Advance Directives Change Frequently in Nursing Home Residents.

OBJECTIVES: To describe the rate, timing, and pattern of changes in advance directives (ADs) of do not resuscitate (DNR) and do not hospitalize (DNH) orders among new admissions to nursing homes (NHs). DESIGN: A retrospective cohort study. SETTING AND PARTICIPANTS: Admissions to all publicly funded NHs in Ontario, Canada, between January 1, 2013, and December 31, 2017. METHODS: Residents were followed until discharged from incident NH stay, death, or were still present at the end of study (December 31, 2019). They were categorized into 3 mutually exclusive baseline composite AD groups: Full Code, DNR Only, and DNR+DNH. We used Poisson regression models to estimate the incidence rate ratios of AD change between different AD groups and different decision makers for personal care, adjusted for baseline clinical and sociodemographic variables. RESULTS: A total of 102,541 NH residents were eligible for inclusion. Residents with at least 1 AD change accounted for 46% of Full Code, 30% of DNR Only, and 25% of DNR+DNH group. Median time to first AD change ranged between 26 and 55 weeks. For Full Code and DNR Only residents, the most frequent change was to an AD 1 level lower in aggressiveness or intervention, whereas for DNR+DNH residents the most frequent change was to DNR Only. About 16% of residents had 2 or more AD changes during their stay. After controlling for covariates, residents with a DNR-only order or DNR+DNH orders at admission and those with a surrogate decision maker were associated with lower AD change rates. CONCLUSIONS AND IMPLICATIONS: Measuring AD adherence rates that are documented only at a particular time often underestimates the dynamics of AD changes during a resident's stay and results in an inaccurate measure of the effectiveness of AD on resident care. There should be more frequent reviews of ADs as they are quite dynamic. Mandatory review after an acute change in a resident's health would ensure that ADs are current.

Intracranial invasion of a mast cell tumour in a dog: A case report and review of the literature.

An 11-year-old, female-neutered beagle was presented with a growing soft tissue mass arising within the deep tissues of the left cranial cervical region. At presentation, facial asymmetry was evident along with palpable lymphadenomegaly. Magnetic resonance imaging demonstrated a locally invasive cervical mass with intracranial invasion through focal osteolysis of the occipital bone. After antihistamine administration, cytology confirmed mast cell tumour (MCT) with metastasis to local lymph nodes and liver. The owner chose to pursue lomustine and prednisolone, which were dispensed, but, before home administration, prolonged seizures/status epilepticus occurred prompting euthanasia. Postmortem examination confirmed a high-grade MCT associated with, and infiltrating through, muscle, calvarium, dura mata, leptomeninges and the underlying brain. We present the clinical, imaging, and pathological findings of an unprecedented case of extracranial MCT tumour causing osteolysis of an imperforate flat bone (occipital bone) and intracranial invasion.

Clinical remission of feline sino-nasal aspergillosis despite evidence of persistent infection.

Case summary: Feline sino-nasal aspergillosis is a rare condition with only sparse heterogeneous reports in the literature regarding its treatment. This report describes the presentation, treatment and outcome of a cat with sino-nasal aspergillosis treated by meticulous debridement in combination with topical and systemic azole therapy. Diagnosis was based on MRI, in combination with rhinoscopic assessment and visualisation of fungal plaques, followed by histopathology, fungal culture and panfungal PCR. The cat was treated by debridement of fungal plaques via anterior rhinoscopy and frontal sinusotomy and local instillation of 1% clotrimazole solution, followed by a 4-week course of oral itraconazole. Histopathology confirmed fungal rhinitis and culture identified Aspergillus fumigatus and Aspergillus versicolor. Clinical remission was achieved after treatment; however, evidence of persistent infection was confirmed in the post-mortem examination 8 months after the cat was euthanased for unrelated reasons. Relevance and novel information: Despite clinical remission, the persistence of fungal infection post mortem highlights the challenges of monitoring the response to treatment and illustrates that the resolution of clinical signs does not necessarily equate with a disease cure.

Patent hepatic ciliated foregut remnant resulting in an umbilicobiliary sinus tract, with gallbladder agenesis, in an 8-wk-old male French Bulldog.

Hepatic ciliated foregut remnants or cysts are congenital abnormalities resulting from retention of embryonic ciliated foregut within the liver. These structures are rarely reported in the human medical literature and have not been reported in the veterinary literature previously, to our knowledge. We describe here a case of an 8-wk-old male French Bulldog with a congenital patent hepatic ciliated foregut remnant resulting in an umbilicobiliary sinus tract. The dog also had concurrent gallbladder agenesis. The patient had yellow fluid discharging from the umbilicus, mimicking a patent urachus. Surgical exploration, removal, and histology provided a conclusive diagnosis of a hepatic foregut remnant and therapeutic resolution of the clinical signs. The histologic appearance of a hepatic foregut remnant is classical, namely a duct composed of 4 layers: an inner ciliated epithelial lining, loose connective tissue, smooth muscle, and a fibrous capsule.

Identification of gut microbial species linked with disease variability in a widely used mouse model of colitis.

Experimental mouse models are central to basic biomedical research; however, variability exists across genetically identical mice and mouse facilities making comparisons difficult. Whether specific indigenous gut bacteria drive immunophenotypic variability in mouse models of human disease remains poorly understood. We performed a large-scale experiment using 579 genetically identical laboratory mice from a single animal facility, designed to identify the causes of disease variability in the widely used dextran sulphate sodium mouse model of inflammatory bowel disease. Commonly used treatment endpoint measures-weight loss and intestinal pathology-showed limited correlation and varied across mouse lineages. Analysis of the gut microbiome, coupled with machine learning and targeted anaerobic culturing, identified and isolated two previously undescribed species, Duncaniella muricolitica and Alistipes okayasuensis, and demonstrated that they exert dominant effects in the dextran sulphate sodium model leading to variable treatment endpoint measures. We show that the identified gut microbial species are common, but not ubiquitous, in mouse facilities around the world, and suggest that researchers monitor for these species to provide experimental design opportunities for improved mouse models of human intestinal diseases.

A Retrospective Study of Clinical and Histopathological Features of 81 Cases of Canine Apocrine Gland Adenocarcinoma of the Anal Sac: Independent Clinical and Histopathological Risk Factors Associated with Outcome.

Canine apocrine gland anal sac adenocarcinoma (AGASAC) is a malignant tumour with variable clinical progression. The objective of this study was to use robust multivariate models, based on models employed in human medical oncology, to establish clinical and histopathological risk factors of poor survival. Clinical data and imaging of 81 cases with AGASAC were reviewed. Tissue was available for histological review and immunohistochemistry in 49 cases. Tumour and lymph node size were determined using the response evaluation criteria in the solid tumours system (RECIST). Modelling revealed tumour size over 2 cm, lymph node size grouped in three tiers by the two thresholds 1.6 cm and 5 cm, surgical management, and radiotherapy were independent clinical variables associated with survival, irrespective of tumour stage. Tumour size over 1.3 cm and presence of distant metastasis were independent clinical variables associated with the first progression-free interval. The presence of the histopathological variables of tumour necrosis, a solid histological pattern, and vascular invasion in the primary tumour were independent risk factors of poor survival. Based upon these independent risk factors, scoring algorithms to predict survival in AGASAC patients are presented.

Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods study.

BACKGROUND: This study contributes to a small but growing body of literature on how context influences perceptions of patient safety in healthcare settings. We examine the impact of senior leadership support for safety, supervisory leadership support for safety, teamwork, and turnover intention on overall patient safety grade. Interaction effects of predictors on perceptions of patient safety are also examined. METHODS: In this mixed methods study, cross-sectional survey data (N = 185) were collected from nurses and non-physician healthcare professionals. Semi-structured interview data (N = 15) were collected from nurses. The study participants worked in intensive care, general medicine, mental health, or the emergency department of a large community hospital in Southern Ontario. RESULTS: Hierarchical regression analyses showed that staff perceptions of senior leadership (p < 0.001), teamwork (p < 0.01), and turnover intention (p < 0.01) were significantly associated with overall patient safety grade. The interactive effect of teamwork and turnover intention on overall patient safety grade was also found to be significant (p < 0.05). The qualitative findings corroborated the survey results but also helped expand the characteristics of the study's key concepts (e.g., teamwork within and across professional boundaries) and why certain statistical relationships were found to be non-significant (e.g., nurse interviewees perceived the safety specific responsibilities of frontline supervisors much more broadly compared to the narrower conceptualization of the construct in the survey). CONCLUSIONS: The results of the current study suggest that senior leadership, teamwork, and turnover intention significantly impact nursing staff perceptions of patient safety. Leadership is a modifiable contextual factor and resources should be dedicated to strengthen relational competencies of healthcare leaders. Healthcare organizations must also proactively foster inter and intra-professional collaboration by providing teamwork educational workshops or other on-site learning opportunities (e.g., simulation training). Healthcare organizations would benefit by considering the interactive effect of contextual factors as another lever for patient safety improvement, e.g., lowering staff turnover intentions would maximize the positive impact of teamwork improvement initiatives on patient safety.

Anaplastic Sarcoma and Sertoli Cell Tumor in a Central Bearded Dragon (Pogona vitticeps).

A five-year-old male central bearded dragon (Pogona vitticeps) was presented for investigation of blood in the voided urates. A small cutaneous mass was detected in the gular region, but clinical examination was otherwise unremarkable. Fecal parasitology was negative. Initially, further diagnostics were declined, and antimicrobial treatment was initiated. At re-examination one month later, the gular mass had increased in size and an additional mass was detected within the celomic cavity. Both masses were surgically excised and diagnosed by histopathology as a high-grade anaplastic sarcoma (gular mass), resembling a histiocytic sarcoma, and a Sertoli cell tumor (coelomic mass). Neither of these have been previously reported in the central bearded dragon. Twenty months post-surgery, the lizard remains well with no recurrence of clinical signs or evidence of tumor re-growth.

Turnover intention of hospital staff in Ontario, Canada: exploring the role of frontline supervisors, teamwork, and mindful organizing.

BACKGROUND: This study contributes to a small but growing body of literature on how context influences employee turnover intention. We examine the impact of staff perceptions of supervisory leadership support for safety, teamwork, and mindful organizing on turnover intention. Interaction effects of safety-specific constructs on turnover intention are also examined. METHODS: Cross-sectional survey data were collected from nurses, allied health professionals, and unit clerks working in intensive care, general medicine, mental health, or the emergency department of a large community hospital in Southern Ontario. RESULTS: Hierarchical regression analyses showed that staff perceptions of teamwork were significantly associated with turnover intention (p < 0.001). Direct associations of supervisory leadership support for safety and mindful organizing with turnover intention were non-significant; however, when staff perceived lower levels of mindful organizing at the frontlines, the positive effect of supervisory leadership on turnover intention was significant (p < 0.01). CONCLUSIONS: Our results suggest that, in addition to teamwork perceptions positively affecting turnover intentions, safety-conscious supportive supervisors can help alleviate the negative impact of poor mindful organizing on frontline staff turnover intention. Healthcare organizations should recruit and retain individuals in supervisory roles who prioritize safety and possess adequate relational competencies. They should further dedicate resources to build and strengthen the relational capacities of their supervisory leadership. Moreover, it is important to provide on-site workshops on topics (e.g., conflict management) that can improve the quality of teamwork and consequently reduce employees' intention to leave their unit/organization.

Importance of safety climate, teamwork climate and demographics: understanding nurses, allied health professionals and clerical staff perceptions of patient safety.

BACKGROUND: There is growing evidence regarding the importance of contextual factors for patient/staff outcomes and the likelihood of successfully implementing safety improvement interventions such as checklists; however, certain literature gaps still remain-for example, lack of research examining the interactive effects of safety constructs on outcomes. This study has addressed some of these gaps, together with adding to our understanding of how context influences safety. PURPOSE: The impact of staff perceptions of safety climate (ie, senior and supervisory leadership support for safety) and teamwork climate on a self-reported safety outcome (ie, overall perceptions of patient safety (PS)) were examined at a hospital in Southern Ontario. METHODS: Cross-sectional survey data were collected from nurses, allied health professionals and unit clerks working on intensive care, general medicine, mental health or emergency department. RESULTS: Hierarchical regression analyses showed that perceptions of senior leadership (p<0.001) and teamwork (p<0.001) were significantly associated with overall perceptions of PS. A non-significant association was found between perceptions of supervisory leadership and the outcome variable. However, when staff perceived poorer senior leadership support for safety, the positive effect of supervisory leadership on overall perceptions of PS became significantly stronger (p<0.05). PRACTICE IMPLICATIONS: Our results suggest that leadership support at one level (ie, supervisory) can substitute for the absence of leadership support for safety at another level (ie, senior level). While healthcare organisations should recruit into leadership roles and retain individuals who prioritise safety and possess adequate relational competencies, the field would now benefit from evidence regarding how to build leadership support for PS. Also, it is important to provide on-site workshops on topics (eg, conflict management) that can strengthen working relationships across professional and unit boundaries.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population.

OBJECTIVE: This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use. METHODS: Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score. RESULTS: After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions. CONCLUSIONS: Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.

Odontoameloblastoma with extensive chondroid matrix deposition in a guinea pig.

Odontoameloblastomas (previously incorporated within ameloblastic odontomas) are matrix-producing odontogenic mixed tumors and are closely related in histologic appearance to the 2 other types of matrix-producing odontogenic mixed tumors: odontomas and ameloblastic fibro-odontomas. The presence or absence of intralesional, induced non-neoplastic tissue must be accounted for in the diagnosis. Herein we describe a naturally occurring odontoameloblastoma with extensive chondroid cementum deposition in a guinea pig ( Cavia porcellus). Microscopically, the mass featured palisading neoplastic odontogenic epithelium closely apposed to ribbons and rings of a pink dental matrix (dentinoid), alongside extensive sheets and aggregates of chondroid cementum. The final diagnosis was an odontoameloblastoma given the abundance of odontogenic epithelium in association with dentinoid but a paucity of pulp ectomesenchyme. Chondroid cementum is an expected anatomical feature of cavies, and its presence within the odontoameloblastoma was interpreted as a response of the ectomesenchyme of the dental follicle to the described neoplasm. Our case illustrates the inductive capabilities of odontoameloblastomas while highlighting species-specific anatomy that has resulted in a histologic appearance unique to cavies and provides imaging and histologic data to aid diagnosis of these challenging lesions.

An analysis of messages sent between nurses and physicians in deteriorating internal medicine patients to help identify issues in failures to rescue.

OBJECTIVE: To evaluate in patients who deteriorate and require transfer to the intensive care unit (ICU), how many have a critical text message communicating deterioration and what is the quality of this message? Is message quality, message response or the timeliness of rapid response team (RRT) activation related to death? METHODS: We conducted a retrospective chart review of all ICU transfers from General Internal Medicine (GIM) wards from January 2012 until August 2014. All critical messages (CM) in the 48h prior to ICU transfer were analyzed for RRT calling criteria, time to RRT activation, message quality, presence of vitals, and the quality and timeliness of physician response. RESULTS: Of the 236 patients in the study, 93 (39%) had a CM in the 48h prior to ICU transfer. Within this subset, 76 patients did not have prior RRT activation and the median times from CM to RRT activation and CM to ICU transfer were 8.9 [IQR 2.9, 20.7] and 15.6 [IQR 9.0, 28.7] hours, respectively. Only 45% of messages contained 2 or more vitals and only 3% of messages contained Situation, Background, Assessment, and Recommendations (SBAR). Physician response was timely (3 [IQR 2, 17] min) but response quality was poor; nearly one quarter of responses only acknowledged receipt. Among message characteristics, only the number of SBAR elements was correlated with in-hospital survival (p=0.047). CONCLUSION: Communication between nurses and physicians about critically ill patients could be improved. There appear to be significant gaps in the quality of messages, their responses, and delays in RRT activation.

Goals of care discussions among hospitalized long-term care residents: Predictors and associated outcomes of care.

INTRODUCTION: There are limited data on the occurrence, predictors, and impact of goals of care (GOC) discussions during hospitalization for seriously ill elderly patients, particularly for long-term care (LTC) residents. METHODS: The study was a retrospective chart review of 200 randomly sampled LTC residents hospitalized via the emergency department and admitted to the general internal medicine service of 2 Canadian academic hospitals, from January 2012 through December 2012. We applied logistic regression models to identify factors associated with, and outcomes of, these discussions. RESULTS: Overall, 9.4% (665 of 7084) of hospitalizations were patients from LTC. In the sample of 200 patients, 37.5% had a documented discussion. No baseline patient characteristic was associated with GOC discussions. Low Glasgow Coma Scale, high respiratory rate, and low oxygen saturation were associated with discussions. Patients with discussions had higher rates of orders for no resuscitation (80% vs 55%) and orders for comfort measures only (7% vs 0%). In adjusted analyses, patients with discussions had higher odds of in-hospital death (52.0, 95% confidence interval [CI]: 6.2-440.4) and 1-year mortality (4.1, 95% CI: 1.7-9.6). Nearly 75% of patients with a change in their GOC did not have this documented in the discharge summary. CONCLUSION: In hospitalized LTC patients, GOC discussions occurred infrequently and appeared to be triggered by illness severity. Orders for advance directives, in-hospital death, and 1-year mortality were associated with discussions. Rates of GOC documentation in the discharge summary were poor. This study provides direction for developing education and practice standards to improve GOC discussion rates and their communication back to LTC. Journal of Hospital Medicine 2015;11:824-831. © 2015 Society of Hospital Medicine.

Conceptualizing type 2 diabetes and its management.

Type 2 diabetes is growing worldwide due to population growth, increased rates of obesity, unhealthy diet, and physical inactivity. Risk assessment methods can effectively evaluate the risk of diabetes, and a healthy lifestyle can significantly reduce risk or prevent complications of type 2 diabetes. However, risk assessment alone has not significantly improved poor adherence to recommended medical interventions and lifestyle changes. This paper focuses on the challenge of nonadherence and posits that improving adherence requires tailoring interventions that explicitly consider the social determinants of health.

Inpatient and emergent resource use of patients on dialysis at an academic medical center.

BACKGROUND/AIM: End-stage renal disease patients require resources for emergent and inpatient care in addition to ambulatory dialysis. There are two dialysis modalities and settings which patients switch between. Our aim was to characterize the patterns and reasons for switching, as well as the emergent and inpatient utilization of these patients at the University Health Network. METHODS: Patients who received chronic dialysis between March 1, 2006, and April 30, 2011, were identified. Utilization was measured by emergency department (ED) visits, inpatient hospitalizations, and bed-days occupied per year. RESULTS: Out of 576 patients identified, 18.6% switched modality and/or setting. The majority of switches occurred during the first year of dialysis. Patients who switched had increased utilization compared to those on a continuous modality/setting. Overall, patients had a median rate of 0.91 ED visits per patient-year, compared to 1.56 for patients who switched modality and setting. Median inpatient bed resource requirement was 4.46 bed-days/patient-year overall, compared to 8.91 for patients who switched modality and setting. CONCLUSIONS: Emergent and inpatient utilization is related to the setting and modality of dialysis, although differences are partly explained by comorbidities. Patients who switch modalities use more resources and may be a prime population for interventions.

Use of imaging in the emergency department: physicians have limited effect on variation.

PURPOSE: To quantify interphysician variation in imaging use during emergency department (ED) visits and examine the contribution of factors to this variation at the patient, visit, and physician level. MATERIALS AND METHODS: This study was HIPAA compliant and approved by the institutional review board of Partners Healthcare System (Boston, Mass), with waiver of informed consent. In this retrospective study of 88 851 consecutive ED visits during 2011 at a large urban teaching hospital, a hierarchical logistic regression model was used to identify multiple predictors for the probability that low- or high-cost imaging would be ordered during a given visit. Physician-specific random effects were estimated to articulate (by odds ratio) and quantify (by intraclass correlation coefficient [ICC]) interphysician variation. RESULTS: Patient- and visit-level factors found to be statistically significant predictors of imaging use included measures of ED busyness, prior ED visit, referral source to the ED, and ED arrival mode. Physician-level factors (eg, sex, years since graduation, annual workload, and residency training) did not correlate with imaging use. The remaining amount of interphysician variation was very low (ICC, 0.97% for low-cost imaging; ICC, 1.07% for high-cost imaging). These physician-specific odds ratios of imaging estimates were moderately reliable at 0.78 (95% confidence interval [CI]: 0.77, 0.79) for low-cost imaging and 0.76 (95% CI: 0.74, 0.78) for high-cost imaging. CONCLUSION: After careful and comprehensive case-mix adjustment by using hierarchical logistic regression, only about 1% of the variability in ED imaging utilization was attributable to physicians.

Temporal trends in the utilization of echocardiography in Ontario, 2001 to 2009.

The purpose of this study was to examine utilization and growth in echocardiography among the general population of Ontario between 2001 and 2009. The age- and sex-adjusted rates of echocardiography grew from 39.1 per 1,000 persons in 2001 to 59.9 per 1,000 persons in 2009, for an annual rate of increase of 5.5%. Repeat echocardiograms increased at a rate of 10.6% per year and accounted for 25.3% of all procedures in 2009 as compared to 18.5% in 2002. While significant increases in echocardiography utilization were observed, opportunities may exist to improve the clinical utility of the echocardiograms performed in Ontario.

Our patients expect more (and so do we): it's time to rethink patient satisfaction.

A current focus of healthcare organizations and legislation requires hospitals to place more importance on patient experience and satisfaction than ever before. Institutional patient satisfaction survey tools yield data that represent approximately 5% of patients and may not represent the typical patient experience. Moreover, our research demonstrates that only 1% of surveyed providers rely on these data as their primary source of patient satisfaction feedback. The low response rate, the delayed timing of the feedback and a lack of usability for clinicians raise questions about the value of these tools to front-line healthcare providers - those most responsible for the patients' experience of care.

Immunohistochemical features of the gastrointestinal tract tumors.

Gastrointestinal tract tumors include a wide variety of vastly different tumors and on a whole are one of the most common malignancies in western countries. These tumors often present at late stages as distant metastases which are then biopsied and may be difficult to differentiate without the aid of immunohistochemical stains. With the exception of pancreatic and biliary tumors where there are no distinct immunohistochemical patterns, most gastrointestinal tumors can be differentiated by their unique immunohistochemical profile. As the size of biopsies decrease, the role of immunohistochemical stains will become even more important in determining the origin and differentiation of gastrointestinal tract tumors.