Use of Palliative Care in Patients With End-Stage COPD and Receiving Home Oxygen: National Trends and Barriers to Care in the United States.

BACKGROUND: To investigate the use of palliative care (PC) in patients with end-stage COPD receiving home oxygen hospitalized for an exacerbation. METHODS: A retrospective nationwide cohort analysis was performed, using the Nationwide Inpatient Sample. All patients ≥ 18 years of age with a diagnosis of COPD, receiving home oxygen, and admitted for an exacerbation were included. RESULTS: A total of 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Sample were examined. There were 181,689 patients with COPD, receiving home oxygen, and admitted for an exacerbation; 3,145 patients (1.7%) also had a PC contact. There was a 4.5-fold relative increase in PC referral from 2006 (0.45%) to 2012 (2.56%) (P < .01). Patients receiving PC consultations compared with those who did not were older (75.0 years [SD 10.9] vs 70.6 years [SD 9.7]; P < .01), had longer hospitalizations (4.9 days [interquartile range, 2.6-8.2] vs 3.5 days [interquartile range, 2.1-5.6]), and more likely to die in hospital (32.1% vs 1.5%; P < .01). Race was significantly associated with referral to palliative care, with white patients referred more often than minorities (P < .01). Factors associated with PC referral included age (OR, 1.03; 95% CI, 1.02-1.04; P < .01), metastatic cancer (OR, 2.40; 95% CI, 2.02-2.87; P < .01), nonmetastatic cancer (OR, 2.75; 95% CI, 2.43-3.11; P < .01), invasive mechanical ventilation (OR, 4.89; 95% CI, 4.31-5.55; P < .01), noninvasive mechanical ventilation (OR, 2.84; 95% CI, 2.58-3.12; P < .01), and Do Not Resuscitate status (OR, 7.95; 95% CI, 7.29-8.67; P < .01). CONCLUSIONS: The use of PC increased dramatically during the study period; however, PC contact occurs only in a minority of patients with end-stage COPD admitted with an exacerbation.

Utilization of electroencephalogram post cardiac arrest in the United States: A nationwide retrospective cohort analysis.

OBJECTIVE: The use of electroencephalogram (EEG) has been demonstrated to have diagnostic and prognostic value in cardiac arrest patients. The use of this modality across the United States in this population is unknown. METHODS: The Nationwide Inpatient Sample (NIS) is a federal database capturing 20% of all US hospital admissions. A cohort of patients who suffered both in and out of hospital cardiac arrests from the 2006 to 2012 NIS datasets was created. RESULTS: The records of 55,208,382 hospitalizations were analyzed, of which 207,703 patients suffered a cardiac arrest. There were 2952 (1.42%) patients who also had an EEG. Patients who had an EEG compared to those who did not were: younger (62.2 years SD 16.6 vs 66.9 years SD 16.2, p<0.01), were less likely to have insurance coverage (89.9% vs 91.6%, p=0.03) and had significantly longer length of stay (8.6days IQR 3.7-17.1 vs 4.1days IQR 1.0-10.5, p<0.01). Patients treated at urban teaching hospitals were more likely to receive an EEG than patients treated at urban non-teaching and rural hospitals (p<0.01). The rate of EEG in survivors of cardiac arrest increased from 1.03% in 2006 to 2.16% in 2012, a relative increase of 110% (p<0.02). The median time to performance of an EEG was 1.6days IQR 0.33-4.53 days. CONCLUSION: EEG is performed on approximately 2% of patients who suffer cardiac arrest in the United States. The treatment hospital and patient characteristics of those who received an EEG different from those who did not.

Principles and Practices Fostering Inclusive Excellence: Lessons from the Howard Hughes Medical Institute's Capstone Institutions.

Best-practices pedagogy in science, technology, engineering, and mathematics (STEM) aims for inclusive excellence that fosters student persistence. This paper describes principles of inclusivity across 11 primarily undergraduate institutions designated as Capstone Awardees in Howard Hughes Medical Institute's (HHMI) 2012 competition. The Capstones represent a range of institutional missions, student profiles, and geographical locations. Each successfully directed activities toward persistence of STEM students, especially those from traditionally underrepresented groups, through a set of common elements: mentoring programs to build community; research experiences to strengthen scientific skill/identity; attention to quantitative skills; and outreach/bridge programs to broaden the student pool. This paper grounds these program elements in learning theory, emphasizing their essential principles with examples of how they were implemented within institutional contexts. We also describe common assessment approaches that in many cases informed programming and created traction for stakeholder buy-in. The lessons learned from our shared experiences in pursuit of inclusive excellence, including the resources housed on our companion website, can inform others' efforts to increase access to and persistence in STEM in higher education.

Association between seizures and mortality in patients with aneurysmal subarachnoid hemorrhage: A nationwide retrospective cohort analysis.

PURPOSE: The impact of seizures on outcomes in patients with subarachnoid hemorrhage (SAH) is not well understood, with conflicting results published in the literature. METHOD: For this retrospective cohort analysis, data from the Nationwide Inpatient Samples (NIS) for 2006-2011 were utilized. All patients aged ≥18 years with a primary admitting diagnosis of subarachnoid hemorrhage were included. Patients with a diagnosis of seizure were segregated from the initial cohort. Multivariable logistic regression modeled the risk of death while adjusting for severity of SAH as well as co-morbidities. The primary outcome of this analysis was in-hospital mortality. RESULTS: 12,647 patients met inclusion criteria for the study, of which 1336 had a diagnosis of seizures. The unadjusted in-hospital mortality was higher for patients with seizures compared to those without (16.2% vs 11.6%, p<0.01). Compared to patients without seizures, patients with seizures were younger (52.4 years SD 13.9 vs 54.8 years, SD 13.6; p<0.01), more likely to be male (35.6% vs 31.0%, p<0.01) and had longer hospital stays (18.3 days, IQR 12.0-27.5 vs 14.8 days, IQR 10.0-21.9; p<0.01). After adjusting for the severity of SAH, seizures were found to be associated with increased mortality (OR 1.57, 95% CI 1.32-1.87, p<0.01). CONCLUSION: In this large nationwide analysis, the presence of seizures in patients with SAH was associated with higher in-hospital mortality. This finding has potentially important implications for goals of care decision-making and prognostication, but further study in the area is needed.

Reproducibility of In Vivo Corneal Confocal Microscopy Using an Automated Analysis Program for Detection of Diabetic Sensorimotor Polyneuropathy.

OBJECTIVE: In vivo Corneal Confocal Microscopy (IVCCM) is a validated, non-invasive test for diabetic sensorimotor polyneuropathy (DSP) detection, but its utility is limited by the image analysis time and expertise required. We aimed to determine the inter- and intra-observer reproducibility of a novel automated analysis program compared to manual analysis. METHODS: In a cross-sectional diagnostic study, 20 non-diabetes controls (mean age 41.4±17.3y, HbA1c 5.5±0.4%) and 26 participants with type 1 diabetes (42.8±16.9y, 8.0±1.9%) underwent two separate IVCCM examinations by one observer and a third by an independent observer. Along with nerve density and branch density, corneal nerve fibre length (CNFL) was obtained by manual analysis (CNFLMANUAL), a protocol in which images were manually selected for automated analysis (CNFLSEMI-AUTOMATED), and one in which selection and analysis were performed electronically (CNFLFULLY-AUTOMATED). Reproducibility of each protocol was determined using intraclass correlation coefficients (ICC) and, as a secondary objective, the method of Bland and Altman was used to explore agreement between protocols. RESULTS: Mean CNFLManual was 16.7±4.0, 13.9±4.2 mm/mm2 for non-diabetes controls and diabetes participants, while CNFLSemi-Automated was 10.2±3.3, 8.6±3.0 mm/mm2 and CNFLFully-Automated was 12.5±2.8, 10.9 ± 2.9 mm/mm2. Inter-observer ICC and 95% confidence intervals (95%CI) were 0.73(0.56, 0.84), 0.75(0.59, 0.85), and 0.78(0.63, 0.87), respectively (p = NS for all comparisons). Intra-observer ICC and 95%CI were 0.72(0.55, 0.83), 0.74(0.57, 0.85), and 0.84(0.73, 0.91), respectively (p<0.05 for CNFLFully-Automated compared to others). The other IVCCM parameters had substantially lower ICC compared to those for CNFL. CNFLSemi-Automated and CNFLFully-Automated underestimated CNFLManual by mean and 95%CI of 35.1(-4.5, 67.5)% and 21.0(-21.6, 46.1)%, respectively. CONCLUSIONS: Despite an apparent measurement (underestimation) bias in comparison to the manual strategy of image analysis, fully-automated analysis preserves CNFL reproducibility. Future work must determine the diagnostic thresholds specific to the fully-automated measure of CNFL.

Asynchronous evolution of physiology and morphology in Anolis lizards.

Species-rich adaptive radiations typically diversify along several distinct ecological axes, each characterized by morphological, physiological, and behavioral adaptations. We test here whether different types of adaptive traits share similar patterns of evolution within a radiation by investigating patterns of evolution of morphological traits associated with microhabitat specialization and of physiological traits associated with thermal biology in Anolis lizards. Previous studies of anoles suggest that close relatives share the same "structural niche" (i.e., use the same types of perches) and are similar in body size and shape, but live in different "climatic niches" (i.e., use habitats with different insolation and temperature profiles). Because morphology is closely tied to structural niche and field active body temperatures are tied to climatic niches in Anolis, we expected phylogenetic analyses to show that morphology is more evolutionarily conservative than thermal physiology. In support of this hypothesis, we find (1) that thermal biology exhibits more divergence among recently diverged Anolis taxa than does morphology; and (2) diversification of thermal biology among all species often follows diversification in morphology. These conclusions are remarkably consistent with predictions made by anole biologists in the 1960s and 1970s.

Why tropical forest lizards are vulnerable to climate warming.

Biological impacts of climate warming are predicted to increase with latitude, paralleling increases in warming. However, the magnitude of impacts depends not only on the degree of warming but also on the number of species at risk, their physiological sensitivity to warming and their options for behavioural and physiological compensation. Lizards are useful for evaluating risks of warming because their thermal biology is well studied. We conducted macrophysiological analyses of diurnal lizards from diverse latitudes plus focal species analyses of Puerto Rican Anolis and Sphaerodactyus. Although tropical lowland lizards live in environments that are warm all year, macrophysiological analyses indicate that some tropical lineages (thermoconformers that live in forests) are active at low body temperature and are intolerant of warm temperatures. Focal species analyses show that some tropical forest lizards were already experiencing stressful body temperatures in summer when studied several decades ago. Simulations suggest that warming will not only further depress their physiological performance in summer, but will also enable warm-adapted, open-habitat competitors and predators to invade forests. Forest lizards are key components of tropical ecosystems, but appear vulnerable to the cascading physiological and ecological effects of climate warming, even though rates of tropical warming may be relatively low.

Two-axis MEMS Scanning Catheter for Ultrahigh Resolution Three-dimensional and En Face Imaging.

Ultrahigh resolution two and three-dimensional optical coherence tomography (OCT) imaging was performed using a miniaturized, two-axis scanning catheter based upon microelectromechanical systems (MEMS) mirror technology. The catheter incorporated a custom-designed and fabricated, 1-mm diameter MEMS mirror driven by angular vertical comb (AVC) actuators on both an inner mirror axis and an outer, orthogonal gimbal axis. Using a differential drive scheme, a linearized position response over +/- 6 degrees mechanical angle was achieved. The flexible, fiber-optic catheter device measured < 5 mm in outer diameter with a rigid length of ~ 2.5 cm at the distal end. In vivo and ex vivo images are presented with < 4 microm axial and ~ 12 microm transverse resolution in tissue.

Niche lability in the evolution of a Caribbean lizard community.

Niche conservatism--the tendency for closely related species to be ecologically similar--is widespread. However, most studies compare closely related taxa that occur in allopatry; in sympatry, the stabilizing forces that promote niche conservatism, and thus inhibit niche shifts, may be countered by natural selection favouring ecological divergence to minimize the intensity of interspecific interactions. Consequently, the relative importance of niche conservatism versus niche divergence in determining community structure has received little attention. Here, we examine a tropical lizard community in which species have a long evolutionary history of ecological interaction. We find that evolutionary divergence overcomes niche conservatism: closely related species are no more ecologically similar than expected by random divergence and some distantly related species are ecologically similar, leading to a community in which the relationship between ecological similarity and phylogenetic relatedness is very weak. Despite this lack of niche conservatism, the ecological structuring of the community has a phylogenetic component: niche complementarity only occurs among distantly related species, which suggests that the strength of ecological interactions among species may be related to phylogeny, but it is not necessarily the most closely related species that interact most strongly.

Behavioral drive versus behavioral inertia in evolution: a null model approach.

Some biologists embrace the classical view that changes in behavior inevitably initiate or drive evolutionary changes in other traits, yet others note that behavior sometimes inhibits evolutionary changes. Here we develop a null model that quantifies the impact of regulatory behaviors (specifically, thermoregulatory behaviors) on body temperature and on performance of ectotherms. We apply the model to data on a lizard (Anolis cristatellus) and show that thermoregulatory behaviors likely inhibit selection for evolutionary shifts in thermal physiology with altitude. Because behavioral adjustments are commonly used by ectotherms to regulate physiological performance, regulatory behaviors should generally constrain rather than drive evolution, a phenomenon we call the "Bogert effect." We briefly review a few other examples that contradict the classical view of behavior as the inevitable driving force in evolution. Overall, our analysis and brief review challenge the classical view that behavior is invariably the driving force in evolution, and instead our work supports the alternative view that behavior has diverse--and sometimes conflicting--effects on the directions and rates at which other traits evolve.