Impact of Advance Directives on Outcomes and Charges in Elderly Trauma Patients.

Background: As the number of geriatric trauma patients rises, end-of-life planning is of increased importance. A community-wide initiative to increase advance care planning was undertaken in the 1990s, resulting in a high rate (85%) of completed advance directives (ADs). Objectives: To assess the impact of ADs on quality measures of care and outcomes for elderly trauma patients. To determine if the historically high rate of completed ADs in the community applied to the trauma patient population. Design: A single trauma center's registry was retrospectively reviewed. Patients with versus without an AD were compared. A case-control analysis was completed. Statistical analysis included chi-square test, Wilcoxon rank sum, and multivariate linear regression modeling. Setting: American College of Surgeons-verified level II trauma center with a 325-bed teaching hospital. Subjects: Patients ≥55 years admitted as level I or II activations from January 2007 through April 2017. Measurements: Hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and 30-day mortality. Results: Nine hundred thirty-six patients were identified; 173 (18%) had an AD and 763 (82%) did not. ADs were more common among older, female patients. The majority of patients with ADs lived within the medical center's service area (99% vs. 1%) and had a primary care provider within the health care system (72% vs. 28%). Although 30-day mortality was higher in patients with ADs versus without (21% vs. 15%; p = 0.03), this difference was not significant on case-control analysis (20% vs. 15%, p = 0.31). No difference was identified in LOS, ICU days, ventilator days, or charges. Conclusions: Presence of an AD was not associated with any difference in 30-day mortality, LOS, or hospital charges. More widespread efforts at AD education and documentation are necessary, particularly in the setting of trauma.

A Strategy for Changing Adherence to National Guidelines for Decreasing Laboratory Testing for Early Breast Cancer Patients.

INTRODUCTION: Past studies indicate delays in adoption of consensus-based guideline updates. In June 2016, the National Comprehensive Cancer Network changed its guidelines from routine testing to omission of ordering complete blood cell count (CBC) and liver function tests (LFT) in patients with early breast cancer. In response, we developed an implementation strategy to discontinue our historical practice of routine ordering of these tests in asymptomatic patients. METHODS: The ordering of CBC and LFT for clinical stage I-IIIA breast cancer patients was audited in 2016. In June 2016, we utilized the levers of the National Quality Strategy implementation methodology to enact a system-wide change to omit routine ordering. To measure the plan's effectiveness, guideline compliance for ordering was tracked continually. RESULTS: Of 92 patients with early stage cancer in 2016, the overall rate of compliance with guidelines for ordering a CBC and LFT was 82% (88/107) and 87% (93/107), respectively. Segregated by the pre- and post-guideline change time period, the compliance rates for ordering a CBC and LFT were 78% and 87% (P = 0.076). CONCLUSION: In contrast to historical reports of delays in adoption of new evidence-based guideline changes, we were able to quickly change provider practice during the transition from routine ordering to omission of ordering screening blood tests in newly diagnosed patients with early breast cancer.

Identification and validation of an anthracycline/cyclophosphamide-based chemotherapy response assay in breast cancer.

BACKGROUND: There is no method routinely used to predict response to anthracycline and cyclophosphamide-based chemotherapy in the clinic; therefore patients often receive treatment for breast cancer with no benefit. Loss of the Fanconi anemia/BRCA (FA/BRCA) DNA damage response (DDR) pathway occurs in approximately 25% of breast cancer patients through several mechanisms and results in sensitization to DNA-damaging agents. The aim of this study was to develop an assay to detect DDR-deficient tumors associated with loss of the FA/BRCA pathway, for the purpose of treatment selection. METHODS: DNA microarray data from 21 FA patients and 11 control subjects were analyzed to identify genetic processes associated with a deficiency in DDR. Unsupervised hierarchical clustering was then performed using 60 BRCA1/2 mutant and 47 sporadic tumor samples, and a molecular subgroup was identified that was defined by the molecular processes represented within FA patients. A 44-gene microarray-based assay (the DDR deficiency assay) was developed to prospectively identify this subgroup from formalin-fixed, paraffin-embedded samples. All statistical tests were two-sided. RESULTS: In a publicly available independent cohort of 203 patients, the assay predicted complete pathologic response vs residual disease after neoadjuvant DNA-damaging chemotherapy (5-fluorouracil, anthracycline, and cyclophosphamide) with an odds ratio of 3.96 (95% confidence interval [Cl] =1.67 to 9.41; P = .002). In a new independent cohort of 191 breast cancer patients treated with adjuvant 5-fluorouracil, epirubicin, and cyclophosphamide, a positive assay result predicted 5-year relapse-free survival with a hazard ratio of 0.37 (95% Cl = 0.15 to 0.88; P = .03) compared with the assay negative population. CONCLUSIONS: A formalin-fixed, paraffin-embedded tissue-based assay has been developed and independently validated as a predictor of response and prognosis after anthracycline/cyclophosphamide-based chemotherapy in the neoadjuvant and adjuvant settings. These findings warrant further validation in a prospective clinical study.

Transitioning into the nurse practitioner role through mentorship.

Transitioning into the nurse practitioner (NP) role is stressful. The stress arises from both internal or personal and external or organizational and professional sources. The novice NP may have a sense of inadequacy and lack of confidence in the ability to provide optimal patient care. The organizational expectations to be clinically competent and able to meet the demands of a complex health care system can be overwhelming. Most NP programs excel in their ability to provide the didactic information and clinical exposure necessary for the beginning-level practitioner; however, additional guidance and support are essential for the novice NP to evolve into an expert clinical practitioner. To this end, mentorship is an effective transition strategy for novice NPs. An awareness of the many stressors facing the novice NP, the benefits of mentorship, and how an effective mentoring relationship can ease the transition establishes sound rationale for mentoring as a strategy for optimal transitioning into the NP role.

Gender differences in lateralized semantic priming.

Previous literature suggests that women evidence more bilateral cerebral organization, particularly in language processing, whereas men show greater left hemisphere dominance for language. This study examined the magnitude of these gender differences in a lateralized lexical decision task and the implications of such differences to semantic processing and cerebral organization. As predicted, women, as compared to men, recruited greater bilateral hemispheric resources, as evidenced by greater contralateral hemispheric priming. Spatial skills predicted less priming in women, but not in men. Implications for laterality research in aging populations as well as future directions are discussed.