Achieving a Diverse, Equitable and Inclusive Environment Using the Pathway to Excellence® Framework as a Model.

Diversity, equity, inclusion, and belonging (DEIB) are essential in building effective healthcare teams to provide quality patient care. Striving to achieve a DEIB culture in the healthcare setting presents challenges and opportunities, and using a framework facilitates this important work. This article details how 2 Pathway to Excellence® (Pathway) designated organizations used the Pathway framework foundations around leadership, shared decision-making, professional development, safety, quality, and well-being to build and support their DEIB structures.

Emergency siren detection technology and hearing impairment: a systematized literature review.

PURPOSE: We aimed to identify evidence supporting emergency vehicle technology in out-of-vehicle systems and in-vehicle-systems that can be used by people with hearing impairment. METHODS: We conducted a systematized review to determine what technologies, at any readiness level, are currently being developed in the area of emergency vehicle detection technology. The studies and websites of technologies for emergency vehicles that are currently available to the general public were identified by searching in one electronic database, Scopus and grey literature using Google, respectively. RESULTS: A total of 359 studies were retrieved from Scopus. The grey literature search identified 189 websites related to the search terms under study. Technological devices have included satellite, out-of-vehicle and in-vehicle technology. The analysis shows that most of the technologies are at the stage of laboratory testing. Knowing the availability and the level of readiness of devices, as well as their effectiveness, provides rehabilitation professionals with tools for making evidence-based recommendations to clients with hearing impairment. Knowing which devices are available also provides information to individuals living with hearing impairment so that they can play an active role in the decision-making process of acquiring the existing technologies. CONCLUSIONS: So far, few technologies have been identified, and most of them are in the laboratory development stage (i.e., low product readiness level). These results indicate a justified need for the development of new in-vehicle technologies to detect emergency vehicles and actions to transform the new devices into products that are available for people with hearing impairment.IMPLICATIONS FOR REHABILITATIONThere is a need to design new assistive technology devices that are intended to detect emergency service vehicles, which in turn may reduce stress and anxiety related to driving for people with hearing impairment.The majority of the included articles discussed siren detection, with only three discussing the necessary next step of communication to humans.Due to the research being in its early stages, the evidence for emergency vehicle technology on health and participation-related outcomes in people living with hearing impairment is unknown.Most websites do not include information on where to purchase emergency vehicle technology or how much the devices cost, thus making it difficult for people with hearing impairment or rehabilitation professionals to make informed decisions about acquiring these technologies.

The Role of Extent of Resection in IDH1 Wild-Type or Mutant Low-Grade Gliomas.

BACKGROUND: Maximizing extent of resection (EOR) improves outcomes in adults with World Health Organization (WHO) grade II low-grade gliomas (LGG). However, recent studies demonstrate that LGGs bearing a mutation in the isocitrate dehydrogenase 1 (IDH1) gene are a distinct molecular and clinical entity. It remains unclear whether maximizing EOR confers an equivalent clinical benefit in IDH mutated (mtIDH) and IDH wild-type (wtIDH) LGGs. OBJECTIVE: To assess the impact of EOR on malignant progression-free survival (MPFS) and overall survival (OS) in mtIDH and wtIDH LGGs. METHODS: We performed a retrospective review of 74 patients with WHO grade II gliomas and known IDH mutational status undergoing resection at a single institution. EOR was assessed with quantitative 3-dimensional volumetric analysis. The effect of predictor variables on MPFS and OS was analyzed with Cox regression models and the Kaplan-Meier method. RESULTS: Fifty-two (70%) mtIDH patients and 22 (30%) wtIDH patients were included. Median preoperative tumor volume was 37.4 cm3; median EOR of 57.6% was achieved. Univariate Cox regression analysis confirmed EOR as a prognostic factor for the entire cohort. However, stratifying by IDH status demonstrates that greater EOR independently prolonged MPFS and OS for wtIDH patients (hazard ratio [HR] = 0.002 [95% confidence interval {CI} 0.000-0.074] and HR = 0.001 [95% CI 0.00-0.108], respectively), but not for mtIDH patients (HR = 0.84 [95% CI 0.17-4.13] and HR = 2.99 [95% CI 0.15-61.66], respectively). CONCLUSION: Increasing EOR confers oncologic and survival benefits in IDH1 wtLGGs, but the impact on IDH1 mtLGGs requires further study.

Surveillance after resection of vestibular schwannoma: measurement techniques and predictors of growth.

OBJECTIVES: To compare different methods of measuring tumor growth after resection of vestibular schwannoma and to identify predictors of growth. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center, inpatient surgery with ambulatory follow-up. PATIENTS: All patients who underwent vestibular schwannoma resection by the senior author from September 1991 to April 2012 and had two or more postoperative MRI scans. INTERVENTIONS: Vestibular schwannoma resection. Measurement of tumor size and enhancement pattern on postoperative magnetic resonance imaging scans. MAIN OUTCOME MEASURES: Tumor size as measured in one (linear), two (planar), and three (volumetric) dimensions using standard radiology workstation tools versus time elapsed since surgical resection. RESULTS: Eighty-eight patients were included with mean follow-up of 3.9 years. Linear measurement of tumor size was found to have modest correlation with planar and volumetric measurements. Excellent correlation was found between the planar and volumetric methods. Nodular enhancement increased risk for tumor growth (OR 6.25, p = 0.03 on planar analysis). If there was growth, tumors with nodular enhancement typically showed increase in size beginning 2 years postoperatively, whereas those with linear or no enhancement were typically stable in size through 5 years. Younger age and larger preoperative tumor size were also risk factors for growth (OR 0.9/p = 0.01 and OR 1.09/p = 0.02). CONCLUSION: Simple planar measurement is an efficient method that correlates well with the more time-consuming volumetric method. The major risk factor for tumor growth is nodular enhancement on a baseline scan, a finding that warrants annual MRI beginning 2 years postoperatively. Younger age and larger preoperative size minimally increased risk of growth.

Intraventricular twin fetuses in fetu.

The authors report a rare case of multiple intracranial fetuses in fetu, fulfilling Willis' traditional criteria, which include an axial and appendicular skeleton with surrounding organized tissue. This case was ascertained from studies of a full-term female neonate who presented with ventriculomegaly. A CT scan showed intracranial calcifications that were suggestive of an axial skeleton. Her birth weight was 3.176 kg (50th-75th percentile), length was 52 cm (90th percentile), head circumference was 35 cm (50th-75th percentile), and Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Prenatal ultrasonography studies performed at 12 weeks and 5 days, and 19 weeks and 6 days revealed normal findings. A 37-week prenatal ultrasonography study showed ventriculomegaly and obstructive hydrocephalus, with a possible intracranial teratoma. Cranial imaging at birth with ultrasonography, CT and MR imaging, and MR angiography demonstrated 2 complex intraventricular masses with cystic, solid, and bony elements. A craniotomy with resection of the masses was performed at 3 months of age. The infant survived and is now 12 months old with some developmental progress. Two axial skeletons, with accompanying rib cage and extremities, including well-formed feet and toes, were noted. Both anencephalic structures had skin with hair, fat, skeletal and smooth muscle, and bony structures with bone marrow and focal areas of calcification. Multiple viscera were present and included thymus, bowel, stomach, salivary gland, kidney, adrenal gland, lung, and presumed adnexal structures. A diagnosis of fetuses in fetu was rendered. Chromosomal studies of the child and tissue from the 2 fetuses in fetu showed normal female karyotypes. A single nucleotide polymorphism array analysis from the proband infant and tissue from the 2 identified fetuses in fetu appeared to be genetically identical. These results are consistent with a monozygotic twin embryonic origin of the fetus in fetu tissue, which is a mechanism that has been suggested in previous reports in which karyotypes, blood types, and limited genetic loci have been studied. This is the first report of a rare example of intracranial intraventricular twin fetuses in fetu for which a genome-wide single nucleotide polymorphism assay has confirmed their genetic identity.

The relative importance of systolic versus diastolic blood pressure control and incident symptomatic peripheral artery disease in women.

Prospective data regarding risk factors for peripheral artery disease (PAD) are sparse, especially among women; the relative contribution of systolic versus diastolic blood pressure control for incident PAD has not been well studied. We evaluated the association of self-reported blood pressure control with incident symptomatic PAD in middle-aged and older women. We examined the relationship between reported hypertension and incident confirmed symptomatic PAD (n = 178) in 39,260 female health professionals aged ≥ 45 years without known vascular disease at baseline. Median follow-up was 13.3 years. Women were grouped according to presence of reported isolated diastolic (IDH), isolated systolic (ISH), or combined systolic-diastolic hypertension (SDH) using cut-points of 90 and 140 mmHg for diastolic and systolic blood pressure, respectively. SBP and DBP were modeled as continuous and categorical exposures. Multivariable-adjusted hazard ratios (HRs), including adjustment for cardiovascular risk factors, were derived from Cox proportional hazards models. Adjusted HRs compared to women without reported hypertension were 1.0 (0.4-2.8) for IDH, 2.0 (1.3-3.1) for ISH, and 2.8 (1.8-4.5) for SDH. There was a 43% increased adjusted risk per 10 mmHg of reported SBP (95% CI 27-62%) and a gradient in risk according to SBP category (< 120, 120-139, 140-159, and ≥ 160 mmHg); HRs were 1.0, 2.3, 4.3, and 6.6 (p-trend < 0.001), respectively. Reported DBP, while individually predictive in models excluding SBP, was not predictive after adjustment for SBP. In conclusion, these prospective data suggest a strong prognostic role for uncontrolled blood pressure and, particularly, uncontrolled systolic blood pressure in the development of peripheral atherosclerosis in women.

Therapeutic approaches to obesity.

OPINION STATEMENT: Obesity in the United States has become a public health crisis, with one third of the US population having a body mass index ≥30 kg/m(2). Given the profound impact of obesity on cardiovascular disease (CVD), studies of lifestyle modification, pharmacotherapy, and surgical interventions must be reappraised to better define the roles of these approaches in preventing cardiovascular events. Recent clinical trials have attempted to quell the debate over macronutrient composition versus caloric restriction in the dietary approach to weight loss. Our interpretation of these results is that caloric reduction and adherence to diets are of greater consequence than the particular dietary content for weight reduction. For cardiovascular risk factor modification, however, specific macronutrient composition of the diet may have additional impact outside weight loss, although the ultimate relationship between various dietary macronutrients and clinical cardiovascular outcomes is unclear. Although pharmacotherapy has been used for decades to treat obesity, there currently are limited options and recurrent cautionary tales; therefore, we use these agents sparingly. Sibutramine, one of only two medications approved by the US Food and Drug Administration for the long-term treatment of obesity, recently came under intense scrutiny because of a possible increase in cardiovascular events, and it now is contraindicated in patients with established CVD. Orlistat and its over-the-counter form, Alli (GlaxoSmithKline, Research Triangle Park, NC), can induce modest weight loss but frequently are not tolerated because of unpleasant gastrointestinal side effects. Fortunately, there are new medications in phase 3 clinical trials that hold promise as potential alternatives for obesity treatment. Finally, bariatric surgery for morbid obesity refractory to lifestyle interventions has become considerably more common. Surgery can effectively reduce body weight and treat cardiovascular risk factors, particularly diabetes, with acceptable complication rates and should be considered a viable option for appropriate patients. Ongoing clinical trials will clarify the impact of bariatric surgery on cardiovascular events and mortality, as well as the role of surgery as a treatment option that may be considered earlier than currently recommended.

Endothelial progenitor cell mobilization and increased intravascular nitric oxide in patients undergoing cardiac rehabilitation.

PURPOSE: We investigated whether cardiac rehabilitation participation increases circulating endothelial progenitor cells (EPCs) and benefits vasculature in patients already on stable therapy previously shown to augment EPCs and improve endothelial function. METHODS: Forty-six of 50 patients with coronary artery disease completed a 36-session cardiac rehabilitation program: 45 were treated with HMG-CoA reductase inhibitor (statin) therapy > or = 1 month (average baseline low-density lipoprotein cholesterol = 81 mg/dL). Mononuclear cells isolated from blood were quantified for EPCs by flow cytometry (CD133/VEGFR-2 cells) and assayed in culture for EPC colony-forming units (CFUs). In 23 patients, EPCs were stained for annexin-V as a marker of apoptosis, and nitrite was measured in blood as an indicator of intravascular nitric oxide. RESULTS: Endothelial progenitor cells increased from 35 +/- 5 to 63 +/- 10 cells/mL, and EPC-CFUs increased from 0.9 +/- 0.2 to 3.1 +/- 0.6 per well (both P < .01), but 11 patients had no increase in either measure. Those patients whose EPCs increased from baseline showed significant increases in nitrite and reduction in annexin-V staining (both P < .01) versus no change in patients without increase in EPCs. Over the course of the program, EPCs increased prior to increase in nitrite in the blood. CONCLUSIONS: Cardiac rehabilitation in patients receiving stable statin therapy and with low-density lipoprotein cholesterol at goal increases EPC number, EPC survival, and endothelial differentiation potential, associated with increased nitric oxide in the blood. Although this response was observed in most patients, a significant minority showed neither EPC mobilization nor increased nitric oxide in the blood.

The role of lumbar shunts in the management of slit ventricles: does the slit-ventricle syndrome exist?

OBJECT: Slit-ventricle syndrome (SVS) is a confusing description of presentations in patients with chronic shunt-treated hydrocephalus. These patients are prone to acute deterioration with recurrent malfunction. The authors describe the clinical profile and management outcome of using lumboperitoneal (LP) shunts in this population of patients. METHODS: Thirty-three patients with slit ventricles and recurrent malfunctions were converted to LP shunts (mean age 12 years). The initial ventricular shunt was placed at a mean age of 16.5 months. Ten patients had failed endoscopic third ventriculostomies prior to placement of their LP shunt. At a previous presentation, in 11 patients suspected to have SVS following revision of the shunt, intracranial pressure normalized after insertion of a contralateral shunt, suggesting that their ventricles were isolated. The rate of infection and malfunction was compared before and after conversion to an LP shunt. Twenty-seven patients were successfully converted to LP shunts. Four of the 11 patients with isolated ventricles required ventricular shunts in addition to the LP shunt. During a mean follow-up period of 16.7 months, the malfunction rate per patient decreased from 4.81 for ventriculoperitoneal shunts, prior to conversion to 1.48 after conversion to LP shunts, a statistically significant reduction (p < 0.000). No significant difference was found in the rate of shunt infections (7.1% for VP shunts and 9.6% for LP shunts, p = 0.44). No patient presented with acute symptoms following malfunction of an LP shunt or suffered from a Chiari I malformation. CONCLUSIONS: Conversion to an LP shunt is a safe and effective procedure in patients prone to rapid decompensation and recurrent shunt malfunctions from small, slitlike ventricles. The term SVS is confusing. The condition is a manifestation of an unrecognized slitlike isolated ventricle and should be abandoned.

Outcomes and risks of granulocyte colony-stimulating factor in patients with coronary artery disease.

OBJECTIVES: Cytokine mobilization of progenitor cells from bone marrow may promote myocardial neovascularization with relief of ischemia. BACKGROUND: Patients with coronary artery disease (CAD) have low numbers of endothelial progenitor cells compared with healthy subjects. METHODS: Granulocyte colony-stimulating factor (G-CSF), 10 microg/kg/day for five days, was administered to 16 CAD patients. Progenitor cells were measured by flow cytometry; ischemia was assessed by exercise stress testing and by dobutamine stress cardiac magnetic resonance imaging. RESULTS: Granulocyte colony-stimulating factor increased CD34+/CD133+ cells in the circulation from 1.5 +/- 0.2 microl to 52.4 +/- 10.4 microl (p < 0.001), similar to the response observed in 15 healthy subjects (75.1 +/- 12.6 microl, p = 0.173). Indices of platelet and coagulation activation were not changed by treatment, but C-reactive protein increased from 4.5 +/- 1.3 mg/l to 8.6 +/- 1.3 mg/l (p = 0.017). Two patients experienced serious adverse events: 1) non-ST-segment elevation myocardial infarction (MI) 8 h after the fifth G-CSF dose, and 2) MI and death 17 days after treatment. At 1 month after treatment, there was no improvement from baseline values (i.e., reduction) in wall motion score (from 25.7 +/- 2.1 to 28.3 +/- 1.9, p = 0.196) or segments with abnormal perfusion (7.6 +/- 1.1 to 7.7 +/- 1.1, p = 0.916) and a trend towards a greater number of ischemic segments (from 4.5 +/- 0.6 to 6.1 +/- 1.0, p = 0.068). There was no improvement in exercise duration at 1 month (p = 0.37) or at 3 months (p = 0.98) versus baseline. CONCLUSIONS: Granulocyte colony-stimulating factor administration to CAD patients mobilizes cells with endothelial progenitor potential from bone marrow, but without objective evidence of cardiac benefit and with the potential for adverse outcomes in some patients.

Endothelial progenitor cell therapy for atherosclerosis: the philosopher's stone for an aging population?

Much of the increased risk for atherosclerosis progression with age may be a result of age-related declines in the capacity of precursor cells to repair damage in the arterial endothelium. To estimate the impact of progenitor cell therapy for atherosclerosis on cardiovascular disease (CVD) mortality, life expectancy, and survival, as compared with the lifetime control of conventional risk factors, we modeled the health effects of bone marrow-derived endothelial progenitor cell therapy using data from the 1950 to 1996 follow-up of the Framingham Heart Study. To model cardiovascular disease mortality, we assumed that progenitor cell therapy was applied at age 30, with the effect assumed to be a 10-year delay in atherosclerosis progression. Age projections were constructed analytically using the stochastic process model for risk factor dynamics and mortality and microsimulation techniques. We considered three types of interventions: (i) keeping risk factors within selected limits to model current clinical recommendations; (ii) an age shift of 10 years to model the effects of progenitor cell therapy; and (iii) elimination of a competing risk (such as cancer). Our study suggests that progenitor cell therapy might increase life expectancy in the population as much as the complete elimination of cancer (in females, an additional 3.67 versus 3.37 years; in males, an additional 5.94 versus 2.86 years, respectively).

Granulocyte colony-stimulating factor mobilizes functional endothelial progenitor cells in patients with coronary artery disease.

OBJECTIVE: Endothelial progenitor cells (EPCs) that may repair vascular injury are reduced in patients with coronary artery disease (CAD). We reasoned that EPC number and function may be increased by granulocyte colony-stimulating factor (G-CSF) used to mobilize hematopoietic progenitor cells in healthy donors. METHODS AND RESULTS: Sixteen CAD patients had reduced CD34(+)/CD133(+) (0.0224+/-0.0063% versus 0.121+/-0.038% mononuclear cells [MNCs], P<0.01) and CD133(+)/VEGFR-2(+) cells, consistent with EPC phenotype (0.00033+/-0.00015% versus 0.0017+/-0.0006% MNCs, P<0.01), compared with 7 healthy controls. Patients also had fewer clusters of cells in culture, with out-growth consistent with mature endothelial phenotype (2+/-1/well) compared with 16 healthy subjects at high risk (13+/-4/well, P<0.05) or 14 at low risk (22+/-3/well, P<0.001) for CAD. G-CSF 10 microg/kg per day for 5 days increased CD34(+)/CD133(+) cells from 0.5+/-0.2/microL to 59.5+/-10.6/microL and CD133(+)/ VEGFR-2(+) cells from 0.007+/-0.004/microL to 1.9+/-0.6/microL (both P<0.001). Also increased were CD133(+) cells that coexpressed the homing receptor CXCR4 (30.4+/-8.3/microL, P<0.05). Endothelial cell-forming clusters in 10 patients increased to 27+/-9/well after treatment (P<0.05), with a decline to 9+/-4/well at 2 weeks (P=0.06). CONCLUSIONS: Despite reduced EPCs compared with healthy controls, patients with CAD respond to G-CSF with increases in EPC number and homing receptor expression in the circulation and endothelial out-growth in culture. Endothelial progenitor cells (EPCs) are reduced in coronary artery disease. Granulocyte colony-stimulating factor (CSF) administered to patients increased: (1) CD133+/VEGFR-2+ cells consistent with EPC phenotype; (2) CD133+ cells coexpressing the chemokine receptor CXCR4, important for homing of EPCs to ischemic tissue; and (3) endothelial cell-forming clusters in culture. Whether EPCs mobilized into the circulation will be useful for the purpose of initiating vascular growth and myocyte repair in coronary artery disease patients must be tested in clinical trials.

Collaborative planning for formative assessment and cultural appropriateness in the Girls health Enrichment Multi-site Studies (GEMS): a retrospection.

OBJECTIVE: The Girls health Enrichment Multi-site Studies (GEMS), Phase 1, developed and pilot-tested interventions to prevent obesity in African-American preadolescent girls. This article describes the collaborative planning process undertaken to take full advantage of formative assessment activities for improving contextual relevance and cultural appropriateness. DESIGN: Working group activities were designed to stimulate awareness and reflection among group members and, through them, among other field center investigators and staff about developmental, cultural, and contextual issues for formative assessment. SETTING: Telephone, Internet, and face-to-face interactions across GEMS field centers in Houston, Texas; Memphis, Tennessee; Minneapolis, Minnesota; and Palo Alto, California. PARTICIPANTS: Investigators and staff involved in intervention development. MAIN OUTCOME MEASURES: The utility of the process was judged from feedback by participants and field center principal investigators about the contribution of the collaborative effort to improving the perceived relevance and cultural appropriateness of formative assessment data collection and interpretation. RESULTS: A working bibliography was compiled. A detailed matrix of programmatic, child, family, and contextual issues related to ethnicity, socioeconomic status, general health and lifestyle, food, physical activity, and body image/weight control was completed. Additional guidance was derived from a workshop that involved scholars with expertise in aspects of African-American culture, child development, and family processes. CONCLUSIONS: This process improved the breadth and depth of GEMS formative assessment activities by increasing the appreciation of the complex structural, contextual, and personal forces at play. A similar process may be useful to other investigators when attempting to develop culturally appropriate interventions.

Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study.

OBJECTIVE: To test the feasibility, acceptability, and potential efficacy of after-school dance classes and a family-based intervention to reduce television viewing, thereby reducing weight gain, among African-American girls. DESIGN: Twelve-week, 2-arm parallel group, randomized controlled trial. SETTING: Low-income neighborhoods. PARTICIPANTS: Sixty-one 8-10-year-old African-American girls and their parents/guardians. INTERVENTIONS: The treatment intervention consisted of after-school dance classes at 3 community centers, and a 5-lesson intervention, delivered in participants' homes, and designed to reduce television, videotape, and video game use. The active control intervention consisted of disseminating newsletters and delivering health education lectures. MAIN OUTCOME MEASURES: Implementation and process measures, body mass index, waist circumference, physical activity measured by accelerometry, self-reported media use, and meals eaten with TV. RESULTS: Recruitment and retention goals were exceeded. High rates of participation were achieved for assessments and intervention activities, except where transportation was lacking. All interventions received high satisfaction ratings. At follow up, girls in the treatment group, as compared to the control group, exhibited trends toward lower body mass index (adjusted difference = -.32 kg/m2, 95% confidence interval [CI] -.77, .12; Cohen's d = .38 standard deviation units) and waist circumference (adjusted difference = -.63 cm, 95% CI -1.92, .67; d = .25); increased after-school physical activity (adjusted difference = 55.1 counts/minute, 95% CI -115.6, 225.8; d = .21); and reduced television, videotape, and video game use (adjusted difference = -4.96 hours/week, 95% CI -11.41, 1.49; d = .40). The treatment group reported significantly reduced household television viewing (d = .73, P = .007) and fewer dinners eaten while watching TV (adjusted difference = -1.60 meals/week, 95% CI -2.99, -.21; d = .59; P = .03). Treatment group girls also reported less concern about weight (d = .60; P = .03), and a trend toward improved school grades (d = .51; P = .07). CONCLUSIONS: This study confirmed the feasibility, acceptability, and potential efficacy of using dance classes and a family-based intervention to reduce television viewing, thereby reducing weight gain, in African-American girls.