Implementation of a Multimodal Heart Failure Management Protocol in a Skilled Nursing Facility.

Hospitals and skilled nursing facilities (SNFs) are incentivized to reduce hospital readmissions among patients with heart failure (HF). We used the RE-AIM framework and mixed quantitative and qualitative data to evaluate the implementation of a multimodal HF management protocol (HFMP) administered in a SNF in 2021. Over 90% of eligible patients were enrolled in the HFMP (REACH). Of the 42 enrolled patients (61.9% female, aged 81.9 ± 8.9 years, 9.5% Medicaid), 2 (4.8%) were readmitted within 30 days of hospital discharge and 4 (9.5%) were readmitted within 30 days of SNF discharge compared with historical (2020) rates of 16.7% and 22.2%, respectively (a potential savings of $132,418-$176,573 in hospital costs) (EFFECTIVENESS). Although stakeholder feedback about ADOPTION and IMPLEMENTATION was largely positive, challenges associated with clinical data collection, documentation, and staff turnover were described. Findings will inform refinement of the HFMP to facilitate further testing and sustainability (MAINTENANCE).

THE EFFECTS OF WHOLE BODY VIBRATION ON VERTICAL JUMP, POWER, BALANCE, AND AGILITY IN UNTRAINED ADULTS.

BACKGROUND: Despite the increased use of whole body vibration among athletes, there is limited literature on its acute effects within heterogeneous populations such as untrained adults or recreational athletes. HYPOTHESIS/PURPOSE: The purpose of this study was to investigate the acute effects of whole body vibration on vertical jump, power, balance, and agility for untrained males and females. It was hypothesized that there would be an effect on each outcome variable. STUDY DESIGN: Quasi-experimental, pretest-posttest design. METHODS: Twenty males and sixteen females, mean age 24.5 years, were assessed for vertical jump height and power as measured by the Myotest accelerometer, balance as measured by the NeuroCom Balance Master System, and agility as measured by a modified T-test. Each session consisted of a five-minute treadmill warm-up, a practice test, a baseline measurement, a two-minute rest period, whole body vibration at 2 mm and 30 Hz for 60 seconds, and a final measurement. Three different counterbalanced testing sessions were separated by a minimum of 48 hours in between sessions to minimize fatigue. RESULTS: Significant differences existed for both genders for main effect of time for Agility (p = 0.022); end point excursion Left (p = 0.007); and maximum endpoint excursion Left (p = 0.039). Differences for main effect of gender revealed females performed better than males in the following respects: end point excursion Right (p = 0.035); end point excursion Left (p = 0.014); maximum endpoint excursion Right (p = 0.024); and maximum endpoint excursion Left (p = 0.005). Males performed better than females in two respects: Agility (p < 0.0005) and Power (p < 0.0005). A significant interaction was observed between time and gender for vertical jump (p = 0.020). Simple main effects revealed males jumped higher than females during both pre and post intervention, p < 0.0005. Females had a significant decrease in the vertical jump post intervention (p = 0.05). CONCLUSION: Results indicated that whole body vibration produced significant differences in the main effect of time and agility, and end point and maximum end point excursion Left for both genders, acutely. Females performed better in balance compared to males and poorer in vertical jump, but males performed better in agility and power.

Regression of Anterior Disk-Osteophyte Complex Following Cervical Laminectomy and Fusion for Cervical Spondylotic Myelopathy.

STUDY DESIGN: A retrospective case-control study. OBJECTIVE: To investigate whether posterior cervical laminectomy and fusion modifies the natural course of anterior disk-osteophyte complex in patients with multilevel cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: Dorsal migration of the spinal cord is the main purported mechanism of spinal cord decompression following cervical laminectomy and fusion but other potential mechanisms have received scant attention in the literature. This study was conducted to investigate whether cervical laminectomy and fusion affects the size of anterior disk-osteophyte complex. METHODS: The medical records and radiographic imaging of 44 patients who underwent cervical laminectomy and fusion for cervical spondylotic myelopathy between 2006 and 2013 were analyzed. The size of the anterior disk-osteophyte complex was measured preoperatively and postoperatively on MR images taken at an interval of >3 months apart. A control group consisted of 20 nonoperatively treated advanced cervical spondylosis patients. Patients in the control met the same inclusion and exclusion criteria and also had sequential magnetic resonance imaging (MRI) taken at an interval of >3 months apart. RESULTS: The nonoperative and operative groups were statistically similar in the pertinent patient demographics and characteristics including sex, age, time to second MRI, size of anterior disk-osteophyte complex on baseline MRI, mean number of levels affected, and percentage of patients with T2 signal change. As expected the mJOA scores were significantly lower in the operative versus nonoperative cohort (13.6 vs. 16.5, P<0.01). A significant decrease in the size of anterior disk osteophyte was observed in the operative group postoperatively (P<0.01). In comparison, there was no statistically significant change in the size of the anterior disk-osteophyte complex in the control group (P>0.05). The magnitude of the change in disk size between the 2 groups was statistically significant (P<0.01). CONCLUSIONS: The findings of this study suggest that regression of anterior disk-osteophyte complex occurs following cervical laminectomy and fusion, and likely provides another mechanism of spinal cord decompression.

Panoramic view of a superfamily of phosphatases through substrate profiling.

Large-scale activity profiling of enzyme superfamilies provides information about cellular functions as well as the intrinsic binding capabilities of conserved folds. Herein, the functional space of the ubiquitous haloalkanoate dehalogenase superfamily (HADSF) was revealed by screening a customized substrate library against >200 enzymes from representative prokaryotic species, enabling inferred annotation of ∼35% of the HADSF. An extremely high level of substrate ambiguity was revealed, with the majority of HADSF enzymes using more than five substrates. Substrate profiling allowed assignment of function to previously unannotated enzymes with known structure, uncovered potential new pathways, and identified iso-functional orthologs from evolutionarily distant taxonomic groups. Intriguingly, the HADSF subfamily having the least structural elaboration of the Rossmann fold catalytic domain was the most specific, consistent with the concept that domain insertions drive the evolution of new functions and that the broad specificity observed in HADSF may be a relic of this process.

A minimally-invasive rat model of subarachnoid hemorrhage and delayed ischemic injury.

BACKGROUND: Double-injection models of subarachnoid hemorrhage (SAH) in rats are the most effective in producing vasospasm, delayed neurological deficits and infarctions. However, they require two large surgeries to expose the femoral artery and the atlanto-occipital membrane. We have developed a minimally-invasive modification that prevents confounding effects of surgical procedures, leakage of blood from the subarachnoid space and minimizes risk of infection. METHODS: Rats are anesthetized and the ventral tail artery is exposed through a small (5 mm), midline incision, 0.2 mL of blood is taken from the artery and gentle pressure is applied for hemostasis. The rat is flipped prone, and with the head flexed to 90 degrees in a stereotactic frame, a 27G angiocath is advanced in a vertical trajectory, level with the external auditory canals. Upon puncturing the atlanto-occipital membrane, the needle is slowly advanced and observed for cerebrospinal fluid (CSF). A syringe withdraws 0.1 mL of CSF and the blood is injected into the subarachnoid space. The procedure is repeated 24 hours later by re-opening the tail incision. At 8 days, the rats are euthanized and their brains harvested, sectioned, and incubated with triphenyltetrazolium chloride (TTC). RESULTS: Rats develop neurological deficits consistent with vasospasm and infarction as previously described in double-injection models. Cortical and deep infarctions were demonstrated by TTC staining and on histopathology. CONCLUSIONS: A minimally invasive, double-injection rat model of SAH and vasospasm is feasible and produces neurological deficits and infarction. This model can be used to study neuroprotective treatments for vasospasm and delayed neurological deficits following SAH, reducing the confounding effects of surgical interventions.

Lip reconstruction.

Lip reconstruction remains challenging. Accurate analysis of the defect and a thorough understanding of the anatomy and options for reconstruction will maintain the functional and aesthetic quality of this sensitive area.

Microvascular surgery.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Describe the common room set-up, medical considerations, and technical equipment necessary to perform microvascular surgery. 2. Describe the common arterial and venous techniques in performing microvascular surgery. 3. Recognize the common flap types along with their vascular supply and innervation used for microvascular surgery. 4. Describe common techniques for flap monitoring. 5. Describe techniques and medications for thrombolytic therapy. 6. Describe common medical conditions that may preclude an optimal result in microvascular surgery. SUMMARY: This article will explore common approaches to microsurgery. It is anticipated that the readers can utilize this article for maintenance of certification educational components and take the principles outlined and apply them to their daily practice.

Phase I study of temozolomide and escalating doses of oral etoposide for adults with recurrent malignant glioma.

BACKGROUND: Although temozolomide is active against recurrent malignant glioma, responses in many patients are modest and short-lived. Temozolomide may prove more effective in combination with other agents. Therefore, combination oral chemotherapy for these patients is a particularly attractive approach. METHODS: The authors conducted a Phase I study of temozolomide in combination with escalating doses of oral etoposide (VP-16) to determine the maximum tolerated doses of these two agents when given together. The temozolomide dose was fixed at 150 mg/m(2) per day on Days 1-5. The oral VP-16 was escalated in cohorts of 3 to 6 patients by numbers of days of VP-16 administered: 50 mg/m(2) per day, Days 1-5 (dose level 1), Days 1-8 (dose level 2), Days 1-12 (dose level 3), Days 1-16 (dose level 4), and Days 1-20 (dose level 5). Therapy was given in 28-day cycles. RESULTS: Of the 29 patients enrolled, 26 were fully evaluable and 3 were partially evaluable for toxicity. The 29 patients received a total of 92 cycles. The median age of the patients was 49 years (range, 28-76 years). Diagnoses included glioblastoma (n = 19), gliosarcoma (n = 3), anaplastic astrocytoma (n = 5), and anaplastic oligoastrocytoma (n = 2). The median time from diagnosis to disease recurrence was 8 months (3-188 months). Twenty patients were treated at the first disease recurrence, seven at the second, and two at the third. Twenty-four patients (83%) were receiving anticonvulsants and 24 were receiving dexamethasone. All patients had received previous radiation, and 25 of 29 had been treated with chemotherapy previously. Of the 3 patients at dose level 1, none had dose-limiting toxicity (DLT). Of the 6 patients at dose level 2, 1 patient had DLT: Grade 3 thrombocytopenia resulting in a > 2-week delay in starting the next cycle of chemotherapy. Of the 6 patients at dose level 3, 1 patient had DLT: death due to pneumonia. There were 2 DLTs in the 7 patients at dose level 4: fever, neutropenia, and herpes zoster infection in 1 patient and death due to pneumonia in another. Seven patients had been started at dose level 5 when DLT was established at dose level 4: of the 5 fully evaluable and 2 partially evaluable patients at dose level 5, there was no DLT. CONCLUSIONS: The maximum tolerated dose of temozolomide and oral VP-16 in this heavily treated group of patients with recurrent malignant glioma is temozolomide 150 mg/m(2) per day for 5 days and oral VP-16 50 mg/m(2) per day for 12 days.

Phase II trial of temozolomide in patients with progressive low-grade glioma.

PURPOSE: Temozolomide (Temodar; Schering-Plough Corp, Kenilworth, NJ) is an imidazole tetrazinone that undergoes chemical conversion to the active methylating agent 5-(3-methyltriazen-1yl)imidazole-4-carboximide under physiologic conditions. Previous studies have confirmed activity of Temodar in the treatment of progressive and newly diagnosed malignant gliomas. We have extended these results, and now we report results of a phase II trial of Temodar for patients with progressive, low-grade glioma. PATIENTS AND METHODS: Temodar was administered orally once a day for five consecutive days (in a fasting state) at a starting dose of 200 mg/m(2)/d. Treatment cycles were repeated every 28 days following the first daily dose of Temodar. Response criteria used a combination of magnetic resonance imaging and physical examination to evaluate activity. RESULTS: Forty-six patients with low-grade glioma have been treated to date. The objective response rate was 61% (24% complete response and 37% partial response), with an additional 35% of patients having stable disease. Median progression-free survival (PFS) was 22 months (95% confidence interval [CI], 15 to infinity months) with a 6-month PFS of 98% (95% CI, 94% to 100%) and a 12-month PFS of 76% (95% CI, 63% to 92%). Toxicity observed during the study was limited to only six patients. Three patients experienced grade 3 neutropenia, with a duration greater than 3 weeks in one patient, and two patients experienced grade 3 thrombocytopenia. One patient experienced > or = grade 4 toxicity, with intracerebral hemorrhage, neutropenia, thrombocytopenia, sepsis, and death. CONCLUSION: Initial results indicate that Temodar may be active in the treatment of low-grade glioma, and thus, further evaluation of this agent in the treatment of these tumors is warranted.