Top Ten Tips Palliative Care Clinicians Should Know About Leveraging the Electronic Health Record for Data Collection and Quality Improvement.

As palliative care (PC) programs rapidly grow and expand across settings, the need to measure, improve, and standardize high-quality PC has also grown. The electronic health record (EHR) is a key component of these efforts as a central hub of care delivery and a repository of patient and system data. Deliberate efforts to leverage the EHR for PC quality improvement (QI) can help PC programs and health systems improve care for patients with serious illnesses. This article, written by clinicians with experience in QI, informatics, and clinical program development, provides practical tips and guidance on EHR strategies and tools for QI and quality measurement.

Hospital palliative care consult improves value-based purchasing outcomes in a propensity score-matched cohort.

BACKGROUND: Hospital-based palliative care consultation is consistently associated with reduced hospitalization costs and more importantly with improved patient quality of life. As healthcare systems move toward value-based purchasing rather than fee-for-service models, understanding how palliative care consultation is associated with value-based purchasing metrics can provide evidence for expanded health system support for a greater palliative care presence. AIM: To understand how a palliative care consultation impacts rates of patient readmission and hospital-acquired infections associated with value-based purchasing metrics. DESIGN: Retrospective propensity-matched case-control study evaluating the impact of palliative care consultation on hospital charges, hospital and intensive care unit length of stay, readmission rates, and rates of hospital-acquired conditions. SETTING/PARTICIPANTS: All adult patients admitted to a two hospital healthcare system over a 2-year period from 1 April 2015 to 31 March 2017. The palliative care team involved three physicians, five advanced practice providers, a social worker, and a chaplain during the study period. RESULTS: A total of 3415 patients receiving a palliative consult were propensity matched to 25,028 controls. Compared to controls, cases had decreased charges per day and decreased rates of 7-, 30-, and 90-day readmissions. CONCLUSION: Through value-based purchasing, hospitals have 3% of their Medicare reimbursements at risk based on readmission rates. By clarifying prognosis and patient goals, palliative care consultation reduces readmission rates. Hospital systems may want to invest in larger palliative care programs as part of their efforts to reduce hospital readmissions.

Neonatal hypoxic insult-mediated cholinergic disturbances in the brain stem: effect of glucose, oxygen and epinephrine resuscitation.

Molecular processes regulating cholinergic functions play an important role in the control of respiration under neonatal hypoxia. The present study evaluates neonatal hypoxic insult-mediated cholinergic alterations and the protective role of glucose, oxygen and epinephrine resuscitation. The changes in total muscarinic, muscarinic M1, M2, M3 receptors and the enzymes involved in acetylcholine metabolism--cholineacetyl transferase and acetylcholine easterase in the brain stem were analyzed. Hypoxic stress decreased total muscarinic receptors along with a reduction in muscarinic M1, M2 and M3 receptor genes in the brain stem. The reduction in acetylcholine metabolism is indicated by the down regulated cholineacetyl transferase and up regulated acetylcholine easterase expression. These cholinergic disturbances in the brain stem were reversed by glucose resuscitation to hypoxic neonates. The adverse effects of immediate oxygenation and epinephrine administration were also reported. This has immense clinical significance in establishing a proper resuscitation for the management of neonatal hypoxia.

Isolated malakoplakia of inguinal lymph node: a rare case report.

Malakoplakia is rare chronic inflammatory disorder which commonly affects urinary tract. Though it has been reported in several sites outside the urinary tract, isolated lympnode involvement is extremely uncommon. Herein we present a case of 20 year old male with right inguinal lymphnodal mass. Histological findings including special stains and immunohistochemistry findings were characteristic of malakoplakia. This case is being presented to create awareness for inclusion of this entity in the differential diagnosis of lymphadenopathy.

Adding insult to injury: effects of interpersonal rejection types, rejection sensitivity, and self-regulation on obsessive relational intrusion.

This study tested the I(3) model [Finkel, 2007; 2008] of intimate partner violence as applied to obsessive relational intrusion (ORI) to assess the relation among self-regulation, rejection, rejection sensitivity (RS), and stalking-related aggression. In Study 1, participants (N=221) read one of three vignettes: no relationship termination, an "internal" rejection (involves an internal attribution to the rejected as cause of relationship ending), or an "external" rejection (external attributions for relationship demise). Next, participants experienced one of two conditions manipulating self-regulation (no depletion vs. depletion). Finally, participants rated their likelihood of engaging in ORI (e.g. unwanted pursuit and/or aggression). Consistent with predictions, participants receiving an internal rejection reported higher aggression than participants experiencing an external rejection, especially when depleted of self-regulation. Study 2 extended the design of Study 1 by adding in a screening survey of RS. Internal rejections still yielded more aggression than other conditions, but this was especially so when rejection-sensitive persons were depleted of self-regulation. In addition to providing support for the I(3) model of aggression, this research shows that not all types of rejection are created equal.

Pulmonary zygomycosis: A clinicopathological study.

BACKGROUND AND OBJECTIVE: Zygomycosis is an emerging infection worldwide. Pulmonary zygomycosis (PZ) is uncommon with only few reported series from India. MATERIALS AND METHODS: All cases of PZ diagnosed on histopathology between 1995 and 2008 were included. Clinical and imageological findings were noted in all cases. Routine hematoxylin and eosin-stained sections were studied to assess the pathology; Gomori's methenamine silver (GMS), periodic acid Schiff were done for delineating fungal morphology. Culture reports were collected wherever available. Treatment and outcome details were noted. RESULTS: Seven patients were diagnosed with PZ during the study period, which included six males and one female patient. Six of these had diabetes mellitus (DM) and one patient was on chemotherapy for the treatment of Hodgkin's lymphoma. Fever and cough were the most common presenting features. Consolidation with or without cavitation was seen in six patients and lung abscess with fungal ball in one patient. All six patients with DM had upper lobe involvement and four had multiple lesions. Histological sections revealed necrotizing inflammation, hemorrhagic infarcts and angioinvasion. Culture was available in two patients, which grew Rhizopus oryzae. Five patients succumbed to disease and remaining two were lost to follow-up. CONCLUSION: Diabetes mellitus is the most common predisposing factor for PZ and carries high mortality.

Epstein-Barr virus as a possible etiologic agent in primary central nervous system lymphoma in immunocompetent individuals.

BACKGROUND: Primary central nervous system lymphoma (PCNSL) occurs in both immunocompetent and immunosuppressed individuals. The role of Epstein-Barr virus (EBV) has been implicated in immunosuppressed individuals but its role is not established in immunocompetent individuals. AIMS: To study the possible role of EBV in PCNSL in immunocompetent individuals. SETTING AND DESIGN: Retrospective study. MATERIALS AND METHODS: Thirty patients with PCNSL were studied immunohistochemically with antibodies to CD45, CD20, CD3 and EBV latent membrane protein-1 (EBV LMP-1). In situ hybridization was done in 19 patients where enough tissue was available using a specific oligonucleotide probe for EBV-Early RNA (EBER). RESULTS: All the patients were immunocompetent and mean age was 41.6 years. Histologically they were diffuse large cell lymphoma: 25 (83.3%) were B cell, 1(3.3%) was T cell and 4 (13.3%) were unclassified. EBV LMP-1 showed variable membrane and cytoplasmic positivity in 24 (80%) patients. In situ hybridization for EBER was negative in all the 19 patients studied. CONCLUSION: In this region of the world probably EBV has no etiologic role in PCNSL in immunocompetent individuals.

Multicentric extramedullary myeloid tumor.

Granulocytic sarcomas or extramedullary myeloid tumors represent the soft tissue counterpart of acute myeloid leukemia. The term is used for any solid collection of leukemic cells. There have been reports of these tumors occurring before the involvement of blood or bone marrow. Our patient had simultaneous involvement of three sites, which was diagnosed on cytology. Further confirmation was done on peripheral blood and bone marrow evaluation.