Next Level Of Care Research Articles

Abstract 435: Targeted exome sequencing to understand tumor progression and identify targeted therapies

Abstract There is a large effort in the public domain to systematically perform DNA and RNA sequencing on large numbers of tumor samples. These efforts will bring us to a greater understanding of tumor biology and lead to identification of new tumor drivers. However, these efforts may fall short in allowing us to understand the progression of tumor resistance, relapse and metastasis, factors which make tumors difficult to treat and increase mortality rates. We are currently performing targeted DNA sequencing on 4000 tumor samples. We have selected 1321 genes, 5 GB of the genome to sequence. Genes were selected through a thorough review of the literature, mutation databases and key pathways in tumorigenesis such as growth factor signaling, DNA damage, p53 signaling, cell cycle and apoptosis. Our effort not only includes a diverse panel of breast, colon, ovarian, and kidney tumors but we have also sequenced pancreatic, liver, esophageal, cervix, endometrial, melanoma, CLL, DLBCL and carcinoid tumors. Our dataset also includes approximately 300 matched tumor-metastatic pairs and an additional 550 metastatic samples. Clinical phenotypes, treatment information, gene expression profiling and copy number variation data is available for all samples. To achieve the next level of care for cancer patients we must understand the biology of the tumors we are trying to treat, which are often metastatic and standard of care resistant. We believe that increasing our efforts in targeted DNA sequencing of key tumor and metastatic samples will allow us to achieve these goals. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 435. doi:1538-7445.AM2012-435

Approach to Trauma Care in the Armed Forces

Approach to Trauma Care in the Armed Forces

Iliac Fracture After a Bone Marrow Biopsy

Rehabilitation care and consultations for oncology patients are expanding as both patients and physicians determine which ongoing therapies may be appropriate, and consultations for these patients will continue to increase as quality-of-life expectations and optimal post-treatment function are addressed. Physiatrists are consulted to facilitate the diagnosis and treatment of multiple issues that may be contributing to a patient’s failure to progress in therapy or recover from an illness, as well as to aid in the patient’s transition to the next level of care. It is important to realize that iatrogenic complications are a consideration for this population, given the variety of treatments and invasive procedures to which they are subjected. Along with bone marrow aspiration, a bone marrow trephine biopsy (ie, the removal of a small core of bone marrow) may be indicated in persons with hematopoietic malignancies to evaluate bone marrow cellularity and involvement and to search for evidence of infiltration [1]. Although these procedures are not without risk, complications are rare and include bleeding with reports of retroperitoneal hemorrhage, infection, tumor seeding, and needle breakage. Sternal aspiration poses special risks because of the relatively thin layer of bone at the site of evaluation, which may lead to penetration of the sternum, with potentially fatal cardiovascular complications. Performing a sternal biopsy is contraindicated for this reason [2,3]. The most typical bone marrow biopsy site is the posterior iliac crest. Postprocedure pain at this site is common. Very rare complications have been reported in the literature, such as gluteal compartment syndrome with transient neuropathy caused by bleeding after the biopsy [4], osteomyelitis, and fracture thought to be a result of osteoporosis [5]. We report an iatrogenic fracture that occurred at the biopsy site and was diagnosed while the patient was in acute care, preparing for his course of rehabilitation.

Perspectives on key principles of generalist medical practice in public service in sub-saharan africa: a qualitative study

BackgroundThe principles and practice of Family Medicine that arose in developed Western countries have been imported and adopted in African countries without adequate consideration of their relevance and appropriateness to the African context. In this study we attempted to elicit a priori principles of generalist medical practice from the experience of long-serving medical officers in a variety of African counties, through which we explored emergent principles of Family Medicine in our own context.MethodsA descriptive study design was utilized, using qualitative methods. 16 respondents who were clinically active medical practitioners, working as generalists in the public services or non-profit sector for at least 5 years, and who had had no previous formal training or involvement in academic Family Medicine, were purposively selected in 8 different countries in southern, western and east Africa, and interviewed.ResultsThe respondents highlighted a number of key issues with respect to the external environment within which they work, their collective roles, activities and behaviours, as well as the personal values and beliefs that motivate their behaviour. The context is characterized by resource constraints, high workload, traditional health beliefs, and the difficulty of referring patients to the next level of care. Generalist clinicians in sub-Saharan Africa need to be competent across a wide range of clinical disciplines and procedural skills at the level of the district hospital and clinic, in both chronic and emergency care. They need to understand the patient's perspective and context, empowering the patient and building an effective doctor-patient relationship. They are also managers, focused on coordinating and improving the quality of clinical care through teamwork, training and mentoring other health workers in the generalist setting, while being life-long learners themselves. However, their role in the community, was found to be more aspirational than real.ConclusionsThe study derived a set of principles for the practice of generalist doctors in sub-Saharan Africa based on the reported activities and approaches of the respondents. Patient-centred care using a biopsychosocial approach remains as a common core principle despite wide variations in context. Procedural and hospital care demands a higher level of skills particularly in rural areas, and a community orientation is desirable, but not widely practiced. The results have implications for the postgraduate training of family physicians in sub-Saharan Africa, and highlight questions regarding the realization of community-orientated primary care.

So Long, Farewell – Sending Patients Home

So Long, Farewell – Sending Patients Home

Cost differences in VHA acute and subacute rehabilitation units: Implications for VHA resource planning

Within the Veterans Health Administration (VHA), the top tier of postacute rehabilitation care is provided in acute rehabilitation bedservice units (ARBUs). The next level of care is provided in subacute rehabilitation bedservice units (SRBUs). We fitted reduced-form and structural models to explain VHA cost differences between ARBUs and SRBUs across time and for the individual cost components. We included sociodemographic variables, time since stroke onset, care facility, and the Functional Independence Measure at admission as explanatory variables. The multivariable results indicate that total index stay costs are lower in ARBUs by almost $6,000 (or approximately 25%) compared with SRBUs. Moreover, the lower costs observed in ARBUs in this study combined with the higher rates of guideline compliance and improved outcomes in ARBUs found in previous work suggest that stroke rehabilitation in an ARBU may be more cost-effective than stroke rehabilitation in an SRBU.

Forward Surgical Teams Provide Comparable Outcomes to Combat Support Hospitals During Support and Stabilization Operations on the Battlefield

Forward Surgical Teams (FST) provide forward deployed surgical care within the battle space. The next level of care in theater, the Combat Support Hospitals (CSH), are distinguished from the FST by advanced resource capabilities including more complex diagnostic imaging, laboratory support with blood banking, and intensive care units. This study was intended to assess the effect of FST capability on the outcome of seriously injured casualties in comparison to the CSH. We reviewed all casualty records in the Joint Theater Trauma Registry database from April 2004 to April 2006. The study cohort included all US military battle casualties who were admitted to either a FST or a CSH and were not returned to duty within 72 hours. Data were tabulated and assessed for basic demographics, mechanism of injury, injury severity score, ventilator and critical care days, and mortality. Statistical inferences were made using Chi square and Student's t tests. As of April 2006, the above information was available in the Joint Theater Trauma Registry on 2,617 US military battle casualties who survived to reach care at a FST and/or CSH. Of this population, 77 subsequently died of wounds and 2,540 survived. We found no significant difference in died of wounds rates between the sample populations or rates of ventilator or critical care days between the two groups, nor did controlling for injury severity score alter this picture. The most significant predictor of mortality in both these groups was head injury. The disparity between the availability of the highest level of injury care and the ability to care for injury as soon as possible is an issue of central importance to both the civilian and military trauma care communities. Our analysis demonstrates that despite the operational and logistic challenges that burden the FST, this level of surgical care confers equivalent battlefield injury outcome results compared with the CSH.

Injury severity and disability in the selection of next level of care following acute medical treatment for traumatic brain injury

Primary objective: To evaluate the association of demographic factors, post-traumatic amnesia (PTA) and a standardized measure of ability limitations with clinical decisions for Next Level of Care following acute hospital treatment for moderate–severe traumatic brain injury (TBI).Research design: A TBI Clinical Nurse specialist recorded PTA for 212 individuals and rated 159 on the Ability and Adjustment Indices of the Mayo-Portland Adaptability Inventory (MPAI-4) for comparison with clinical decisions.Main outcomes and results: Multivariate logistic regression analyses revealed that independent ratings on the MPAI-4 Ability Index and PTA were associated with the clinical decision to admit to Inpatient Rehabilitation vs discharge to Home in 92.7% of the sample; ratings on the Ability Index alone were associated with this decision in 92.2% of cases. Age over 65 was the only variable associated with discharge to a Skilled Nursing Facility, correctly predicting this decision in 64% of cases.Conclusions: Use of a standardized measure of ability limitations appears feasible to provide supportive documentation and potentially improve the consistency of decision-making in recommending Inpatient Rehabilitation vs discharge to Home. Although age is a significant factor in the decision to discharge to a Skilled Nursing Facility, this decision appears complex and merits further study.

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Requirements for Physician Competencies in Allergy: Key Clinical Competencies Appropriate for the Care of Patients With Allergic or Immunologic Diseases: A Position Statement of the World Allergy Organization

Allergic diseases are quite prevalent worldwide, and the incidence of allergy is increasing everywhere [1-7]. Because allergic and immunologic processes overlap all organ systems, allergy is not always taught in medical schools as a separate subject. Indeed, lack of recognition of the specialty and of the need to teach about allergic and immunologic diseases results in allergy not being included at all in some medical school curricula [8]. With an estimated 22% of the global population experiencing allergic and immunologic diseases, it is time to recognize and strengthen education in allergy and immunology [8]. The World Allergy Organization (WAO), an alliance of 74 national and regional allergy societies, created this consensus document to establish educational guidelines for worldwide application to help identify and correct allergy education and training deficiencies and to define appropriate competencies. In creating this consensus, it is recognized that each country has its own principles and goals in medical education at the undergraduate and postgraduate levels. This document defines what WAO considers medical practitioners should know to care appropriately for allergic patients.

The Combat Casualty Care Special Edition

The Combat Casualty Care Special Edition

Develop A Seamless Individualized Pressure Ulcer Care Plan: Recognize–Understand–Solve

The prevalence of pressure ulcers in patients has been recognized as a quality of care indicator. The suffering and expense resulting from this mostly preventable condition requires a more aggressive approach to both the prevention and treatment of pressure ulcers. Government regulations require planning for the next level of care for the at-risk patient in a clinically and financially effective manner.

Evaluation and Development of Potentially Better Practices to Improve the Discharge Process in the Neonatal Intensive Care Unit

Our goal was to identify potentially better practices that create a successful discharge planning process that spans the entire newborn intensive care stay to the next level of care by embedding the discharge planning into all aspects of patient care and communication. Potentially better practices were developed through recommendations from a content expert and a literature review. Internal benchmarking, self-assessment tools, monthly conference calls, the Neonatal Intensive Care Quality Improvement Collaborative 2002 listserv, parent feedback, and semiannual conferences were used to finalize recommendations and implement practices. Potentially better practices included (1) create an easy-to-use/easy-to-access discharge planning tool kit, (2) restructure written and oral communication tools and processes to reflect plans for the day, the stay, and the way to discharge, (3) maximize the impact and use of caregiver educational tools, and update materials and delivery systems for caregiver education, (4) use continuous quality improvement tools and processes to ensure parent/caregiver and staff satisfaction, and (5) analyze and enhance transfers into and interactions with the community. The potentially better practices are recommendations that are designed to integrate organizational, clinical, and operational processes to ensure optimal discharge planning from admission through follow-up in the community.

Considerations for the Head-Injured Air-Evacuated Patient: A Case Report of Frontal Sinus Fracture and Review of the Literature

Head and neck injuries are not uncommon in combat environments and may be increasing due to survivable injuries from the use of kevlar helmets and body armor. With the current capability of rapid evacuation from the battlefield, acutely injured patients with frontal sinus injuries may undergo further barometric challenges. Proper care during transport can prevent the occurrence of secondary injury (increased intracranial pressure, tension pneumocephalus) that would complicate the patient's management at the next level of care. Management principles (importance of low-level flight/pressurized cabin, preflight use of decongestants, avoidance of valsalva, and ability to manage complications either procedurally or by landing) are reviewed. In addition, we propose a simple mechanism for pressure equilibration of a compromised frontal sinus during air evacuation using an angiocatheter placed through the wound before closure.

The Safe Treatment of the Suicidal Patient in an Adult Inpatient Setting: A Proactive Preventive Approach

This paper focuses on the work of an inpatient service in an acute care safety net hospital in the prevention of suicide on its inpatient service and during the high-risk period post discharge. The strategy utilized a comprehensive proactive systems approach to the suicidal patient including: a formalized suicide assessment jointly done by medical and nursing staff, accurate diagnosis and best practice treatment, a flexible nursing observation policy, groups on inpatient units focused on suicide and key risk factors and triggers, and a communication tool to the next level of care that describes the strategies learned by the patient to deal with his or her suicidality. Incidents of self-injurious behaviors and special observation hours were monitored.

Systems for planning and delivering services for Alcohol‐related problems: System‐level thinking much needed. Comment on Chapter 12: Treatment and early intervention services

Alcohol: No Ordinary Commodity's goal of policy relevance leads naturally and appropriately to a discussion of system-level issues in treatment and early intervention (Chapter 12 of Babor et al. 2003). Defining what constitutes a ‘system’ has proved elusive, and many countries’‘alcohol treatment systems’ are systems only in name (Klingemann et al. 1992). Babor et al. (2003) grapple with two aspects of the system question, namely what principles should guide (a) how we identify, understand and prioritize need for intervention in the population, and (b) how we organize available intervention services. Babor et al. (2003) do an admirable job of proposing a system for defining population need for services, which is one of the toughest challenges in public health planning (Andrews & Henderson 2000). The six conditions for a population approach (Box 12.1) surmount the usual problem of equating diagnostic prevalence with treatment need. As the authors are clearly aware, not all diagnosed cases want treatment, not all would benefit if they received it and many others will remit without it. A further excellent aspect of the authors’‘conditions for a population approach for alcohol-related problems’ is its attention to the economic benefits of treatment. To provide treatment solely on compassionate grounds is laudable, but we must recognize a political reality: there will probably always be a limit on how sympathetic the average citizen will feel towards someone who has a problem with alcohol or other drugs. For this reason, any politically viable population approach must establish the benefits of treatment not just to patients, but also to the broader society who will be asked to devote public resources to it. Chapter 12 could have gone further in proposing a system to organize the interventions it describes so ably. The ‘stepped care’ system seems promising in this regard (Sobell & Sobell 1999). Under this model, alcohol-related mutual help organizations could constitute the first line of defense for help-seekers because they do help many individuals, are easy to access and cause minimal intrusion into the individual's life (Humphreys 2004). Policy makers might be particularly interested to learn that several countries have implemented policies that strengthen self-help groups without co-opting them, and that such efforts probably more than pay for themselves through reductions in health-care costs (Humphreys 2004). Those people with alcohol problems who are uninterested in, or not helped by, mutual help groups would become candidates for a brief intervention in a stepped-care treatment system. The authors note correctly that brief interventions cause mean reductions in alcohol consumption in non-dependent problem drinking samples. However, such mean changes prove neither that every non-dependent problem drinker benefits from brief interventions nor that no alcohol-dependent individuals benefit. To set an a priori decision rule based on diagnosis may be less wise than simply giving brief interventions to everyone and then defining the severe cases as those who do not benefit. Many treatment decisions in other areas of medicine are made in a pragmatic fashion in which low-level interventions are used for both treatment and assessment of whether more intensive services are needed. This seems to me a more promising approach for organizing an alcohol treatment system than is the continued pursuit of a priori rules for assigning patients to one type of psychotherapy or another (the ability of the psychotherapy matching hypothesis to keep walking around, post-Project MATCH, with so many empirical stakes in its heart would put Count Dracula to shame). In a stepped-care treatment system, actual data on how each patient responds or fails to respond to lower intensity intervention are used to assign them to the next level of care (e.g. out-patient, residential, telephone follow-ups). I would close with a final comment about systems for planning and organizing alcohol-related services. I share the authors’ belief that science can and must inform policy; but I am sure they would agree with me that empirical comparison of systems is very difficult. For example, conducting the Fort Bragg evaluation of two alternative systems for organizing mental health care cost nearly US$100 million in today's terms (Bickman et al. 1995). As scientists, we can often only test parts of our proposed systems, leaving us always in need of compelling conceptual models in which to arrange our results into coherent policy proposals. Babor et al. (2003) offer an excellent model for assessing and responding to population need, which along with other work in the field on organizing treatment systems (e.g. Sobell & Sobell 1999) should raise the policy relevance of alcohol research. I thank John Finney for comments on these ideas and the US Department of Veterans Affairs Health Services Research and Development Service and National Institute on Alcohol Abuse and Alcoholism for grant support.

FUNCTIONAL ASSESSMENT FOR TRANSITIONS IN PATIENT ACUITY AND CARE

This article provides an overview of functional assessment, describes how functional assessment is performed using standardized tools, and discusses the nurse's role in functional assessment and the interdisciplinary rehabilitation practice setting. In addition, a description of the various levels of care used in the provision of rehabilitative services, and examples of how functional assessment may be related to moving a patient to the next level of care and along the continuum of care, are provided.

Total Population Estimate of Newborn Special-Care Bed Needs

In 1977, 7% of the 38,855 infants born in Utah were estimated to have required a total of 27,439 special-care hospital days. About half (53%) were mildly ill; their average length of stay was 4.6 days, or 24% of the total hospital-days. Another 20% of the infants had intermediate illness, with a 12-day average stay, or 23% of the total hospital-days. The remaining 27% of the infants required intensive care and used 53% of the total hospital-days; their average length of stay was 20 days. As a total population, the state's 38,855 births generated a need for two beds per 1,000 annual live births in special-care facilities. The estimated bed need was: mild illness (Level I), 0.5 beds per 1,000 annual live births; intermediate illness (Level II), 0.5 beds per 1,000 annual live births; and intense illness (Level III), one bed per 1,000 annual live births. Results are based on the assumption that nonstudy births, 30% of the total, have needs proportionate to study births. The following considerations are necessary to extrapolate these bed needs to other populations: convalescence of intensely ill babies may require that up to 50% of their bed needs may be shifted to intermediate care; compliance with criteria for transport to the next level of care may not be 100% as assumed in the study, thus redistributing bed needs; census characteristically fluctuates in special-care nurseries (study results are reported for an unchanging daily census); and the low birth rate of a population is intimately related to the bed needs.