A Quality Improvement Initiative: A Nurse Practitioner-Led Interdisciplinary Approach to Reducing Readmissions in the Subacute Population

Background

To decrease the 30-day Subacute Readmissions in an outpatient facility by using an Advanced Practice Nurse (APN) Project Leader while applying evidence based transitional care processes.

Objective

Determine the effects of APN leadership within the Interdisciplinary Team in the subacute setting.

Methods

Immersion of an APN as Project Leader over a 12-week period.

Results

Outcomes were divided into three groups. They were reorganized and analyzed. The new breakdown included patients readmitted plus hospice referrals (n = 5) and those not readmitted (n = 4). A significant difference in the 30-day outcomes as well as the LACE variable comorbidity scores t (4) = 2.95, p = 0.0418 were identified.

Conclusions

The 30-day readmission rates were decreased using hospice as a referral source. Application of the Lippitt’s Model of Planned Change and the use of the LACE Scoring Tool were instrumental to the success of this project.

Implications for Nursing

To improve optimal outcomes it is necessary for the APN/Doctor of Nursing Practice (DNP) and other healthcare professionals to engage in collaborative practices that result in effective policy changes. This quality improvement project restructured the existing Interdisciplinary Team processes to include the APN Project Leader with improved patient-centered outcomes.

Prevention of Occupational Heat-Related Illnesses

High ambient temperatures and strenuous physical activity put workers at risk for a variety of heat-related illnesses and injuries. Through primary prevention, secondary prevention, and treatment, OEM health providers can protect workers from the adverse effects of heat. This statement by the American College of Occupational and Environmental Medicine provides guidance for OEM providers who serve workers and employers in industries where heat exposure occurs.

Assessment of Methylene Chloride-Related Fatalities in the United States, 1980-2018

Importance

Methylene chloride is a halogenated organic solvent widely used in paint strippers, cleaners, adhesives, and sealants. Despite label warnings and occupational standards, methylene chloride-related fatalities continue to occur in the United States.

Objective

To identify and analyze methylene chloride-related fatalities in the US.

Design, Setting, and Participants

For this case series, we conducted systematic searches of sources, including PubMed and government databases, for unintentional fatalities in the US that were associated with exposure to methylene chloride or products containing methylene chloride between 1980 and 2018. We reviewed all available information, including inspection reports, autopsy reports, and medical records; data analyses were conducted from August 2018 to August 2020. Cases were categorized as those occurring in the home (consumer deaths) or at work (occupational deaths).

Exposures

Methylene chloride or products containing methylene chloride.

Main Outcomes and Measures

To determine characteristics of the methylene chloride-related fatalities, we recorded demographic information; the setting; circumstances, including information on safety measures used, if available; and products used. Where medical records were available, we recorded toxicology results and autopsy findings. We also obtained data about nonfatal methylene chloride cases from the American Association of Poison Control Centers.

Results

From 1980 to 2018, 85 methylene chloride-related fatalities were identified in the US, including 74 (87%) in occupational settings; of those who died, 75 (94%) were men, and for the 70 cases with available information, the median (interquartile range) age of the decedents was 31 (24-46) years. Paint strippers were the most common products involved in methylene chloride-related fatalities (n = 60). The proportion of occupational fatalities related to paint stripping increased from 22 (55%) before 2000 to 30 (88%) after 2000. Similarly, occupational fatalities associated with bathtub or paint stripping in bathrooms increased from 2 (5%) before 2000 to 21 (62%) after 2000. From 1985 to 2017, the American Association of Poison Control Centers documented 37 201 nonfatal methylene chloride cases, with a decrease in the annual number of cases starting in the late 1990s.

Conclusions and Relevance

Results of this case series demonstrated that despite regulations to address the toxic effects of methylene chloride use for consumers and workers, there are continuing fatalities in the US, particularly in occupational settings. Prevention of fatalities associated with methylene chloride exposure should emphasize the use of safer substitutes, rather than hazard warnings or reliance on personal protective equipment.

Occupational Distribution of Campylobacteriosis and Salmonellosis Cases - Maryland, Ohio, and Virginia, 2014

Campylobacter and Salmonella are leading causes of bacterial gastroenteritis in the United States and are estimated to cause >1 million episodes of domestically acquired illness annually (1). Campylobacter and Salmonella are primarily transmitted through contaminated food, but animal-to-human and human-to-human transmission can also occur (2,3). Although occupationally acquired infections have been reported, occupational risk factors have rarely been studied. In 2015, the Occupational Safety and Health Administration (OSHA) identified 63 suspected or confirmed cases of Campylobacter infection over 3.5 years at a poultry-processing plant (Kathleen Fagan, OSHA, personal communication, December 2015); most involved new workers handling chickens in the "live hang" area where bacterial contamination is likely to be the highest. These findings were similar to those of a previous study of Campylobacter infections among workers at another poultry-processing plant (4). The investigation led to discussions among OSHA, state health departments, and CDC's National Institute for Occupational Safety and Health (NIOSH); and a surveillance study was initiated to further explore the disease incidence in poultry-processing plant workers and identify any additional occupations at increased risk for common enteric infections. Deidentified reports of campylobacteriosis and salmonellosis among Maryland, Ohio, and Virginia residents aged ≥16 years were obtained and reviewed. Each employed patient was classified into one of 23 major occupational groups using the 2010 Standard Occupational Classification (SOC) system.* Risk ratios (RR) and 95% confidence intervals (CI) for associations between each occupational group and each disease were calculated to identify occupations potentially at increased risk, contrasting each group with all other occupations. In 2014, a total of 2,977 campylobacteriosis and 2,259 salmonellosis cases were reported. Among the 1,772 (60%) campylobacteriosis and 1,516 (67%) salmonellosis cases in patients for whom occupational information was available, 1,064 (60%) and 847 (56%), respectively, were employed. Persons in farming, fishing, and forestry as well as health care and technical occupations were at significantly increased risk for both campylobacteriosis and salmonellosis compared with all other occupations. Targeting education and prevention strategies could help reduce disease, and improving the systematic collection of occupational information in disease surveillance systems could provide a better understanding of the extent of occupationally acquired diseases.

Chromosome microarray proficiency testing and analysis of quality metric data trends through an external quality assessment program for Australasian laboratories

Chromosome microarrays are an essential tool for investigation of copy number changes in children with congenital anomalies and intellectual deficit. Attempts to standardise microarray testing have focused on establishing technical and clinical quality criteria, however external quality assessment programs are still needed. We report on a microarray proficiency testing program for Australasian laboratories. Quality metrics evaluated included analytical accuracy, result interpretation, report completeness, and laboratory performance data: sample numbers, success and abnormality rate and reporting times. Between 2009 and 2014 nine samples were dispatched with variable results for analytical accuracy (30-100%), correct interpretation (32-96%), and report completeness (30-92%). Laboratory performance data (2007-2014) showed an overall mean success rate of 99.2% and abnormality rate of 23.6%. Reporting times decreased from >90 days to <30 days for normal results and from >102 days to <35 days for abnormal results. Data trends showed a positive correlation with improvement for all these quality metrics, however only 'report completeness' and reporting times reached statistical significance. Whether the overall improvement in laboratory performance was due to participation in this program, or from accumulated laboratory experience over time, is not clear. Either way, the outcome is likely to assist referring clinicians and improve patient care.

Farmworker Housing in the United States and Its Impact on Health

Farmworkers in the United States occupy a range of housing, including both on- and off-farm family and communal dwellings. As the farmworker population is becoming more settled, housing needs are changing. Existing regulations designed originally for grower-supplied migrant housing may need to be expanded. Much of farmworker housing is in poor condition, and likely linked to negative mental and physical health outcomes of residents because of exposures to crowding; mold, mildew, and other allergens; pesticides; and structural deficiencies. The existing research literature, both on housing conditions and their associations with farmworker health, is sparse, and large areas of the country and significant domains of health are omitted. This paper reviews this literature and formulates research and policy recommendations for addressing these deficiencies.

Cleaning and disinfecting environmental surfaces in health care: Toward an integrated framework for infection and occupational illness prevention

BACKGROUND

The Cleaning and Disinfecting in Healthcare Working Group of the National Institute for Occupational Safety and Health, National Occupational Research Agenda, is a collaboration of infection prevention and occupational health researchers and practitioners with the objective of providing a more integrated approach to effective environmental surface cleaning and disinfection (C&D) while protecting the respiratory health of health care personnel.

METHODS

The Working Group, comprised of >40 members from 4 countries, reviewed current knowledge and identified knowledge gaps and future needs for research and practice.

RESULTS

An integrated framework was developed to guide more comprehensive efforts to minimize harmful C&D exposures without reducing the effectiveness of infection prevention. Gaps in basic knowledge and practice that are barriers to an integrated approach were grouped in 2 broad areas related to the need for improved understanding of the (1) effectiveness of environmental surface C&D to reduce the incidence of infectious diseases and colonization in health care workers and patients and (2) adverse health impacts of C&D on health care workers and patients. Specific needs identified within each area relate to basic knowledge, improved selection and use of products and practices, effective hazard communication and training, and safer alternatives.

CONCLUSION

A more integrated approach can support multidisciplinary teams with the capacity to maximize effective and safe C&D in health care.

Neonatal lung side population cells demonstrate endothelial potential and are altered in response to hyperoxia-induced lung simplification

Lung side population (SP) cells are resident lung precursor cells with both epithelial and mesenchymal potential that are believed to play a role in normal lung development and repair. Neonatal hyperoxic exposure impairs lung development leading to a long-term decrease in gas exchange surfaces. The hypothesis that lung SP cells are altered during impaired lung development has not been studied. To address this issue, we characterized the endothelial potential of neonatal lung SP and subsets of lung SP from neonatal mice following hyperoxic exposure during room air recovery. Lung SP cells were isolated and sorted on the basis of their capacity to efflux Hoechst 33342. The lung SP was further sorted based on expression of Flk-1 and CD45. In vitro, both CD45pos/Flk-1pos and CD45neg/Flk-1pos bind isolectin B4 and incorporate LDL and form networks in matrigel, indicating that these populations have endothelial cell characteristics. Hyperoxic exposure of neonatal mice resulted in subtle changes in vascular and alveolar density on P13, which persisted with room air recovery to P41. During room air recovery, a decrease in lung SP cells was detected in the hyperoxic-exposed group on postnatal day 13 followed by an increase on day 41. Within this group, the lung SP subpopulation of cells expressing CD45 increased on day 21, 41, and 55. Here, we show that lung SP cells demonstrate endothelial potential and that the population distribution changes in number as well as composition following hyperoxic exposure. The hyperoxia-induced changes in lung SP cells may limit their ability to effectively contribute to tissue morphogenesis during room air recovery.

The t(4;8) is mediated by homologous recombination between olfactory receptor gene clusters, but other 4p16 translocations occur at random

The t(4;8)(p16;p23) is the second most common constitutional chromosomal translocation and is caused by an ectopic meiotic recombination between the olfactory receptor gene clusters (ORGC), located on chromosome 4p and 8p. Given that ORGCs are scattered across the genome and make-up about 0.1% of the human genome we reasoned that translocations between 4p16 and other chromosomes might be mediated by ectopic recombination between different ORGC. In 13 patients, we mapped the breakpoints of either a balanced or unbalanced translocation between chromosome 4p16 and different chromosomes. For all four t(4;8) cases, the breakpoints fall within the 4p and 8pter ORGC, confirming that non-allelic homologous recombination (NAHR) between the ORGC is the main mechanism of the t(4;8) formation. For the nine other translocations, the breakpoints on chromosome 4 mapped to different loci, one of them within the ORGC and in two flanking the ORGC. In these three cases, the translocation breakpoint at the reciprocal chromosome did not contain ORGC sequences. We conclude that only the t(4;8) is mediated by NAHR between ORGC.

Beyond the principle of plentitude: a review of terrestrial planet habitability

We review recent work that directly or indirectly addresses the habitability of terrestrial (rocky) planets like the Earth. Habitability has been traditionally defined in terms of an orbital semimajor axis within a range known as the habitable zone, but it is also well known that the habitability of Earth is due to many other astrophysical, geological, and geochemical factors. We focus this review on (1) recent refinements to habitable zone calculations; (2) the formation and orbital stability of terrestrial planets; (3) the tempo and mode of geologic activity (e.g., plate tectonics) on terrestrial planets; (4) the delivery of water to terrestrial planets in the habitable zone; and (5) the acquisition and loss of terrestrial planet carbon and nitrogen, elements that constitute important atmospheric gases responsible for habitable conditions on Earth's surface as well as being the building blocks of the biosphere itself. Finally, we consider recent work on evidence for the earliest habitable environments and the appearance of life itself on our planet. Such evidence provides us with an important, if nominal, calibration point for our search for other habitable worlds.

The t(8;13)(p11;q11-12) rearrangement associated with an atypical myeloproliferative disorder fuses the fibroblast growth factor receptor 1 gene to a novel gene RAMP

A recently described atypical myeloproliferative disorder is invariably associated with reciprocal translocations involving 8p11-12. The most common rearrangement is a t(8;13)(p11;q11-12). Here we determine that this translocation results in the fusion of the fibroblast growth factor receptor 1 gene (FGFR1), a member of the receptor tyrosine kinase family at 8p11, to a novel gene at 13q11-12 designated RAMP . The predicted RAMP protein exhibits strong homology to the product of a recently cloned candidate gene for X-linked mental retardation, DXS6673E . We also provide the first report of a novel, putative metal-binding motif, present as five tandem repeats in both RAMP and DXS6673E. RT-PCR detected only one of the two possible fusion transcripts, encoding a product in which the N-terminal 641 amino acids of RAMP become joined to the tyrosine kinase domain of FGFR1. Receptor tyrosine kinases are not commonly involved in the formation of tumour-specific fusion proteins. However, the previous reports of involvement of receptor tyrosine kinases in fusion proteins in non-Hodgkin's lymphoma, chronic myelomonocytic leukaemia and papillary thyroid carcinoma described similar rearrangements. By analogy with these, we propose that the RAMP-FGFR1 fusion product will contribute to progression of this myeloproliferative disorder by constitutive activation of tyrosine kinase function.

Collection and analysis of peripheral blood mononuclear cells during haemopoietic recovery following PBSCT for CML: autografting as an in vivo purging manoeuvre?

A 47-year-old man with a 2-year history of Philadelphia chromosome-positive chronic phase (CP) chronic myeloid leukaemia (CML) underwent autologous PBSCT. During the period of haemopoietic reconstitution he underwent five leucapheretic (LP) harvests yielding a total of 2.6 x 10(6)/kg CD34+ cells. Cytogenetic analyses revealed 94, 83, 83, 96 and 85% Ph negativity respectively for the five harvests. RT-PCR analyses for BCR-ABL performed on randomly picked CFU-GM from the five LP products were negative in all cases. These observations suggest that the majority of harvested cells, including the more primitive clonogenic cells, were BCR-ABL (Ph) negative and presumably were not part of the leukaemic clone. These findings support the notion that autologous PBSCT in CML whilst serving as a therapeutic manoeuvre may also facilitate the collection of non-leukaemic progenitor cells for further transplantation procedures.

Translocations involving 4p16.3 in three families: deletion causing the Pitt-Rogers-Danks syndrome and duplication resulting in a new overgrowth syndrome

Three families are reported who have a translocation involving 4p16.3. Nine subjects are described with the clinical features of the Pitt-Rogers-Danks (PRD) syndrome confirming pre- and postnatal growth failure, microcephaly, severe mental retardation, seizures, and a distinctive facial appearance; a deletion of 4p16.3 was seen in all eight patients studied with fluorescence in situ hybridisation (FISH). Eleven subjects had a new syndrome with physical overgrowth, heavy facial features, and mild to moderate mental handicap; a duplication of the chromosome region 4p16.3 was found in the four subjects studied. It is suggested that the growth abnormalities in these two families may be explained by a dosage effect of the fibroblast growth factor receptor gene 3 (FGFR3), which is located at 4p16.3, that is, a single dose leads to growth failure and a triple dose to physical overgrowth. We describe the molecular mapping of the translocation breakpoint and define it to within locus D4S43.

Construction of a full-length Ca2+-sensitive adenylyl cyclase/aequorin chimera

Ca2+-sensitive adenylyl cyclases are key integrators of Ca2+ and cAMP signaling. To selectively probe dynamic changes in [Ca2+]i at the plasma membrane where adenylyl cyclases reside, a full-length, Ca2+-inhibitable type VI adenylyl cyclase/aequorin chimera has been constructed by a two-stage polymerase chain reaction method. The expressed adenylyl cyclase/aequorin chimera was appropriately localized to the plasma membrane, as judged by biochemical fractionation and functional analysis. The chimera retained full adenylyl cyclase activity and sensitivity to inhibition by physiological [Ca2+]i elevation. The aequorin portion of the chimeric construct was also capable of measuring changes in [Ca2+] both in vitro and in vivo. When the plasma membrane-tagged aequorin and cytosolic aequorin were compared in their measurement of [Ca2+]i, they showed contrasting sensitivities depending on whether the [Ca2+]i originated from internal stores or capacitative entry. This is the first full-length enzyme-aequorin chimera that retains the full biological properties of both aequorin and a Ca2+-sensitive adenylyl cyclase. This novel chimeric Ca2+ sensor provides the unique ability to directly report the dynamics of [Ca2+]i that regulates this Ca2+-sensitive enzyme under a variety of physiological conditions. Since this chimera is localized to the plasma membrane, it can also be used to assess local changes in [Ca2+]i at the plasma membrane as distinct from global changes in [Ca2+]i within the cytosol.

Supernumerary ring chromosome 17 identified by fluorescent in situ hybridization

We present a patient with multiple anomalies and severe developmental delay. A small supernumerary ring chromosome was found in 40% of her lymphocyte cells at birth. The origin of the marker chromosome could not be determined by GTG banding, but fluorescent in situ hybridization (FISH) later identified the marker as deriving from chromosome 17.

Anal anomalies: an uncommon feature of velocardiofacial (Shprintzen) syndrome?

We report three cases of velocardiofacial syndrome (VCFS) with anal anomalies who have deletions of the 22q11 region and a further case where the proband has VCFS clinically and her father has an anal anomaly. It is important to consider VCFS in the differential diagnosis of children with anal anomalies and to look for other features of the syndrome, such as asymmetrical crying facies, submucous cleft of the palate, developmental delay, cardiac anomalies, and hypoparathyroidism.

Velo-cardio-facial and partial DiGeorge phenotype in a child with interstitial deletion at 10p13--implications for cytogenetics and molecular biology

We report on a female with a interstitial deletion of 10p13 and a phenotype similar to that seen with the 22q deletion syndromes (DiGeorge/velo-cardio-facial). She had a posterior cleft palate, perimembranous ventricular septal defect, dyscoordinate swallowing, T-cell subset abnormalities, small ears, maxillary and mandibular hypoplasia, broad nasal bridge, deficient alae nasi, contractures of fingers and developmental delay. This could indicate homology of some developmental genes at 22q and 10p so that patients with the velocardiofacial phenotype who do not prove to be deleted on 22q are candidates for a 10p deletion.

An interstitial deletion of chromosome 7(q35)

We describe a patient with developmental delay, mild dysmorphic features, and monosomy of 7q35. Only one other patient with an interstitial deletion of this band has been previously reported. A review of clinical features of these two children did not show similarities in dysmorphic features. Reports of patients with other 7q interstitial deletions are listed.

"CATCH 22" sans cardiac anomaly, thymic hypoplasia, cleft palate, and hypocalcaemia: cAtch 22. A common result of 22q11 deficiency?

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Translocation (8;13) and T-cell lymphoma. A case report

A patient with a myeloproliferative disorder is described with an eosinophilia together with T-cell lymphoma. A unique translocation t(8;13)(p11.2;q12) was present in all bone marrow cells examined at presentation. No evidence of this translocation was found in a peripheral blood lymphocyte culture. Chromosome analysis after 9 months revealed this same translocation as well as an extra chromosome 21 in all cells; 4.5% of cells also had an additional chromosome 9. The morphologic diagnosis at this stage was chronic myelomonocytic leukemia. Immunophenotyping 3 months later was consistent with a stem-cell leukemia.

Failure of ondansetron to block the discriminative or reinforcing stimulus effects of cocaine in the rat

Ondansetron (GR38032F), a serotonin 5HT3 antagonist, is active in numerous behavioral paradigms and neurochemical systems. Since 5HT3 antagonists have been suggested as therapeutic agents for the treatment of drug abuse, the action of ondansetron on cocaine drug discrimination and self-administration paradigms in rats was investigated. Doses of ondansetron (0.001 - 1.0 mg/kg) had no effect on the discriminative stimulus properties of 10 mg/kg cocaine. In contrast SCH23390, a dopamine D1 antagonist known to block cocaine discrimination, acted as previously reported. Ondansetron did not augment the effects of SCH23390, but at higher doses, combinations of ondansetron and SCH23390 produced disruption of lever pressing in the presence of cocaine. Ondansetron (0.001-1.0 mg/kg) had no effect on the self-administration of various doses of cocaine, nor did it have any effect on reacquisition of cocaine self-administration in animals with a history of active administration followed by a period of abstinence. As before, SCH23390, known to block cocaine self-administration, acted as previously reported. Although other 5HT antagonists may prove to be efficacious in cocaine abuse, ondansetron appears unlikely to alter the subjective or rewarding stimulus properties of cocaine.

A human colon cancer cell line established from collagen matrix cultures transplanted into nude mice

A new human colon cancer cell line (020588) has been derived by means of a combined in vitro matrix-in vivo xenograft technique. The tumour cell line is carcino-embryonic antigen positive, displays a marker chromosome and proliferates in chemically-defined serum-free culture medium. The chemosensitivity pattern for the tumour cell line was similar to that observed for the parent tumour cells. The novel method used to establish this continuous human tumour cell line may have several advantages over standard techniques.

Localization of the human UbB polyubiquitin gene to chromosome band 17p11.1-17p12

The chromosomal location of the human ubiquitin genes has been evaluated by in situ hybridization. Because of the conservation of the ubiquitin sequence, coding-region probes cannot distinguish between specific ubiquitin genes and reveal ubiquitin sequences in a number of different chromosomal regions. The major sites of hybridization with a coding-region probe include 17p11.1-p12, 12p24.2-q24.32, and 2q21-q24, with weaker hybridization over 1p3, 1q4, 2q3, and 13q. Hybridization with a probe isolated from the UbB gene intron indicated that this gene is located within the region 17p11.1-17p12. This region showed the strongest hybridization with the coding-region probe and is presumably also the location of the duplicated UbB pseudogene.

A summary of 7q interstitial deletions and exclusion mapping of the gene for beta-glucuronidase

Three patients are described with different phenotypes and differing de novo interstitial deletions of the long arm of a chromosome 7. The first patient has a deletion with loss of the proximal 7q11.23 band. Only three other cases have been reported with this particular deletion. Our second case shows mild dysmorphism similar to the other four patients reported with deletion of bands 7q21.12----21.3. Our third patient has a deletion of the 7q22.1----32.2 segment and has many of the phenotypic features of the other reported cases of del 7q22----32. GUSB, the gene for beta-glucuronidase, has been localised to the 7cen----q22 region. Analysis of beta-glucuronidase levels in blood leucocytes of our patients has helped more precisely to assign this gene locus to 7q21.11 or 7q22.1.

A new interstitial deletion of 4q (q21.1::q22.1)

A unique case of de novo interstitial deletion of chromosome 4 is described involving loss of band q21. The male newborn had multiple abnormalities including frontal bossing, prominent occiput, low set ears, micrognathia, short sternum, short, broad hands and feet, agenesis of the corpus callosum, and cardiac defects. The phenotypic abnormalities are compared with other reported cases of deletion 4q involving adjacent regions.

Ring chromosome 11 and café-au-lait spots

We report on the segregation of a cytogenetically non-deleted ring chromosome 11 and café-au-lait spots in a family. This appears to be the largest inherited ring autosome yet reported.

The coagulation factor VII regulator is located on 8p23.1

Cytogenetic and coagulation studies have been performed on two patients with different abnormalities of chromosome 8, i.e. del(8p23.1----pter) and dup(8q23.1----qter). Results confirm the existence of a regulatory mechanism for clotting factor VII on chromosome 8 and define its location to the p23.1----p23.2 region.

A deletion of heterochromatin only of the Y chromosome in an azoospermic male

A patient with a deletion of the distal portion of the long arm (q21) of chromosome Y is described clinically and cytogenetically. The proband has a normal male habitus but with azoospermia. The proband was investigated because of infertility. Male relatives were also investigated cytogenetically. The deleted Y chromosome was measured and compared with the normal Y of male family members. The results suggest that no Y euchromatin was lost.