapy and pelvic floor physical therapy with electrical stimulation were dominated at any willingness to pay threshold.

Conclusion: This model shows that surgical correction is likely the most cost-effective treatment option for young healthy women with stress urinary incontinence. These results are driven by the high success rate of minimally invasive slings compared to other treatment modalities. More studies are needed to define utility values for heath states experienced by women with stress urinary incontinence. This will enhance our ability to develop more accurate cost-utility models and offer the best treatment for women affected by incontinence.

Methods: A comprehensive literature search was conducted in MEDLINE, EMBASE, and International Pharmaceutical Abstracts between January 1970 and October 2011 using the terms “antipsychotic agent or neuroleptic agent,” “dementia,” “nursing homes,” and “withdrawal.” One investigator reviewed abstracts for inclusion based on: English-language, human subjects, clinical trial, nursing home site, and ≥5 participants, and reported reduction in medications due to an intervention. We excluded review articles and commentaries and secondary analysis of main trial results. The remaining articles were reviewed by 2 investigators for final inclusion, resulting in 9 articles.

Results: The nine articles meeting inclusion criteria included randomized controlled trials of both typical and atypical antipsychotics. Study populations ranged in size from 55 to 183 NH residents with dementia and typically targeted patients who were not psychotic and did not have a history of violent behavior. Gradual dose reduction protocols typically followed a strategy of 50% dose reduction per week for 2-3 sequential weeks. Outcomes measured included behavioral problems, cognitive function, and resumption of antipsychotic medications. All 9 studies reported that the majority of residents randomized to gradual dose reductions of antipsychotics had no overall detrimental effect on functional and cognitive status, or exacerbation of behavioral symptoms.

Conclusions: Clinical trials evaluating the withdrawal of antipsychotic medications from NH residents with dementia do not show evidence of rebound behavioral escalation after gradual dose reductions.

METHODS: We queried all centers in the University Health Consortium (UHC) database from 2008 to 2010 that have their own HBOT facilities (N=14). Cases of NSTI were identified by ICD-9 diagnosis codes, which included Fournier’s gangrene (608.83), necrotizing fascitis (728.86), and gas gangrene (040.0). HBOT treatment status was identified by the presence (HBOT) or absence (CONTROL) of ICD-9 procedure code (93.95). We then risk stratified and matched our cohort by UHC’s validated severity of illness (SOI) score. Comparisons were then made using univariate tests of association and multivariable logistic regression.

RESULTS: There were 1,583 NSTI cases at the 14 HBOT-capable centers. 117 (7%) cases were treated with HBOT. Risk stratified univariate outcomes are summarized in the table. There was no difference between HBOT and CONTROL groups in hospital length of stay (LOS), direct cost, complications, and mortality across the three less severe SOI classes (minor, moderate, and major). However, for extreme SOI the HBOT group had fewer complications (45% vs. 66%; p<0.01) and fewer deaths (4% vs. 23%; <0.01) while there were no differences in LOS and cost. Multivariable analysis identified age (OR 0.55; 95% CI 0.44 – 0.68) and SOI (OR 0.29; 95% CI 0.21 – 0.40) as independent predictors of survival. HBOT increased the odds of surviving the index hospitalization (OR 8.8; CI 95% 4.4 – 20.4).

CONCLUSION: At HBOT capable centers, receiving HBOT was associated with a significant survival benefit. HBOT in conjunction with current practices for the treatment of NSTI can be both a cost effective and life saving therapy.

Methods: We conducted 18 open-ended interviews with ACS leaders (1 interview/center representing geographic [New England, Northeast, Mid-Atlantic, South, West, Midwest] and practice [Public/Charity, Community, University] variations). Two independent reviewers analyzed transcribed interviews using an inductive approach to determine major themes in practice variation (NVivo qualitative analysis software).

Results: All respondents described ACS as a specialty treating "time sensitive surgical disease" including trauma, emergency general surgery (EGS), and surgical critical care (SCC). 11/18 combined trauma and EGS into a single clinical team; 6/18 included elective general surgery. Emergency orthopedics, neurosurgery, and triage for all surgical services were rare (1/18 each). 11/18 had blocked OR time. All had a core group of trauma and SCC surgeons; 8/18 shared EGS due to volume, manpower, or competition for EGS call. Many (12/18) had formal morning signout rounds; few (2/18) had prospective EGS data registries. Streamlined access to EGS, evidence-based EGS protocols, and improved communication were considered strengths of ACS. ACS was described as the "last great surgical service" reinvigorated to provide "timely," cost-effective EGS by experts in "resuscitation and critical care" and to attract "young, talented, eager surgeons" to trauma and SCC; however, there was concern that it might become the "waste basket for everything that happens at inconvenient times."

Conclusion: Despite rapid adoption of ACS, its implementation varies widely. Standardization of scope of practice, continuity of care, and registry development may improve EGS outcomes and allow the specialty to thrive.