Application of novel AI-based algorithms to biobank data: uncovering of new features and linear relationships.

We independently analyzed two large public domain datasets that contain 1H-NMR spectral data from lung cancer and sex studies. The biobanks were sourced from the Karlsruhe Metabolomics and Nutrition (KarMeN) study and Bayesian Automated Metabolite Analyzer for NMR data (BATMAN) study. Our approach of applying novel artificial intelligence (AI)-based algorithms to NMR is an attempt to globalize metabolomics and demonstrate its clinical applications. The intention of this study was to analyze the resulting spectra in the biobanks via AI application to demonstrate its clinical applications. This technique enables metabolite mapping in areas of localized enrichment as a measure of true activity while also allowing for the accurate categorization of phenotypes.

Evaluating the Impact of Executive Orders Lifting Restrictions on Advanced Practice Registered Nurses During the COVID-19 Pandemic.

Background: In the early stages of the COVID-19 pandemic, strains on the healthcare system forced many U.S. states to revisit long-standing statutory limitations on the care coordinated by advanced practice registered nurses (APRNs). This was done by issuing waivers via executive, legislative, or board of nursing orders. Purpose: To identify the impact of temporary practice waivers on APRNs' direct patient care during the COVID-19 pandemic. Methods: This cross-sectional study utilized a two-phased approach. First, a confidential online survey was conducted of APRNs practicing across 27 U.S. states. Second, comprehensive APRN discipline data from 2019 to 2021 were retrieved from the National Council of State Boards of Nursing's Nursys database and reviewed. Univariable and multivariable binary logistic regression models were used to determine the significance of observed trends. Results: A total of 16,699 APRNs responded to the survey for a response rate of 14.2%. APRNs practicing in private outpatient clinics, in rural areas, and in health provider shortage areas were more likely to report a positive effect of the practice waiver (all p < .05). Providers noted that the waivers allowed them more time with their current patients and expanded the geographic boundaries of their direct patient care to take on new patients. Furthermore, despite the changing profile of APRN care during the early stages of the pandemic, including a pronounced increase in telehealth usage, the current review found no evidence of an uptick in discipline cases brought against APRNs in 2021. Conclusion: Full practice authority for APRNs benefits patients by promoting expanded access to care and increasing the resiliency of our healthcare system without compromising patient safety. It is time for states and organizations that employ APRNs to recognize that permanently removing barriers to APRN practice is essential to the health of our nation.

Examining the Global Nursing Regulatory Response to the COVID-19 Pandemic.

Background: During the COVID-19 pandemic, nursing regulatory bodies (NRBs) worldwide adopted a variety of measures to bolster the nursing workforce and ensure patient safety. Purpose: To examine the plethora of actions undertaken by the global nursing community in response to the public health emergency so that NRBs can increase transparency and better prepare for future crises. Methods: In early 2021, the National Council of State Boards of Nursing developed an online survey to capture data on the global regulatory response to the COVID-19 pandemic. The survey focused on five specific domains: (a) governance, (b) telehealth practices, (c) nurse mobility, (d) prelicensure education, and (e) the disciplinary process. The instrument was translated into 11 languages before being deployed to 150 non-U.S. regulatory representatives. Frequencies and proportions were generated for all fixed-item responses, and descriptive content analyses were applied to translated open-text responses. Results: Regulators representing 27 jurisdictions provided valid responses to the survey. Most jurisdictions reported that components of nursing education were adapted in some way during the pandemic. More than half (53.8%, n = 14) of respondents indicated that changes were made to clinical and didactic curricula to ensure students graduated on time. About one-third (30.8%, n = 8) of representatives revealed that their jurisdiction had made changes to telehealth regulations, with many granting telehealth-specific nursing licenses. Most jurisdictions (88.5%, n = 23) also reported fewer or about the same number of regulatory complaints compared to before the pandemic. Conclusions: The results of this study highlight the range of actions nursing regulators worldwide adopted, which may be drawn upon to inform best practices to ensure jurisdictions are ready for the next public health emergency.

Examining the Impact of the COVID-19 Pandemic on Burnout and Stress Among U.S. Nurses.

Background: The COVID-19 pandemic has amplified long-standing issues of burnout and stress among the U.S. nursing workforce, renewing concerns of projected staffing shortages. Understanding how these issues affect nurses' intent to leave the profession is critical to accurate workforce modeling. Purpose: To identify the personal and professional characteristics of nurses experiencing heightened workplace burnout and stress. Methods: We used a subset of data from the 2022 National Nursing Workforce Survey for analysis. Binary logistic regression models and natural language processing were used to determine the significance of observed trends. Results: Data from a total of 29,472 registered nurses (including advanced practice registered nurses) and 24,061 licensed practical nurses/licensed vocational nurses across 45 states were included in this analysis. More than half of the sample (62%) reported an increase in their workload during the COVID-19 pandemic. Similarly high proportions reported feeling emotionally drained (50.8%), used up (56.4%), fatigued (49.7%), burned out (45.1%), or at the end of their rope (29.4%) "a few times a week" or "every day." These issues were most pronounced among nurses with 10 or fewer years of experience, driving an overall 3.3% decline in the U.S. nursing workforce during the past 2 years. Conclusion: High workloads and unprecedented levels of burnout during the COVID-19 pandemic have stressed the U.S. nursing workforce, particularly younger, less experienced RNs. These factors have already resulted in high levels of turnover with the potential for further declines. Coupled with disruptions to prelicensure nursing education and comparable declines among nursing support staff, this report calls for significant policy interventions to foster a more resilient and safe U.S. nursing workforce moving forward.

Virtual Clinical Simulation Adoption and Use by Licensed Practical Nurse/Licensed Vocational Nurse Education Programs During the COVID-19 Pandemic.

Background: In the early stages of the COVID-19 pandemic, as clinical site restrictions were implemented, education programs leading to licensed practical nurse/licensed vocational nurse (LPN/LVN) degrees increasingly relied on virtual simulation-based experiences to provide clinical training to their students. However, scant evidence exists regarding the extent of this change and the various modalities employed by LPN/LVN programs across the United States. Purpose: We sought to identify the degree to which virtual clinical simulation was adopted by LPN/LVN education programs during the early stages of the COVID-19 pandemic to address clinical site restrictions. In addition, we hoped to identify the practices and activities that educators included under the broad umbrella definition of virtual clinical simulation. Methods: All active U.S. prelicensure LPN/LVN nursing education programs were contacted in September 2020. Program leaders were asked to estimate the proportion of clinical hours completed in virtual clinical simulation before the pandemic and the proportion anticipated for the fall 2020 term. Descriptive statistics were generated, with repeated measures analysis of covariance applied to evaluate the average change in virtual simulation within programs stratified by reported clinical restrictions. Results: Representatives from 265 LPN/LVN programs in 44 U.S. jurisdictions responded to the survey. Responding programs significantly increased the proportion of clinical hours completed in virtual clinical simulation between fall 2019 (M = 10.7, SD = 15.3) and fall 2020 (M = 35.3, SD = 27.6, p < .001). Furthermore, there was an interaction between clinical site restrictions and term, with a more pronounced uptick in virtual simulation usage among programs that indicated they found identifying clinical sites "very difficult" (M = 41.1, SD = 28.9) relative to those who found it "somewhat more difficult" (M = 23.9, SD = 18.8, p < .001). Programs adopted a range of modalities, including simply watching videos and participating in virtual or augmented reality, online software packages, or other forms of screen-based learning. Conclusion: As the adoption of virtual simulation increases, clear definitions of what constitutes clinical virtual simulation must be established. Additionally, rigorous inquiry to support evidence-based regulatory guidelines is needed.

A Preliminary Examination of Healthcare Facilities' Nurse Staffing Strategies to Address COVID-19 Surges.

Background: COVID-19 surge events exacerbated many healthcare facilities' pre-existing nursing shortages. To address staff shortfalls, nurse leaders adopted a variety of strategies to supplement their workforce. Purpose: To identify and assess the interplay between board of nursing (BON) emergency guidance and the strategies healthcare facilities adopted to bolster their nursing workforce during peak pandemic periods. Methods: A national survey of nurse executives, as identified by the American Organization for Nursing Leadership, was conducted. Univariable and multivariable ordinal logistic regression models were used to evaluate the significance of observed trends. Results: Half of the 391 nurse executives who completed the survey indicated that their facility needed to supplement their RN staffing during peak periods of the COVID-19 pandemic (n = 202, 51.7%). Most relied on hiring local experienced nurses (n = 111) or some combination of travel nurses (n = 61) or support workers (n = 60) to drive a median 10% increase in nurse staffing (n = 153, range 0%-100%). A large proportion of respondents also indicated their facility simply increased the work volume and hours of their current RN staff. Respondents rated retired nurses as significantly more competent relative to licensed new nurse graduates and pre-NCLEX new nurse graduates. Conclusion: Although the small sample limits the generalizability of these findings, preliminary evidence suggests recently retired nurses and prelicensure nursing students may provide valuable support services in the event of another public health emergency.

Assessing the Impact of the COVID-19 Pandemic on Nursing Education: A National Study of Prelicensure RN Programs.

Background: The COVID-19 pandemic has had a profound impact on prelicensure nursing education, leading to widespread disruptions that may have implications for nursing students' learning and engagement outcomes. Understanding how the rapid shift to online and simulation-based teaching methods has affected new graduates' clinical preparedness is critical to ensure patient safety moving forward. Purpose: To assess the impact of institutional, academic, and demographic characteristics on prelicensure nursing students' academic, initial postgraduation, and early career outcomes during the COVID-19 pandemic. Methods: We conducted a mixed-methods longitudinal study focused on prelicensure registered nurse (RN) students entering the core of their didactic and clinical nursing coursework during the pandemic. This study uses a combination of real-time student and faculty self-report data, including externally validated instruments, within and end-of-program standardized test scores, and focus group findings. Various statistical methods, ranging from simpler descriptive and non-parametric methods to Generalized Estimating Equation (GEE) models and detailed textual analysis, are applied to assess student, faculty, and institution-level data. Results: The final sample includes more than 1,100 student and faculty participants affiliated with 51 prelicensure RN programs located across 27 states. Leveraging more than 4,000 course observations collected from fall 2020 to spring 2022 and supplemented by the rich personal narratives of over 60 focus group participants, this study illuminates the breadth, scale, and ever-evolving nature of prelicensure RN programs' efforts to maintain the continuity of nursing students' education during the public health crisis. In doing so, it captures the many ways in which nursing administrators, faculty, and students sought to address the unparalleled challenges they confronted on a day-to-day basis. In particular, the findings provide critical insights into the efficacy of the changes nursing programs made to their course delivery formats to adjust to the confluence of rapidly evolving federal, state, and private restrictions to stem the spread of COVID-19. Conclusion: This study stands as the most comprehensive assessment of prelicensure nursing education in the United States since the onset of COVID-19. It extends knowledge by linking potential deficiencies in students' didactic and clinical education during the pandemic and their early career preparedness, clinical competence, and the patient safety implications therein.

Fibrous Cap Thickness Predicts Stable Coronary Plaque Progression: Early Clinical Validation of a Semiautomated OCT Technology.

Background: Imaging-based characteristics associated with the progression of stable coronary atherosclerotic lesions are poorly defined. Utilizing a combination of optical coherence tomography (OCT) and intravascular ultrasound (IVUS) imaging, we aimed to characterize the lesions prone to progression through clinical validation of a semiautomated OCT computational program. Methods: Patients with stable coronary artery disease underwent nonculprit vessel imaging with IVUS and OCT at baseline and IVUS at the 12-month follow-up. After coregistration of baseline and follow-up IVUS images, paired 5-mm segments from each patient were identified, demonstrating the greatest plaque progression and regression as measured by the change in plaque burden. Experienced readers identified plaque features on corresponding baseline OCT segments, and predictors of plaque progression were assessed by multivariable analysis. Each segment then underwent volumetric assessment of the fibrous cap (FC) using proprietary software. Results: Among 23 patients (70% men; median age, 67 years), experienced-reader analysis demonstrated that for every 100 µm increase in mean FC thickness, plaques were 87% less likely to progress (P = .01), which persisted on multivariable analysis controlling for baseline plaque burden (P = .05). Automated FC analysis (n = 17 paired segments) confirmed this finding (P = .01) and found thinner minimal FC thickness (P = .01) and larger FC surface area of <65 µm (P = .02) and <100 µm (P = .04) in progressing segments than in regressing segments. No additional imaging features predicted plaque progression. Conclusions: A semiautomated FC analysis tool confirmed the significant association between thinner FC and stable coronary plaque progression along entire vessel segments, illustrating the diffuse nature of FC thinning and suggesting a future clinical role in predicting the progression of stable coronary artery disease.

Occipital Neuralgia following Acoustic Neuroma Resection.

Background While postoperative outcomes of acoustic neuroma (AN) resection commonly consider hearing preservation and facial function, headache is a critical quality of life factor. Postoperative headache is described in the literature; however, there is limited discussion specific to occipital neuralgia (ON) following AN resection. Objective The aim of this study is to investigate the effectiveness of conservative management and surgery. Methods We conducted a retrospective review of 872 AN patients who underwent resection at our institution between 1988 and 2017 and identified 15 patients (1.9%) that met International Classification of Headache Disorders criteria for ON. Results Of the 15 ON patients, surgical approaches included 13 (87%) retrosigmoid (RS), one (7%) translabyrinthine (TL), and one (7%) combined RS + TL. Mean clinical follow-up was 119 months (11-263). Six (40%) patients obtained pain relief through conservative management, while the remaining nine (60%) underwent surgery or ablative procedure. Three (38%) patients received an external neurolysis, four (50%) received a neurectomy, one (13%) had both procedures, and one (13%) received two C2 to 3 radio frequency ablations. Of the nine patients who underwent procedural ON treatment, seven (78%) patients achieved pain relief, one patient (11%) continued to have pain, and one patient (11%) was lost to follow-up. Of the six patients whose pain was controlled with conservative management and nerve blocks, five (83%) found relief by using neuropathic pain medication and one (17%) found relief on nonsteroidal anti-inflammatory drug. Conclusion Our series demonstrates success with conservative management in some, but overall a minority (40%) of patients, reserving decompression only for refractory cases.

Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study.

OBJECTIVE: To evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals. DESIGN: Cross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data.Setting: 87 acute care hospitals in Illinois. PARTICIPANTS: 210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical-surgical unit in a study hospital. MAIN OUTCOME MEASURES: Primary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios. RESULTS: Patient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse's workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse's workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million. CONCLUSIONS: Patient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical-surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.

Transsphenoidal Resection of Pituitary Tumors in the United States, 2009 to 2011: Effects of Hospital Volume on Postoperative Complications.

Introduction Higher surgical volumes correlate with superior patient outcomes for various surgical pathologies, including transnasal transsphenoidal (TNTS) pituitary tumor resection. With the introduction of endoscopic approaches, there have been nationwide shifts in technique with relative declines in microsurgery. We examined the volume-outcome relationship (VOR) for TNTS pituitary tumor surgery in an era of increasingly prevalent endoscopic approaches. Methods Patients who underwent TNTS pituitary tumor resection between 2009 and 2011 were retrospectively identified in the State Inpatient Database subset of the Healthcare Cost and Utilization Project. Generalized linear mixed-effect models were used to assess odds of various outcome measures. Institutions were grouped into quartiles by case volume for analysis. Results A total of 6,727 patients underwent TNTS pituitary tumor resection between 2009 and 2011. White or Asian American patients and those with private insurance were more likely to receive care at higher volume centers (HVC). Patients treated at HVC (>60 cases/year) were less likely to have nonroutine discharges (3.9 vs. 1.9%; p = 0.002) and had shorter length of stay (LOS; 4 vs. 2 days; p = 0.001). Overall, care at HVC trended toward lower rates of postoperative complications, for example, a 10-case/year increase correlated with a 10% decrease in the rate of iatrogenic panhypopituitarism (odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.81-0.99; p = 0.04) and 5% decrease in likelihood of diabetes insipidus (OR = 0.95, 95% CI: 0.90-0.99; p = 0.04) on multivariable analysis. Conclusions Our analysis shows that increased case volume is related to superior perioperative outcomes for TNTS pituitary tumor resections. Despite the recent adoption of newer endoscopic techniques and concerns of technical learning curves, this VOR remains undisturbed.

Is Hospital Nurse Staffing Legislation in the Public's Interest?: An Observational Study in New York State.

BACKGROUND: The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. OBJECTIVES: To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). RESEARCH DESIGN: Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. SUBJECTS: A total of 417,861 Medicare medical and surgical patients. MEASURES: Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. RESULTS: Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. CONCLUSIONS: Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.

Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes.

BACKGROUND: Despite nurses' responsibilities in recognition and treatment of sepsis, little evidence documents whether patient-to-nurse staffing ratios are associated with clinical outcomes for patients with sepsis. METHODS: Using linked data sources from 2017 including MEDPAR patient claims, Hospital Compare, American Hospital Association, and a large survey of nurses, we estimate the effect of hospital patient-to-nurse staffing ratios and adherence to the Early Management Bundle for patients with Severe Sepsis/Septic Shock SEP-1 sepsis bundles on patients' odds of in-hospital and 60-day mortality, readmission, and length of stay. Logistic regression is used to estimate mortality and readmission, while zero-truncated negative binomial models are used for length of stay. RESULTS: Each additional patient per nurse is associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality, 7% higher odds of 60-day readmission, and longer lengths of stay, even after accounting for patient and hospital covariates including hospital adherence to SEP-1 bundles. Adherence to SEP-1 bundles is associated with lower in-hospital mortality and shorter lengths of stay; however, the effects are markedly smaller than those observed for staffing. DISCUSSION: Improving hospital nurse staffing over and above implementing sepsis bundles holds promise for significant improvements in sepsis patient outcomes.

Chronic hospital nurse understaffing meets COVID-19: an observational study.

INTRODUCTION: Efforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public's health. Despite numerous studies indicating better staffing is associated with more favourable patient outcomes, only one US state (California) sets patient-to-nurse staffing standards. To inform staffing legislation actively under consideration in two other US states (New York, Illinois), we sought to determine whether staffing varies across hospitals and the consequences for patient outcomes. Coincidentally, data collection occurred just prior to the COVID-19 outbreak; thus, these data also provide a real-time example of the public health implications of chronic hospital nurse understaffing. METHODS: Survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 document associations of nurse staffing with care quality, patient experiences and nurse burnout. RESULTS: Mean staffing in medical-surgical units varied from 3.3 to 9.7 patients per nurse, with the worst mean staffing in New York City. Over half the nurses in both states experienced high burnout. Half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavourable reports; ORs ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units. CONCLUSIONS: Hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public's health. Such risks could be addressed by safe nurse staffing policies currently under consideration.

The Utility of Using Preoperative MRI as a Predictor for Intraoperative Pituitary Adenoma Consistency and Surgical Resection Technique.

Objective Most pituitary adenomas are of soft consistency and can be resected during surgery with routine suction instruments. However, fibrous adenomas may require more aggressive techniques. The ability to predict consistency on magnetic resonance imaging (MRI) would improve preoperative preparation and may have implications on the extent of resection. Design A retrospective review of MRI and tumor histology of 50 consecutive patients who underwent endoscopic endonasal resection for nonfunctional adenomas was performed. Methods An intensity ratio was calculated based on quantitative MRI signal intensity of the adenoma and pons. Intraoperatively, a sequentially graded technique required for resection ranged from suction (R1) for softer tumors, curettes (R2) for tumors with intermediate consistency, and aspirators and/or other microinstruments (R3) for firmer tumors. Fibrotic content was determined from histologic collagen percentage, and rates of gross total resection (GTR) were calculated from postoperative imaging. Statistical analyses were performed to determine if resection classification could be predicted by intensity ratio or collagen percentage, calculate ratio of cut-off points for clinical use, and assess for correlation between intensity ratios and collagen percentage. Results Tumors with ratios < 1.6 on the T2-weighted coronal image and collagen content > 5.3% were likely to have required a more aggressive resection technique. Statistically significant lower rates of GTR and higher rates of perioperative complications were seen with such tumors. Conclusion Preoperative MRI analyses can be helpful but not definitive in predicting adenoma consistency. Fibrous adenomas, associated with higher collagen content, are more difficult to resect and have higher rates of subtotal resection.

An optical coherence tomography comparison of coronary arterial plaque calcification in patients with end-stage renal disease and diabetes mellitus.

BACKGROUND: Coronary arterial plaques in patients with end-stage renal disease (ESRD) are assumed to have increased calcification due to underlying renal disease or initiation of dialysis. This relationship may be confounded by comorbid type 2 diabetes mellitus (DM). METHODS: From a single-center OCT registry, 60 patients were analyzed. Twenty patients with ESRD and diabetes (ESRD-DM) were compared to 2 groups of non-ESRD patients: 20 with and 20 without diabetes. In each patient, one 20 mm segment within the culprit vessel was analyzed. RESULTS: ESRD-DM patients exhibited similar calcium burden, arc, and area compared to patients with diabetes alone. When compared to patients without diabetes, patients with diabetes exhibited a greater summed area of calcium (DM: Median 9.0, IQR [5.3-28] mm2 vs Non-DM: 3.5 [0.1-14] mm2, p = 0.04) and larger calcium deposits by arc (DM: Mean 45 ± SE 6.2° vs Non-DM: 21 ± 6.2°, p = 0.01) and area (DM: 0.58 ± 0.10 mm2 vs Non-DM: 0.26 ± 0.10 mm2, p = 0.03). Calcification deposits in ESRD-DM patients (0.14 ± 0.02 mm) and patients with diabetes (0.14 ± 0.02 mm) were more superficially located relative to patients without diabetes (0.21 ± 0.02 mm), p = 0.01 for both. CONCLUSIONS: Coronary calcification in DM and ESRD-DM groups exhibited similar burden, deposit size, and depth within the arterial wall. The increase in coronary calcification and cardiovascular disease events seen in ESRD-DM patients may not be secondary to ESRD and dialysis, but instead due to a combination of declining renal function and diabetes.

Evaluation of lymphocytic thyroiditis in children with quantitative gray-scale ultrasound echo intensity using a PACS-based tool.

PURPOSE: To evaluate diagnostic performance of PACS-based quantitative gray-scale ultrasound as an objective method in evaluation of pediatric thyroiditis. METHODS: Quantitative measurements of the echo-intensity level of the thyroid were obtained from ultrasound images, retrospectively using a PACS-based tool in 37 children with the tissue-proven diagnosis. Thyroid/muscle ratio was calculated by dividing the mean echo intensity of thyroid by that of adjacent strap muscle. Heterogeneity index (HI) was calculated by dividing thyroid standard deviation (SD) by thyroid mean values. For qualitative evaluation, two radiologists independently reviewed ultrasounds twice for the presence of thyroiditis. A consensus session was performed for patients for whom there was disagreement. Intra- and inter-observer reliability were assessed. Thyroid/muscle ratio and HI were correlated with final pathology. RESULTS: Lymphocytic thyroiditis was found by histopathology in 19/37 (51%). No significant difference between thyroiditis and normal thyroid groups was found for either thyroid/muscle ratio (1.51 and 1.62, respectively, p = .82) or HI (0.23 and.23, respectively, p = .37). A larger proportion of patients for whom the consensus review indicated thyroiditis were confirmed by histopathology than would be expected by chance alone (12/19 (63%), p = .03). There was fair inter-observer agreement (κ with 95% confidence intervals of 0.36 (0.14-0.57), p = .004) and slight intra-observer agreement for each radiologist (κ with 95% confidence intervals of 0.13 (0.17-0.43), p = .39 and 0.17 (0.15-0.49), p = .31). CONCLUSION: Quantitative gray-scale echo intensity analysis of US was not sufficient to diagnose thyroiditis in a pediatric population. Consensus qualitative analysis of ultrasound was more consistent with pathological diagnosis.

How collaborative practice agreements impede the provision of vital behavioral health services.

BACKGROUND: The critical shortage of behavioral health professionals impairs the ability of the U.S. health care system to respond to the growing demand for services to address mental illness and substance use disorders. PURPOSE: To identify how restrictive state regulations act as barriers to full utilization of psychiatric mental health advanced practice registered nurses (PMH-APRN), whose scope of practice enables them to provide a full range of behavioral health services. METHODS: A sequential mixed methods study combining interview data (n = 94) from a qualitative study of PMH-APRN practice with a subset of quantitative data (n = 699) from a national APRN survey examining the impact of state-mandated APRN/MD collaborative practice agreements. DISCUSSION: Data sources converged to portray challenges to optimal use of APRNs providing psychiatric/mental health services, including high out-of-pocket fees, irregular communication with supervisors, mandated chart reviews, and supervisor turnover. CONCLUSION: Inconsistent and burdensome supervision requirements contribute to cost inflation and may limit patient access.

How Collaborative Practice Agreements Impede the Administration of Vital Women's Health Services.

INTRODUCTION: Women's health services delivered by nurse practitioners (NP) and certified nurse-midwives (CNM) are safe and effective, often providing a crucial point of access in underserved regions. However, restrictive and unnecessary regulatory requirements, such as collaborative practice agreements, create artificial barriers to practice. METHODS: This analysis used a subsample of respondents from a large national study focused on the common challenges and practice restrictions introduced by collaborative practice agreements. This cohort included respondents licensed in all 22 states that place some level of restriction on one or both roles. This study used univariable and multivariable logistic regression to examine the financial and administrative constraints collaborative practice agreements place on NPs and CNMs. RESULTS: The median fee to establish a collaborative agreement was $500 (n = 25; interquartile range [IQR], $175-$1200; range, $30-$3000). The monthly median fee to maintain a collaborative agreement was $500 (n = 29; IQR, $250-$1200; range, $100-$2000). NPs and CNMs working in rural areas and remotely are more likely to encounter barriers to practice. Similarly, the loss or lack of supervising physicians and fees were also identified as impediments to care. DISCUSSION: Removing unnecessary regulatory requirements permits NPs and CNMs to be full market participants, thereby allowing them to address health care disparities in women's health and primary care settings. Targeted legislative efforts should seek to improve access to these vital services and re-establish evidence-based patient care and safety best practices as the drivers of health care regulation.

Vascular endothelial growth factor in bipolar depression: A potential biomarker for diagnosis and treatment outcome prediction.

BACKGROUND: Vascular Endothelial Growth Factor (VEGF) has been implicated in the neurotrophic model of depression. We explored the potential role of VEGF in the pathophysiology of bipolar depression and potential utility as a diagnostic or outcome predictive biomarker. METHODS: In a double-blind study, treatment-resistant bipolar depressed patients received Escitalopram and were randomized to receive add-on Celecoxib (26 participants) or Placebo (21 participants). There were 32 healthy controls. Plasma levels of VEGF were determined at three timepoints over eight weeks. RESULTS: Bipolar patients had significantly higher VEGF levels at baseline compared to healthy controls. Logistic regression analysis revealed that the AUC is 0.67 and the VEGF cut point is 8.21. At all timepoints, patients receiving Celecoxib had comparable VEGF levels to those receiving Placebo. VEGF levels did not change significantly over time. Baseline VEGF was a poor predictor of treatment response with an AUC of 0.53. CONCLUSIONS: The increased VEGF in bipolar depression agrees with similar findings in major depressive disorder. A high VEGF level tended to accurately predict bipolar disorder, with apparent differential VEGF expression. Baseline VEGF did not predict treatment response, and levels did not change with treatment. Plasma VEGF may have diagnostic utility and guide personalized treatment.