Faculty Bibliography

BACKGROUND: The discipline of health care ethics consultation (EC) has been limited by the lack of both high quality data and quality standards. To promote high quality ethics consultation practices, staff at the National Center for Ethics in Health Care within the Veterans Health Administration (VHA) developed 2 specific EC tools, ECWeb and the EC Feedback Tool. ECWeb is a web-based database tool that promotes process standards consistent with "CASES," VA's systematic approach to ethics consultation. The EC Feedback Tool, which links to ECWeb records, enables consultation participants to rate their experience on various aspects of EC. This paper describes the ethics consultation requests, processes, and evaluations from all facilities in our system. METHODS: We analyzed data from completed ethics consultations from ECWeb records initiated between October 2008 and September 2011. For each consultation record, users documented in ECWeb the data related to utilization of the EC service (e.g., type of consultation request, requester role (i.e., physician, nurse, patient). Additionally, ECWeb users documented, as applicable, various processes performed during the ethics consultation (e.g., capacity assessment (y/n), a face-to-face patient visit (y/n), and if the consult was identified as being symptomatic of underlying issues that are best addressed at the systems level). The EC Feedback Tool asked respondents to rate the ethics consultant(s) on 12 specific ethics knowledge and skill areas as well as their overall experience with ethics consultation, both on a 5 point Likert scale. RESULTS: We analyzed ECWeb data for 4628 completed consults from 140 facilities across theVHAhealth system .Median consultation volume per facility was 7 in 2009 (mean=9.6, range=0-60), 8 in 2010 (mean=12.4, range=0-106), and 8 in 2011 (mean =12.1, range=0-119). The majority of consultations were classified by the consultants as related to shared decision making (73%). Most consultations (63%) related to patients in the !

BACKGROUND: Studies of the nursing work environment are increasingly common in developed countries, but few exist in developing countries. Because of resource differences between the two contexts, researchers need to clarify what aspects of the work environments are similar and different. OBJECTIVES: To study the perspectives of Mexican nurses about their work environments to determine similarities and differences to results from developed world studies. DESIGN: A secondary, directed content analysis of qualitative data from 46 Spanish language interviews using workplace-oriented themes. SETTING: Purposively selected Mexican states from four regions of the country that reflect the country's socioeconomic differences. PARTICIPANTS: Practicing Mexican nurses with at least 1year of clinical experience and currently working in nursing. Participants were recruited through convenience and snowball sampling techniques. METHODS: Initial data collection occurred in 2006 and 2008 during a broader study about professionalization processes that occurred in Mexican nursing between 1980 and 2005. The secondary, directed content analysis focused on an in-depth exploration of a central theme that emerged from the two original studies: the workplace. The directed content analysis used themes from the global nursing work environment literature to structure the analysis: professional relationships, organizational administrative practices, and quality of care and services. RESULTS: The three themes from the global literature were relevant for the Mexican context and a new one emerged related to hiring practices. By category, the same factors that created positive or negative perceptions of the work environment matched findings from other international studies conducted in developed countries. The descriptors of the category, however, had different conceptual meanings that illustrate the health system challenges in Mexico. CONCLUSIONS: Findings from this study suggest that studies that seek to measure nursing work environments will most likely apply in Mexico and other Latin American or middle-income countries. Instruments designed to measure the work environment of nurses in these countries may prove relevant in those contexts, but require careful adaptation and systematic translations to ensure it.

LEARNING OBJECTIVE 1: Identify indications for surgical intervention in the case of hepatic abscesses LEARNING OBJECTIVE 2: Review appropriate management of new pleural effusions CASE: A 56 year-old woman presented with weight loss, malaise and polyuria for two months. On admission, HR 135, BP 107/80, RR 22, T 101, O2 94% on RA. Exam revealed cachexia, bilateral lower extremity edema, decreased breath sounds in lower half of right lung with decreased tactile fremitis and coarse crackles superiorly. Labs were notable for WBC 33 and glucose 559. EKG showed sinus tachycardia. CXR revealed a right pleural effusion. Patient was pan-cultured and empirically started on vancomycin, piperacillin/tazobatam and azithromycin for presumed pneumonia. Despite insulin and IV fluids, she remained tachycardic. CT angiogram revealed a large pulmonary embolus in the left basal pulmonary artery and a large loculated right pleural effusion with no pleural enhancement. Abdominal CT revealed 8 cm septated hepatic mass, hepatic vein thrombus extending into the IVC, and a small amount of air in the wall of the gallbladder. Heparin drip was started and patient was taken for percutaneous drainage of hepatic mass and thoracentesis. Only small samples were obtained given loculation. Pleural fluid was exudative, gram stain showed white cells but no organisms, pH 7.22, glucose 169. Chest tube was placed. Strep viridans grew from pleural and hepatic fluid; blood cultures grew strep anginosus and c. albicans. Antibiotics were narrowed to ceftriaxone and caspofungin. Given pneumobilia, hepatic abscess was presumed to be from GI source with empyema formation from local spread of infection and hepatic vein thrombus from local inflammation. EGD/colonoscopy failed to find communicating track between bowel and biliary systems. Surgical intervention was deemed risky given large clot burden and patient was managed with antibiotics alone. Repeat imaging two months later at discharge showed significant resolution of hepatic and pulmonary!

BACKGROUND:Current guidelines recommend the use of coronary artery calcium (CAC) scoring for intermediate-risk patients; however, the potential role of CAC among individuals who have no risk factors (RFs) is less established. We sought to examine the relationship between the presence and burden of traditional RFs and CAC for the prediction of all-cause mortality. METHODS AND RESULTS/RESULTS:The study cohort consisted of 44,052 consecutive asymptomatic individuals free of known coronary heart disease referred for computed tomography for the assessment of CAC. The following RFs were considered: (1) current cigarette smoking, (2) dyslipidemia, (3) diabetes mellitus, (4) hypertension, and (5) family history of coronary heart disease. Patients were followed for a mean of 5.6 ± 2.6 years for the primary end point of all-cause mortality. Among individuals who had no RF, Cox proportional model adjusted for age and sex identified that increasing CAC scores were associated with 3.00- to 13.38-fold higher mortality risk. The lowest survival rate was observed in those with no CAC and no RF, whereas those with CAC ≥ 400 and ≥3 RFs had the highest all-cause fatality rate. Notably, individuals with no RF and CAC ≥ 400 had a substantially higher mortality rate compared with individuals with ≥3 RFs in the absence of CAC (16.89 versus 2.72 per 1000 person-years). CONCLUSIONS:By highlighting that individuals without RFs but elevated CAC have a substantially higher event rates than those who have multiple RFs but no CAC, these findings challenge the exclusive use of traditional risk assessment algorithms for guiding the intensity of primary prevention therapies.

The objective of this study was to test the hypothesis that corticosteroid and nonsteroidal anti-inflammatory drug (NSAID) medications are associated with less global and regional Alzheimer's disease (AD) neuropathology. This postmortem study was based on 694 brains of subjects from the Mount Sinai School of Medicine Brain Bank who did not have neuropathologies other than neuritic plaques (NPs), neurofibrillary tangles (NFTs), or cerebrovascular disease. Densities of NPs and of NFTs were assessed in several neocortical regions and in the hippocampus, entorhinal cortex, and amygdala. Counts of NPs in several neocortical regions were also assessed. For each neuropathology measure, analyses of covariance controlling for age at death and sex compared subjects who received only corticosteroids (n = 54) or those who received only NSAIDs (n = 56) to the same comparison group, subjects who received neither (n = 576). Subjects receiving corticosteroids had significantly lower ratings and counts of NPs for all neuropathological measures, and NFTs overall and in the cerebral cortex and amygdala. In contrast, no measures were significant for subjects who received NSAIDs. Use of corticosteroids was associated with approximately 50% fewer NPs and NFTs in most brain regions examined, compared with nonmedicated subjects. In contrast, use of NSAIDs was not substantially associated with the reductions in hallmark lesions of AD. Because corticosteroids have anti-inflammatory as well as a myriad of other neurobiological effects, more direct studies in model systems could reveal novel therapeutic targets and mechanisms for AD lesion reduction.

An agar-plate assay was developed for detecting the induction of drug-resistant mycobacterial mutants during exposure to inhibitors of DNA gyrase. When Mycobacterium smegmatis was plated on drug-containing agar, resistant colonies arose over a period of two weeks. A recA deficiency reduced mutant recovery, consistent with involvement of the SOS response in mutant induction. The C-8-methoxy compounds gatifloxacin and moxifloxacin allowed recovery of fewer resistant mutants than either ciprofloxacin or levofloxacin when present at the same multiple of MIC; a quinolone-like 8-methoxy-quinazoline-2,4-dione was more effective at restricting the emergence of resistant mutants than its cognate fluoroquinolone. Thus, the structure of fluoroquinolone-like compounds affects mutant recovery. A spontaneous mutator mutant of M. smegmatis, obtained by growth in medium containing both isoniazid and rifampicin, increased mutant induction during exposure to ciprofloxacin. Moreover, the mutator increased the size of spontaneous, resistant-mutant subpopulations, as detected by population analysis. Induction of ciprofloxacin resistance was also observed with Mycobacterium tuberculosis H37Rv. When measured with clinical isolates, no difference in mutant recovery was observed between multidrug-resistant (MDR) and pan-susceptible isolates. This finding is consistent with at least some MDR isolates of M. tuberculosis lacking mutators detectable by the agar-plate assay. Collectively the data indicate that the use of fluoroquinolones with tuberculosis may induce resistance and that choice of quinolone may be important for restricting the recovery of induced mutants.

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): Primary care providers need a way to formalize and simplify complicated follow-up instructions so patients can successfully navigate the health-care system in between visits with their doctor. OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): The individualized Electronic Primary Care Follow-up Plan is designed to maximize the efficiency and utility of face-to-face visits; encourage patient participation; and facilitate communication between the patient and health care team. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): Using the Veterans Affairs (VA) electronic medical record we designed a Follow-up Plan that translates physician follow-up orders into a single page, individualized instruction sheet for the patient to take home at the end of each primary-care visit. This templated note not only supplies the patient with an instruction tool; it also provides the physician with the convenience of ordering all referrals from one place. Physicians view a checklist of all possible relevant follow-up orders, expandable when prompted to offer additional, more specific options. For instance, if a physician orders imaging, a menu box of options appears with different imaging modalities; if a referral is required, a list of specialty clinics appears. The selected follow-up then automatically links to electronic orders. The final chart note pulls in only patient-relevant data. The patient leaves the primary care visit with a one-page personalized instruction sheet explaining how, when and why to accomplish each follow-up task. Checkout lines are minimized as patients no longer wait in line to schedule appointments. The note, which documents that patient communication took place with an electronic signature, remains in the medical record and can be consulted and reprinted at any time between visits by any member of Patient Aligned Care Team (PACT!

OBJECTIVE:The use of ergot-derived dopamine agonists (DA) to treat patients with prolactinomas has not been associated with an increased risk of significant heart valve dysfunction. Accordingly, the present study evaluated whether the long-term use of DA for hyperprolactinaemia may be associated with increased risk of significant valvular heart disease. METHODS:A total of 74 patients (mean age 48 ± 1·4 years, 23% male) with prolactinoma treated with DA for at least 1 year were evaluated with 2-dimensional echocardiography at baseline. After 2 years of follow-up, a repeat echocardiography was performed to evaluate significant changes in valvular heart structure (thickening, calcifications and leaflet motion abnormalities) and function (regurgitation or stenosis). Patients were classified according to treatment: patients treated with cabergoline (group 1: n = 45), and patients not treated with cabergoline (group 2: n = 29). RESULTS:At 2-year follow-up, no significant valvular stenosis was observed in any patient. In addition, the prevalence of any significant valve regurgitation did not change significantly (from 12% to 15%, P = NS). However, there was a significant increase in the prevalence of valvular calcifications (from 48% to 58%, P = 0·004) and, particularly, in the prevalence of aortic valve calcifications (from 39% to 53%, P = 0·002). In a per-treatment-based analysis, the group of patients treated with cabergoline had significantly higher prevalence of aortic valve calcification at 2 years follow-up as compared to the group of patients not treated with cabergoline (63%vs 38%, P = 0·016). CONCLUSIONS:The long-term therapy with DA (cabergoline) of patients with prolactinoma is associated with an increased prevalence of valvular calcification. However, these structural changes were not accompanied by an increased prevalence of valvular dysfunction.

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): To determine how adding a non-clinical member to primary care teams can improve hypertension and smoking cessation outcomes in Veteran Affairs New York Harbor Healthcare System's (VA NYHHS) implementation of the VA's Patient Centered Medical Home (PCMH) model, known as Patient Aligned Care Teams (PACT). OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): As part of the Program for Research on Outcomes of VA Education (PROVE) study, we sought to define a toolkit of panel management strategies that Panel Management Assistants (PMAs) will use to improve outcomes in smoking cessation and hypertension across patient panels. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENTVS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): Coincident with the nation-wide implementation of PACT across the VA system, PROVE explores the incremental impact of panel management and clinical microsystem education on hypertension and smoking outcomes. Two-thirds of randomly selected PACT teams in ambulatory care clinics at the Brooklyn and Manhattan campuses of the VA NYHHS had a PMA added to the team. Based on literature review and qualitative interviews of clinicians and key stakeholders at VA NYHHS, we developed a core toolkit of strategies utilizing clinical databases to target subsets of smokers and hypertensive patients that could benefit from specialized panel management interventions outside of the patient visit, such as identifying smokers who have not recently received tobacco cessation medications. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICH WILL BE USED TOEVALUATE PROGRAM/INTERVENTION): Prior to PROVE's intervention, we determined baseline rates of hypertension (uncontrolled and controlled) and smoking for all PACT panels. To assess PROVE's effectiveness of integrating panel management strategies by PACT teams, we will survey providers and nurses at baseline, 6 and 12 months to me!