Perceived performance and impact of a non-physician-led interprofessional team in a trauma clinic setting

Faced with the challenge of meeting the wide degree of post-discharge needs in their trauma population, the University of Pittsburgh Medical Center (UPMC) developed a non-physician-led interprofessional team to provide follow-up care at its UPMC Falk Trauma Clinic. We assessed this model of care using a survey to gauge team member perceptions of this model, and used clinic visit documentation to apply a novel approach to assessing how this model improves the care received by clinic patients. The high level of perceived team performance and cohesion suggests that this model has been successful thus far from a provider perspective. Patients are seen most frequently by audiologists, while approximately half of physical therapy and speech language therapy consults generate a new therapy referral, which is interpreted as a potential change in the patient's care trajectory. The broader message of this analysis is that a collaborative, non-hierarchical team model incorporating rehabilitative specialists, who often operate independently of one another, can be successful in this setting, where patients appear to have a strong and previously under-attended need for rehabilitative intervention.

Toward Effective Water Pipe Tobacco Control Policy in the United States: Synthesis of Federal, State, and Local Policy Texts

PURPOSE

Water pipe tobacco smoking (WTS) is growing in popularity among U.S. young adults and is associated with health risks similar to those of cigarette smoking. The purpose of this study is to examine existing tobacco control policies (TCPs) in order to investigate how they engage WTS.

APPROACH

A systematic synthesis of content and legal interactions among federal, state, and local TCP documents.

SETTING

Pennsylvania, which represents a politically and demographically diverse microcosm of the United States.

PARTICIPANTS

No human subjects.

METHOD

Federal and state TCPs were retrieved via public legal repositories. Local policy searches were conducted via county/municipal Web sites, inclusive of 13 localities that had autonomous health departments or existing TCPs based on a National Cancer Institute report. Full-text TCPs were double coded within a grounded theory framework for health policy analysis. Emergent codes were used to compare and contrast policy texts and to examine legal interactions among TCPs.

RESULTS

Examination of policy categories including youth access, use restrictions, and taxation revealed WTS as largely omitted from current TCPs. WTS was sometimes addressed as an "other" tobacco product under older TCPs, though ambiguities in language led to questionable enforceability. State preemptions have rolled back or prevented well-tailored reforms at the local level. Federal preemptions have likewise constrained state TCPs.

CONCLUSION

Outdated, preempted, and unclear policies limit the extent to which TCPs engage WTS. Health advocates might target these aspects of TCP reform.

Innovative approaches to interprofessional care at the University of Pittsburgh Medical Center

The enactment of the Affordable Care Act expands coverage to millions of uninsured Americans and creates a new workforce landscape. Interprofessional Collaborative Practice (ICP) is no longer a choice but a necessity. In this paper, we describe four innovative approaches to interprofessional practice at the University of Pittsburgh Medical Center. These models demonstrate innovative applications of ICP to inpatient and outpatient care, relying on non-physician providers, training programs, and technology to deliver more appropriate care to specific patient groups. We also discuss the ongoing evaluation plans to assess the effects of these interprofessional practices on patient health, quality of care, and healthcare costs. We conclude that successful implementation of interprofessional teams involves more than just a reassignment of tasks, but also depends on structuring the environment and workflow in a way that facilitates team-based care.

Comparing Advanced Practice Providers and Physicians as Providers of e-Visits

BACKGROUND

Although electronic delivery (electronic visits [e-visits]) of healthcare services by advanced practice providers (APPs) is growing, literature defining the roles of different providers and comparing outcomes is lacking. We analyzed two e-visit models at the University of Pittsburgh Medical Center (UPMC) to compare their providers (physicians and APPs) and associated outcomes.

MATERIALS AND METHODS

We identified all e-visits for the UPMC AnywhereCare Continuity (physician providers for existing patients) and Convenience (physician and APP providers for Pennsylvania residents) services (n=2,184) using Epic Systems (Verona, WI) MyChart data (November 2013-August 2014). We compared e-visits by service and provider type for patient characteristics, volume, response time, primary diagnoses, and number of prescriptions. We used statistical tests to determine differences in patient characteristics and an ordinary least square linear regression, controlling for patient characteristics, to determine differences in prescribing.

RESULTS

Of the completed e-visits (n=1,791), 72.5% were with APPs, and 27.5% were with physicians. APP patients were younger, higher income, and more likely to be unmarried. Sinusitis patients were more likely to use the Continuity service, whereas those with urinary tract or upper respiratory infections were more likely to use the Convenience service. Finally, provider type was significantly associated with prescribing, with APPs prescribing more.

CONCLUSIONS

Some demographic variation exists between users of APP versus physician e-visits. Provider response time seems more driven by service policy than provider type. Finally, variation exists between provider types in quantities of prescriptions written. As health systems and policymakers develop protocols and reimbursement strategies for e-visits, these model considerations will be important.

Model for a patient-centered comparative effectiveness research center

This special report describes the systematic approach the University of Pittsburgh and the University of Pittsburgh Medical Center (UPMC) undertook in creating an infrastructure for comparative effectiveness and patient-centered outcomes research resources. We specifically highlight the administrative structure, communication and training opportunities, stakeholder engagement resources, and support services offered.

P3-18-07: Multiplex RTK Inhibitor Screening Utilizing a Plate-Based Immunoassay with Near-Infrared Detection

Receptor-tyrosine kinases (RTKs) are transmembrane proteins that have been implicated in various cancers and are considered therapeutic targets. The phosphorylation of RTKs on tyrosine residues leads to their activation. We have previously used the Proteome Profiler™ 96 Human Phospho-RTK Antibody Array, a plate-based multiplex immunoassay, to determine the phospho-tyrosine profile of RTKs in MDA-MB-453 breast cancer cells. Most notably, the ErbB family of RTKs were shown to be hyperactivated in this cell line. In this study, we use the same multiplex assay to screen a small molecule kinase inhibitor library (TOCRIS, Catalog # 3514) to identify inhibitors with selectivity towards the ErbB receptors. MDA-MB-453 cells were treated with the kinase inhibitor library prior to treatment with ligands to stimulate ErbB receptor tyrosine phosphorylation and subsequently lysed. The lysates were analyzed with the Proteome Profiler 96 Human Phospho-RTK Antibody Array using near-infrared fluorescent detection. Ligand-dependent tyrosine phosphorylation of all four ErbB receptors was monitored simultaneously and the effects of different kinase inhibitors were determined. While several known ErbB inhibitors blocked ErbB phosphorylation, our screen also identified several inhibitors reported to be selective for other kinases that effectively inhibited ErbB activation. The activation of ErbB2 was selectively inhibited by NH 125, GF 109203X, SB 202190, SB 216763, and ZM 306416 hydrochloride. The results obtained with this multiplex assay were confirmed by singleplex ELISA for ErbB receptors. Hence, the data collected with our multiplex assay provides a rapid method for the analysis of inhibitor effects on a defined signaling pathway. This may facilitate a faster identification of selective kinase inhibitors that have therapeutic potential for treating ErbB-overexpressing cancers.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-18-07.

BRE is an antiapoptotic protein in vivo and overexpressed in human hepatocellular carcinoma

BRE binds to the cytoplasmic domains of tumor necrosis factor receptor-1 and Fas, and in cell lines can attenuate death receptor-initiated apoptosis by inhibiting t-BID-induced activation of the mitochondrial apoptotic pathway. Overexpression of BRE by transfection can also attenuate intrinsic apoptosis and promote growth of the transfected Lewis lung carcinoma line in mice. There is, however, a complete lack of in vivo data about the protein. Here, we report that by using our BRE-specific monoclonal antibody on the immunohistochemistry of 123 specimens of human hepatocellular carcinoma (HCC), significant differences in BRE expression levels between the paired tumoral and non-tumoral regions (P<2.2e-16) were found. Marked overexpression of BRE was detected in majority of the tumors, whereas most non-tumoral regions expressed the same low level of the protein as in normal livers. To investigate whether BRE overexpression could promote cell survival in vivo, liver-specific transgenic BRE mice were generated and found to be significantly resistant to Fas-mediated lethal hepatic apoptosis. The transgenic model also revealed post-transcriptional regulation of Bre level in the liver, which was not observed in HCC and non-HCC cell lines. Indeed, all cell lines analysed express high levels of BRE. In conclusion, BRE is antiapoptotic in vivo, and may promote tumorigenesis when overexpressed.

Multipotent neural precursors express neural and hematopoietic factors, and enhance ex vivo expansion of cord blood CD34+ cells, colony forming units and NOD/SCID-repopulating cells in contact and noncontact cultures

In view of the possible crosstalks between hematopoiesis and neuropoiesis, we evaluated two microenvironments, murine neonatal neural cell line C17.2 and primary embryonic aorta-gonad-mesonephros (AGM) stromal cells, on the ex vivo expansion of CD34+ cells from human cord blood. In a contact culture system, C17.2 or AGM cells significantly enhanced the expansion of CD34+ cells to a panel of early and committed hematopoietic progenitor cells. In a noncontact transwell system, pre-established C17.2 cells significantly increased the expansion of total nucleated cells, CD34+ cells and multilineage colony forming cells (P<0.01). Expanded cells were infused into nonobese diabetic/severe-combined immunodeficient mice. The engraftment of human (hu)CD45+ cells in the bone marrow of these mice was consistently higher in all the 10 experiments conducted with the support of C17.2 cells when compared with those in respective control groups (11.9 vs 2.43%, P=0.03). Using RT-PCR and Southern blot analysis, we showed that AGM and C17.2 cells expressed a panel of hematopoietic, bone morphogenetic and neurotrophic factors. Our data provided the first evidence on the promoting effects of a neural progenitor cell line on hematopoiesis at a noncontact condition. The mechanism could be mediated by the expression of multilineage regulatory factors.

Cobblestone area-forming cells, long-term culture-initiating cells and NOD/SCID repopulating cells in human neonatal blood: a comparison with umbilical cord blood

Our prior study demonstrated that neonatal blood (NB) contained hematopoietic stem and progenitor cells that declined rapidly after birth. To validate that NB is a source of functional stem cells, we characterized this population in terms of cobblestone area-forming cells (CAFC), long-term culture-initiating cells (LTC-IC) and NOD/SCID mouse repopulating cells (SRC) in NB and umbilical cord blood (CB). Our data demonstrated that the frequencies of CAFC (30.2 vs 37.1, P = 0.14) and LTC-IC (28.6 vs 31.0, P = 0.49) in 1 x 10(5) mononuclear cells (MNC) of NB and CB were similar, suggesting that these cells were preserved in the circulation of the neonates shortly after birth. Sublethally irradiated NOD/SCID mice were transplanted with CD34(+) cells enriched from thawed NB and CB. At 6 weeks post transplant, human (hu)CD45(+) cells were detected in the bone marrow (BM), spleen and peripheral blood (PB) of the mice as demonstrated by flow cytometric and DNA analysis. Levels of huCD45(+)cells and colony forming units (CFU) appeared to be dependent on the infusion cell dose and were higher in animals receiving CB cells when compared with those of the NB group. The transplanted cells were capable of differentiation into multi-lineage progenitor cells (CD34(+) cells and differential CFU), as well as mature myeloid (CD14(+), CD33(+)), B lymphoid (CD19(+)) and megakaryocytic (CD61(+)) cells in the recipients. NB cells, subjected to ex vivo culture in an optimized preclinical condition, were significantly expanded to early and committed progenitor cells. Expanded NB contained SRC at a reduced quantity but with high proportions of CD14(+) cells and CD33(+) cells. Our study confirms that NB contains pluripotent hematopoietic stem and progenitor cells capable of homing and engrafting the NOD/SCID mice.

Preclinical ex vivo expansion of cord blood hematopoietic stem and progenitor cells: duration of culture; the media, serum supplements, and growth factors used; and engraftment in NOD/SCID mice

BACKGROUND

Ex vivo expansion of cord blood (CB) hematopoietic stem and progenitor cells increases cell dose and may reduce the severity and duration of neutropenia and thrombocytopenia after transplantation. This study's purpose was to establish a clinically applicable culture system by investigating the use of cytokines, serum-free media, and autologous plasma for the expansion of CB cells and the engraftment of expanded product in nonobese diabetic/severe combined immunodeficient (NOD/SCID) mice.

STUDY DESIGN AND METHODS

Enriched CB CD34+ cells were cultured in four media (Iscove's modified Dulbecco's medium with FCS, Gibco; X-Vivo-10, BioWhittaker; QBSF-60, Quality Biological; and StemSpan SFEM, Stem Cell Technologies) with four cytokine combinations (thrombopoietin [TPO], SCF, Flt-3 ligand [FL] with and without G-CSF, and/or IL-6). The effect of autologous CB plasma was also investigated. The read-out measures were evaluated on Days 8 and 12. After expansion at the optimized condition, cultured cells were transplanted into sublethally irradiated NOD/SCID mice. The engraftment of human CD45+ cells and subsets in the bone marrow, spleen, and peripheral blood was determined.

RESULTS

QBSF-60 or StemSpan SFEM supported high yields of early progenitors (CD34+ cells, <or= 64.8-fold; CD34+CD38- cells, 330-fold; CFU-granulocyte erythroid macrophage megakaryocyte [GEMM], 248-fold) and CFUs of the myeloid (CFU-GM, 407-fold) and erythroid (BFU/CFU-E, 144-fold) lineages. The expansion of the megakaryocytic lineage was consistently higher in X-Vivo-10 (CFU-megakaryocyte, 684-fold). Autologous plasma promoted colony formation but reduced CD34+ cells and CFU-GEMM. The addition of G-CSF or IL-6 improved cell yields; G-CSF was more effective for committed progenitors. Expansion products from cultures in QBSF-60 with the cytokines engrafted and differentiated into the myeloid and lymphoid lineages in NOD/SCID mice.

CONCLUSION

The data supported the strategy of expansion. The optimized condition may be applicable to clinical expansion for the abrogation or reduction of posttransplant cytopenia.

Delivery and scavenging system for small animal inhalational anesthesia

BACKGROUND

Inhalational agents have been widely used for anesthesia in laboratory animals. However, the safe use of inhalational agents in small laboratory animals has been limited by the lack of a suitable and effective scavenging system for the removal of waste anesthetic gases. The aim of the present study is to develop an anesthetic system that can be manufactured using common household and laboratory items.

MATERIALS AND METHODS

An anesthetic system was designed for rats weighing from 300 to 350 g. A face mask for the rat was made by cutting off the distal part of a 50-ml centrifuge tube. A scavenging hood was made from a transparent plastic food storage box. Exhaust of anesthetic gases from the scavenger hood was facilitated by fitting an outlet connected to a pump. Four experienced researchers or technicians tested the scavenger hood.

RESULTS

In 79.2% of the trials the participants could smell halothane when the pump from the scavenger system was not operational. However, when the pump was switched on, halothane was detected only 16.7% of the time (P < 0.001).

CONCLUSION

We have developed a simple and effective method of delivering inhalational anesthesia to small laboratory animals and of removing waste anesthetic gases.

Certain social considerations in abandoning high technology medical imaging

The growth in medical costs has created significant public concern and has appeared to mandate health care policy changes of great magnitude. These important policy decisions will evoke changes that could alter the traditional relationship in health care and will significantly affect the activities of both consumers and providers. This article will address one of the major areas affected by these recently instituted health care policies, medical imaging technology.

The concepts of wrongful birth and wrongful life and their relation to medical imaging

Although often used interchangeably, "wrongful birth" and "wrongful life" are distinct legal concepts. Wrongful birth involves the physician's duty to impart to expectant parents information about potential fetal defects. Wrongful life suits reflect the child's right to recovery for life-long suffering as a result of the physician's inadequate pre- or peri-natal care. Modern medical imaging techniques can play a major role in the diagnosis of interuterine malformations; this article explores the legal duties which may be imposed upon physicians who interpret such tests.

The effect of percutaneous oestradiol on atheroma formation in ovariectomized cholesterol-fed rabbits

OBJECTIVE

The aim of this study was to examine the effect of percutaneous oestradiol on the lipid profile and on atheroma formation using an animal model.

METHODS

The study was of 12 weeks duration. Fifty sexually mature female New Zealand White rabbits were divided into five groups of equal size. Two groups acted as controls and received normal rabbit chow. Rabbits in one of these groups were ovariectomized. The remaining three groups were ovariectomized but received 1% cholesterol enriched rabbit chow. One of these cholesterol-fed groups received 0.3 mg/kg percutaneous oestradiol daily whilst another received 0.1 mg/kg oral oestradiol daily. Measurements of concentrations of total cholesterol (TC), high density lipoprotein cholesterol (HDL-C) and triglycerides (TG) were made at the beginning and end of the study. Aortic atheroma formation was measured using computerized image analysis of uptake of Sudan III staining.

RESULTS

After 12 weeks there were significant increases in the mean concentrations of TC in the three cholesterol-fed groups compared with controls (P < 0.001). Changes in HDL-C and TG concentrations were less consistent. The mean area of aortic atheroma formation was significantly less in both the percutaneous oestradiol group (4.9%) and the oral oestradiol group (8.6%) compared with the non-oestrogen-treated cholesterol-fed group (19.5%) (P < 0.001, < 0.01 respectively).

CONCLUSION

These results suggest that percutaneous oestradiol has a direct protective effect on atheroma formation independent of serum concentrations of total cholesterol.