Fatal Complication of Mouthguard Used to Treat Awake Bruxism in Patient with Frontotemporal Dementia.

Awake bruxism is an understudied manifestation of frontotemporal dementia, yet awake bruxism can have fatal consequences in the aging population. This report presents a patient suffering from awake bruxism associated with frontotemporal dementia being treated with a mouthguard, which ultimately becomes lodged in her posterior oropharynx leading to asphyxiation. The case highlights the need for investigation into the occurrence and treatment of awake bruxism among patients with dementia, and the unique risk-benefit analysis that must be performed to develop proper treatment plans for patients with dementia.

The Quality Measures Domain in Nursing Home Compare: Is High Performance Meaningful or Misleading?

BACKGROUND AND OBJECTIVES: The reported percent of nursing home residents suffering adverse outcomes decreased dramatically since Nursing Home Compare began reporting them, but the validity of scores is questionable for nursing homes that score well on measures using facility-reported data but poorly on inspections. Our objective was to assess whether nursing homes with these "discordant" scores are meaningfully better than nursing homes that score poorly across domains. RESEARCH DESIGN AND METHODS: We used a convergent mixed-methods design, starting with quantitative analyses of 2012-2016 national data. We conducted in-depth interviews and observations in 12 nursing homes in 2017-2018, focusing on how facilities achieved their Nursing Home Compare ratings. Additional quantitative analyses were conducted in parallel to study performance trajectories over time. Quantitative and qualitative results were interpreted together. RESULTS: Discordant facilities engage in more quality improvement strategies than poor performers, but do not seem to invest in quality improvement in resource-intensive, broad-based ways that would spill over into other domains of quality and change their trajectory of improvement. Instead, they focus on lower-resource improvements related to data quality, staff training, leadership, and communication. In contrast, poor-performing facilities seemed to lack the leadership and continuity of staff required for even these low-resource interventions. DISCUSSION AND IMPLICATIONS: High performance on the quality measures using facility-reported data is mostly meaningful rather than misleading to consumers who care about those outcomes, although discordant facilities still have quality deficits. The quality measures domain should continue to have a role in Nursing Home Compare.

Will We Code for Default ECMO?

Cardiopulmonary resuscitation has become the default treatment for all patients who suffer cardiac arrest. The history of how this came to be suggests the clinical and ethical importance of establishing more humane and appropriate indications for extracorporeal membrane oxygenation and other aggressive therapies for patients at the end of life.

Nursing Home Response to Nursing Home Compare: The Provider Perspective.

Nursing Home Compare (NHC) publishes composite quality ratings of nursing homes based on a five-star rating system, a system that has been subject to controversy about its validity. Using in-depth interviews, we assess the views of nursing home administrators and staff on NHC and unearth strategies used to improve ratings. Respondents revealed conflicting goals and strategies. Although nursing home managers monitor the ratings and expend effort to improve scores, competing goals of revenue maximization and avoidance of litigation often overshadow desire to score well on NHC. Some of the improvement strategies simply involve coding changes that have no effect on resident outcomes. Many respondents doubted the validity of the self-reported staffing data and stated that lack of risk adjustment biases ratings. Policy makers should consider nursing home incentives when refining the system, aiming to improve the validity of the self-reported domains to provide incentives for broader quality improvement.

The Role of Severe Dementia in Nursing Home Report Cards.

Health care report cards are intended to improve quality, but there may be considerable heterogeneity in who benefits. In this article, we examine the intended and unintended effects of quality reporting for nursing home residents with severe dementia relative to other residents, using a difference-in-differences design to examine selected reported and unreported quality measures. Our results indicate that prior to public reporting, nursing home residents with severe dementia were at significantly higher risk of poor outcomes on most reported quality measures. After public reporting was initiated, outcomes for nursing home residents with severe dementia did not consistently improve or worsen. We see no evidence that individuals with severe dementia are being avoided by nursing homes, despite their potential negative impact on quality scores, but we do find an increase in coding of end-stage disease. Additional risk-adjustment, stratification, or additional quality measures may be warranted.

The effects of public reporting on physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment.

OBJECTIVES: To assess whether reductions in physical restraint use associated with quality reporting may have had the unintended consequence of increasing antipsychotic use in nursing home (NH) residents with severe cognitive impairment. DESIGN: Retrospective analysis of NH clinical assessment data from 1999 to 2008 comparing NHs subject to public reporting of physical restraints with nonreporting NHs. SETTING: Medicare- and Medicaid-certified NHs in the United States. PARTICIPANTS: Observations (N = 3.9 million) on 809,645 residents with severe cognitive impairment in 4,258 NHs in six states. INTERVENTION: Public reporting of physical restraint use rates. MEASUREMENTS: Use of physical restraints and antipsychotic medications. RESULTS: Physical restraint use declined significantly from 1999 to 2008 in NH residents with severe cognitive impairment. The decline was larger in NHs that were subject to reporting of restraints than in those that were not (-8.3 vs -3.3 percentage points, P < .001). Correspondingly, antipsychotic use in the same residents increased more in NHs that were subject to public reporting (4.5 vs 2.9 percentage points, P < .001). Approximately 36% of the increase in antipsychotic use may be attributable to public reporting of physical restraints. CONCLUSION: This analysis suggests that public reporting of physical restraint use had the unintended consequence of increasing use of antipsychotics in NH residents with severe cognitive impairment.

Perspective: The doctor as performer: a proposal for change based on a performance studies paradigm.

The authors recognize the pressing need for teaching methods that encourage empathy in both undergraduate and postgraduate medical curricula. While the useful application of theatrical acting techniques in medical education has been reported in major medical journals, these reports present an incomplete picture of these techniques and their potential importance to physician competence. The authors propose a broader understanding of performance theories and practices and a more nuanced appreciation of the experience and knowledge acquired through working with standardized patients and acting exercises. The academic discipline of performance studies offers a paradigm not only for teaching doctors how to "act" in a more truly empathetic and compassionate manner but also for analyzing, and thus evaluating and improving, human interactions in the medical environment. A complex understanding of performance is essential to the development of an empathetic imagination, a cognitive faculty that allows physicians to generate unique responses to given situations rather than employing reactions learned by rote in "communications training." The authors recommend the inclusion of a wide range of performance theories and practices alongside the ubiquitous presence, in medical schools and other physician education forums, of actors performing as standardized patients.

Phospholipase D2 Enhances Epidermal Growth Factor-Induced Akt Activation in EL4 Lymphoma Cells.

Phospholipase D2 (PLD2) generates phosphatidic acid through hydrolysis of phosphatidylcholine. PLD2 has been shown to play a role in enhancing tumorigenesis. The epidermal growth factor receptor (EGFR) can both activate and interact with PLD2. Murine lymphoma EL4 cells lacking endogenous PLD2 present a unique model to elucidate the role of PLD2 in signal transduction. In the current study, we investigated effects of PLD2 on EGF response. Western blotting and RT-PCR were used to establish that both parental cells and PLD2 transfectants express endogenous EGFR. Levels of EGFR protein are increased in cells expressing active PLD2, as compared to parental cells or cells expressing inactive PLD2. EGF stimulates proliferation of EL4 cells transfected with active PLD2, but not parental cells or cells transfected with inactive PLD2. EGF-mediated proliferation in cells expressing active PLD2 is dependent on the activities of both the EGFR and the PI3K/Akt pathway, as demonstrated by studies using protein kinase inhibitors. EGF-induced invasion through a synthetic extracellular matrix is enhanced in cells expressing active PLD2, as compared to parental cells or cells expressing inactive PLD2. Taken together, the data suggest that PLD2 acts in concert with EGFR to enhance mitogenesis and invasion in lymphoma cells.

Effects of active and inactive phospholipase D2 on signal transduction, adhesion, migration, invasion, and metastasis in EL4 lymphoma cells.

The phosphatidylcholine-using phospholipase D (PLD) isoform PLD2 is widely expressed in mammalian cells and is activated in response to a variety of promitogenic agonists. In this study, active and inactive hemagglutinin-tagged human PLD2 (HA-PLD2) constructs were stably expressed in an EL4 cell line lacking detectable endogenous PLD1 or PLD2. The overall goal of the study was to examine the roles of PLD2 in cellular signal transduction and cell phenotype. HA-PLD2 confers PLD activity that is activated by phorbol ester, ionomycin, and okadaic acid. Proliferation and Erk activation are unchanged in cells transfected with active PLD2; proliferation rate is decreased in cells expressing inactive PLD2. Basal tyrosine phosphorylation of focal adhesion kinase (FAK) is increased in cells expressing active PLD2, as is phosphorylation of Akt; inactive PLD2 has no effect. Expression of active PLD2 is associated with increased spreading and elongation of cells on tissue culture plastic, whereas inactive PLD2 inhibits cell spreading. Inactive PLD2 also inhibits cell adhesion, migration, and serum-induced invasion. Cells expressing active PLD2 form metastases in syngeneic mice, as do the parental cells; cells expressing inactive PLD2 form fewer metastases than parental cells. In summary, active PLD2 enhances FAK phosphorylation, Akt activation, and cell invasion in EL4 lymphoma cells, whereas inactive PLD2 exerts inhibitory effects on adhesion, migration, invasion, and tumor formation. Overall, expression of active PLD2 enhances processes favorable to lymphoma cell metastasis, whereas expression of inactive PLD2 inhibits metastasis.