Improving safety and preventing falls using an evidence-based, front-line staff huddling practice: protocol for a pragmatic trial to increase quality of care in State Veterans Homes

INTRODUCTION

Falls in nursing homes are a major cause for decreases in residents' quality of life and overall health. This study aims to reduce resident falls by implementing the LOCK Falls Programme, an evidence-based quality improvement intervention. The LOCK Falls Programme involves the entire front-line care team in (1) focusing on evidence of positive change, (2) collecting data through systematic observation and (3) facilitating communication and coordination of care through the practice of front-line staff huddles.

METHODS AND ANALYSIS

The study protocol describes a mixed-methods, 4-year hybrid (type 2) effectiveness-implementation study in State Veterans Homes in the USA. The study uses a pragmatic stepped-wedge randomised trial design and employs relational coordination theory and the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to guide implementation and evaluation. A total of eight State Veterans Homes will participate and data will be collected over an 18-month period. Administrative data inclusive of all clinical assessments and Minimum Data Set assessments for Veterans with a State Veterans Home admission or stay during the study period will be collected (8480 residents total). The primary outcome is a resident having any fall. The primary analysis will be a partial intention-to-treat analysis using the rate of participants experiencing any fall. A staff survey (n=1200) and qualitative interviews with residents (n=80) and staff (n=400) will also be conducted. This research seeks to systematically address known barriers to nursing home quality improvement efforts associated with reducing falls.

ETHICS AND DISSEMINATION

This study is approved by the Central Institutional Review Board (#167059-11). All participants will be recruited voluntarily and will sign informed consent as required. Collection, assessment and managing of solicited and spontaneously reported adverse events, including required protocol alterations, will be communicated and approved directly with the Central Institutional Review Board, the data safety monitoring board and the Office of Research and Development. Study results will be disseminated through peer-reviewed publications and conference presentations at the Academy Health Annual Research Meeting, the Gerontological Society of America Annual Scientific Meeting and the American Geriatrics Society Annual Meeting. Key stakeholders will also help disseminate lessons learnt.

TRIAL REGISTRATION NUMBER

NCT05906095.

[Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-A German nationwide survey study]

BACKGROUND

Malignant middle cerebral artery infarction is a potentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60 years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization.

OBJECTIVE

This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting.

MATERIAL AND METHODS

From 20 September 2021 to 31 October 2021, 43 members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in a standardized anonymous online survey. Descriptive data analysis was performed.

RESULTS

Out of 43 centers 29 (67.4%) participated in the survey, including 24 university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored a standardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3 days in 30.8%, ≤ 5 days in 19.2%, > 5 days in 15.4%). Early tracheotomy (≤ 7 days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14 days. Hyperosmolar treatment is used on a regular basis in 53.9% and 22 centers (84.6%) agreed to participate in a clinical trial addressing the duration of postoperative sedation and ventilation.

CONCLUSION

The results of this nationwide survey among neurointensive care units in Germany reflect a remarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. A randomized trial in this matter seems warranted.

FACTORS INFORMING CLINICIAN CHOICE OF TELEHEALTH MODALITY TO SUPPORT DEMENTIA CAREGIVERS

In summer 2020, 68 clinicians in the New England area caring for Veterans with dementia as part of a specialty team were surveyed regarding caregiver support services, with a 46% response rate (n=31). When faced with the need to abruptly discontinue in-person dementia support services, the majority of respondents offered caregivers support via telephone rather than video telehealth. Only 4 of 31 (13%) mentioned offering video visits for the first time to replace face-to-face visits. Clinician choice of modality largely reflected shifts among preestablished communication modalities/patterns and were influenced by clinician perception that older patients and their caregivers would prefer the telephone. Clinicians without experience using video telehealth with older adults were unlikely to offer video visits despite evidence that many older adults are willing and able to participate. Assessing caregiver wish/ability to participate in video visits may inform and shape clinician choice of telehealth modality.

Osteoclasts and Macrophages-Their Role in Bone Marrow Cavity Formation During Mouse Embryonic Development

The formation of the bone marrow cavity is a prerequisite for endochondral ossification. In reviews and textbooks, it is occasionally reported that osteoclasts are essential for bone marrow cavity formation removing hypertrophic chondrocytes. Mice lacking osteoclasts or having functionally defective osteoclasts have osteopetrotic bones, yet they still form a bone marrow cavity. Here, we investigated the role of osteoclasts and macrophages in bone marrow cavity formation during embryogenesis. Macrophages can assist osteoclasts in matrix removal by phagocytosing resorption byproducts. Rank-deficient mice, lacking osteoclasts, and Pu.1-deficient mice, lacking monocytes, macrophages, and osteoclasts, displayed a delay in bone marrow cavity formation and a lengthening of the zone of hypertrophic chondrocytes. F4/80-positive monocyte/macrophage numbers increased by about fourfold in the bone marrow cavity of E18.5 Rank-deficient mice. Based on lineage-tracing experiments, the majority of the excess F4/80 cells were derived from definitive hematopoietic precursors of the fetal liver. In long bones of both Rank^-/- and Pu.1^-/- specimens, Mmp9-positive cells were still present. In addition to monocytes, macrophages, and osteoclasts, Ctsb-positive septoclasts were lost in Pu.1^-/- specimens. The mineralization pattern was altered in Rank^-/- and Pu.1^-/- specimens, revealing a significant rise in transverse-oriented mineralized structures. Taken together, our findings imply that early on during bone marrow cavity formation, osteoclasts facilitate the entry of blood vessels and later the turnover of hypertrophic chondrocytes, whereas macrophages appear to play no major role. Furthermore, the absence of septoclasts in Pu.1^-/- specimens suggests that septoclasts are either derived from Pu.1-dependent precursors or require PU.1 activity for their differentiation. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Seasonal shifts in isoprenoid emission composition from three hyperdominant tree species in central Amazonia

Volatile isoprenoids regulate plant performance and atmospheric processes, and Amazon forests comprise the dominant source to the global atmosphere. Still, there is a poor understanding of how isoprenoid emission capacities vary in response to ecophysiological and environmental controls in Amazonian ecosystems. We measured isoprenoid emission capacities of three Amazonian hyperdominant tree species - Protium hebetatum, Eschweilera grandiflora, Eschweilera coriacea - across seasons and along a topographic and edaphic environmental gradient in the central Amazon. From wet to dry season, both photosynthesis and isoprene emission capacities strongly declined, while emissions increased among the heavier isoprenoids: monoterpenes and sesquiterpenes. Plasticity across habitats was most evident in P. hebetatum, which emitted sesquiterpenes only in the dry season, at rates that significantly increased along the hydro-topographic gradient from white sands (shallow root water access) to uplands (deep water table). We suggest that emission composition shifts are part of a plastic response to increasing abiotic stress (e.g. heat and drought) and reduced photosynthetic supply of substrates for isoprenoid synthesis. Our comprehensive measurements suggest that more emphasis should be placed on other isoprenoids, besides isoprene, in the context of abiotic stress responses. Shifting emission compositions have implications for atmospheric responses because of the strong variation in reactivity among isoprenoid compounds.

Mice Lacking Wnt9a or Wnt4 Are Prone to Develop Spontaneous Osteoarthritis With Age and Display Alteration in Either the Trabecular or Cortical Bone Compartment

Osteoarthritis (OA) is a common degenerative disease of the joint, with a complex multifactorial not yet fully understood etiology. Over the past years, the Wnt signaling pathway has been implicated in osteoarthritis. In a recent genomewide association study (GWAS), the chromosomal location on chromosome 1, linked to the Wnt3a-Wnt9a gene locus, was identified as the most significant locus associated with a thumb osteoarthritis endophenotype. Previously, it was shown that WNT9a is involved in maintaining synovial cell identity in the elbow joint during embryogenesis. Here, we report that the conditional loss of Wnt9a in the Prx1-Cre expressing limb mesenchyme or Prg4-CreER expressing cells predispositions the mice to develop spontaneous OA-like changes with age. In addition, the trabecular bone volume is altered in these mice. Similarly, mice with a conditional loss of Wnt4 in the limb mesenchyme are also more prone to develop spontaneously OA-like joint alterations with age. These mice display additional alterations in their cortical bone. The combined loss of Wnt9a and Wnt4 increased the likelihood of the mice developing osteoarthritis-like changes and enhanced disease severity in the affected mice. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Making Green(s) With Black and White: Constructing Soils for Urban Agriculture Using Earthworms, Organic and Mineral Wastes

Urban agriculture has been of growing interest for a decade because it can address many economic and societal issues in the development of modern cities. However, urban agriculture is often limited by the availability of fertile and non-contaminated soils in the cities. Recycling excavated mineral wastes from building activities to construct fertile soils may be a more sustainable alternative than the importation of topsoils from rural zones. The present study aims to evaluate the possibility to grow green vegetables on soils made with excavated deep horizon of soils and green waste compost. During three consecutive seasons, we tested in situ the effects of different amounts of compost (10, 20, and 30%) and the addition of an earthworm species (Lumbricus terrestris) on the production of lettuce (Lactuca sativa L.), arugula (Eruca sativa Mill.), and spinach (Spinacia oleracea L.) in mono- and co-culture. Our results demonstrate that it is possible to reuse mineral and organic urban wastes to engineer soils adapted to agriculture. Here, we observed that higher doses of compost significantly increased plant biomass, especially when earthworms were introduced. For example, in the autumn, going from 10 to 30% of compost in the soil mixture allows to multiply by 2 the arugula biomass, and even by 4 in the presence of earthworms. These results were partly due to the positive effects of these two factors on soil physical properties (micro- and macro-porosity). This preliminary study also showed that some plants (arugula) are more adapted than others (lettuce) to the soil properties and that it only takes few months to get the highest yields. These promising results for the development of urban agricultures encourage to test many other combination of plant and earthworm species but also to conduct experiments over long-term periods.

Experimental and numerical evaluation of the effect of micro-aeration on the thermal properties of chocolate

Thermal properties, such as thermal conductivity, specific heat capacity and latent heat, influence the melting and solidification of chocolate. The accurate prediction of these properties for micro-aerated chocolate products with varying levels of porosity ranging from 0% to 15% is beneficial for understanding and control of heat transfer mechanisms during chocolate manufacturing and food oral processing. The former process is important for the final quality of chocolate and the latter is associated with sensorial attributes, such as grittiness, melting time and flavour. This study proposes a novel multiscale finite element model to accurately predict the temporal and spatial evolution of temperature across chocolate samples. The model is evaluated via heat transfer experiments at temperatures varying from 16 °C to 45 °C. Both experimental and numerical results suggest that the rate of heat transfer within the micro-aerated chocolate is reduced by 7% when the 15% micro-aerated chocolate is compared to its solid counterpart. More specifically, on average, the thermal conductivity decreased by 20% and specific heat capacity increased by 10% for 15% micro-aeration, suggesting that micro-pores act as thermal barriers to heat flow. The latter trend is unexpected for porous materials and thus the presence of a third phase at the pore's interface is proposed which might store thermal energy leading to a delayed release to the chocolate system. The developed multiscale numerical model provides a design tool to create pore structures in chocolate with optimum melting or solidifying response.

Support From the Top: Diverse Leadership Partners for Sustained STAR-VA Implementation

The STAR-VA program was an initiative out of what is now called the VA Office of Mental Health and Suicide Prevention, partnering with the national Offices of Geriatrics and Extended Care and Nursing Services. Ongoing collaboration with these national, as well as regional and medical-center-level leaders, has been critical for informing program implementation and dissemination strategies. We will discuss several key partnered strategies, including (1) linking STAR-VA to national CLC systematic quality improvement efforts; (2) engaging national inter-office program leaders in decisions about outreach to and inclusion of facilities in STAR-VA training and implementation; (3) training local STAR-VA champions on strategies for engaging local leadership support; (4) briefing leaders across the system with program updates; and (5) using national VA data to inform STAR-VA sustained implementation. Discussion will address challenges and opportunities for engaging leadership stakeholders in facilitating sustained implementation of evidence-based programs.

Whole Team, Whole Person High-Involvement Quality Improvement Training for VA Community Living Center Leaders

Long-term care is a challenging environment for quality improvement due to the high resident acuity, wide variation in resident needs, and wide variation in types and backgrounds of the large staff across three daily shifts. We report results from a learning collaborative undertaken to improve care quality and staff quality improvement skills in the VA CLCs through development of high functioning relationally coordinated teams operating in accord with person-centered care principles. The collaborative included 27 CLCs. Over 9 months leadership teams completed action assignments supported by 5 workshops and regular group coaching calls. Evaluation included fidelity monitoring (attendance, mid- and final progress reports), satisfaction questionnaires, and review of the VA quality measures (CLC Compare). Pre-post participant evaluations revealed a significant increase in positive responses to the question “to what extent do you think applying these new skills/knowledge will improve quality in your CLC?” and positive responses trending toward significance in ratings of abilities to apply new skills. Open-ended survey comments were positive and indicated change in understanding and practice: “utilizing the daily huddle to facilitate real time communication afforded the team a proactive approach to providing care and reducing acute exacerbations. We are able to avert, evaluate as a real time team and make it happen in the now not as a look back.”; “definitely unified front-line staff and CLC leadership.” Some changes were achieved in CLC Compare quality scores (e.g., falls with major injury rate had a 9.6 reduction (average rate = 3.39 pre, 3.07 post)).

Distress Behavior Conversations: Supporting Whole Person Whole Team Responses in VA Community Living Centers

Heightened isolation during the pandemic has exacerbated the stress, anxiety, and adverse consequences through the loss of family connections older people experience in LTC. Heavy workload and staffing shortage limit staff’s capacity to assist residents in accessing regular virtual visits. Using a Collaborative Action Research (CAR) approach, this project aims to assess the implementation of a telepresence robot, Double 3 to help residents connect with their families. CAR allows careful planning of implementation with stakeholders (patient and family partners, staff, and decision-makers), tailoring adaption to the complex LTC environment. We will program path planning to allow efficient movement between target destinations (residents' rooms) and the charging dock. For example, the robot will go to a resident’s room every morning or evening to help the resident to make a virtual call with family. The project involves three phases (a) Observe and Reflect, (b) Act and Adapt, (c) Evaluate. We work with two Canadian LTC homes in British Columbia to investigate feasibility and acceptability. CAR emphasizes research with, rather than research on people. Meaningful engagement with patient and family partners, frontline staff, and decision-makers at each site throughout the whole project will ensure the project will meet the local needs. Anticipated resident outcomes include improved quality of life, mood, perceived loneliness, perceived social support, and acceptance. Anticipated staff outcomes include perceived ease of use, and acceptability.

Quality Improvement Efforts in VA Community Living Centers Increased Following Public Reporting of Performance

In 2018, the US Department of Veterans Affairs (VA) began publicly reporting performance ratings for its 134 Community Living Centers (CLCs; nursing homes) based on health inspections, staffing, and clinical quality measures. CLCs operate within a large, integrated healthcare system with unique financial and market incentives. Although public reporting has led to quality improvements in non-VA nursing homes, we do not know whether CLCs respond to public reporting differently than private sector nursing homes. To address this knowledge gap, we used a comparative case study approach involving 3 purposively selected CLCs with varied (low, medium, high) performance ratings. We conducted semi-structured interviews with personnel (n=12) responsible for quality measurement and improvement. Interviews focused on opinions of public reporting, actions taken to improve performance ratings, and motivations for change. Participants indicated public reporting improved transparency and provided an “outside perspective” on their performance. Strategies to improve performance ratings involved 1) data/information, 2) individual roles, and 3) teamwork/communication. All 3 CLCs made changes in these areas, yet respondents in the higher performing CLCs described implementing more strategies immediately after learning their ratings. Respondents in all 3 CLCs described being motivated to deliver good care and achieve public ratings that reflected the care they provided. This meant addressing internal weaknesses that contributed to lower scores for 2 CLCs. Our findings suggest public reporting may improve internal data collection, reporting, and quality improvement efforts in CLCs. They highlight the potential positive impact of public reporting in prompting quality improvement in nursing homes.

Case Management in Primary Care Associated With Service Use by Adults With Dementia and Comorbidities

Community-dwelling adults with dementia are at higher risks than counterpart without dementia of poor health outcomes, and those with dementia and co-occurring conditions face even greater risks. Optimal treatment for dementia includes functional and psychosocial support through long-term services and supports (LTSS), but use remains low. Our study investigated whether case management provided in primary care and in dementia care settings facilitated LTSS use for Veterans with dementia and comorbidities. We performed a cross-sectional analysis of 2019 VA-paid health care on a cohort of Veterans with dementia, defined by clinical diagnoses (International Classification of Disease, Tenth Revision). Receipt of case management was measured by whether or not a Veteran enrolled in a VA (1) home-based primary care, (2) geriatric primary care, or (3) dementia clinic. Comorbidities were measured by an adapted Elixhauser comorbidities index and dichotomized as ≤ 3 or ≥ 4 comorbidities. LTSS use was measured by whether or not Veterans used home health, home respite, adult day care, hospice, or veteran-directed care. Multivariate logistic regressions showed that LTSS use was higher for enrollees in each case management program compared to Veterans not enrolled in any. LTSS use was also higher for enrollees in each primary care program with more comorbidities than program counterparts with fewer comorbidities. Case management in primary care settings may facilitate functional and psychosocial support to meet dementia and non-dementia related needs for adults who have dementia with comorbidities.

Only the Co-Transcriptional Activity of β-Catenin Is Required for the Local Regulatory Effects in Hypertrophic Chondrocytes on Developmental Bone Modeling

In hypertrophic chondrocytes, β-catenin has two roles. First, it locally suppresses the differentiation of osteoclasts at the chondro-osseous junction by maintaining the pro-osteoclastic factor receptor activator of NF-κB ligand (RANKL) at low levels. Second, it promotes the differentiation of osteoblast-precursors from chondrocytes. Yet, β-catenin is a dual-function protein, which can either participate in cell-cell adherens junctions or serve as a transcriptional co-activator in canonical Wnt signaling interacting with T-cell factor/lymphoid enhancer-binding factor (TCF/LEF) transcription factors. Hence, whenever studying tissue-specific requirements of β-catenin using a conventional conditional knockout approach, the functional mechanisms underlying the defects in the conditional mutants remain ambiguous. To decipher mechanistically which of the two molecular functions of β-catenin is required in hypertrophic chondrocytes, we used different approaches. We analyzed the long bones of newborn mice carrying either the null-alleles of Lef1 or Tcf7, or mice in which Tcf7l2 was conditionally deleted in the hypertrophic chondrocytes, as well as double mutants for Lef1 and Tcf7l2, and Tcf7 and Tcf7l2. Furthermore, we analyzed Ctnnb1 mutant newborns expressing a signaling-defective allele that retains the cell adhesion function in hypertrophic chondrocytes. None of the analyzed Tcf/Lef single or double mutants recapitulated the previously published phenotype upon loss of β-catenin in hypertrophic chondrocytes. However, using this particular Ctnnb1 allele, maintaining cell adhesion function, we show that it is the co-transcriptional activity of β-catenin, which is required in hypertrophic chondrocytes to suppress osteoclastogenesis and to promote chondrocyte-derived osteoblast differentiation. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

A pharmacist-led pilot using a performance dashboard to improve psychotropic medication use in a skilled nursing facility

Objectives

Inappropriate use of psychotropic medications in the elderly, particularly those with dementia, is a critical safety and quality concern. This pilot quality improvement study used a novel Department of Veterans Affairs (VA) Psychotropic Drug Safety Initiative performance dashboard (PDSI dashboard) to implement a pharmacist-led intervention to improve psychotropic medication prescribing practices in a VA skilled nursing facility (SNF). While clinical dashboard data have become commonplace, literature describing successful implementation for improved clinical care is scant.

Methods

This study took place from November 2015 to February 2016 at a 112-bed VA SNF. A pharmacist used the PDSI dashboard to identify ‘actionable’ patients with potentially inappropriate psychotropic prescribing and then completed chart reviews to confirm clinical indications. The pharmacist provided recommendations to providers for dose reductions or deprescribing via in-person communication and notes written in the electronic medical record. SNF providers completed anonymous surveys about their experience in receiving recommendations.

Results

Over a 5-month period, the PDSI dashboard identified 21 patients with potentially inappropriate psychotropic medication use, with approximately one new patient identified each week. Prescribing recommendations were accepted 66% of the time. All seven SNF providers reported that recommendations were helpful in improving their psychotropic prescribing practices.

Conclusions

The PDSI dashboard was efficient and effective in identifying patients at risk for inappropriate use of psychotropic medications. A clinical pharmacist was essential for implementing and communicating recommendations from the dashboard to providers.

Effect of micro-aeration on the mechanical behaviour of chocolates and implications for oral processing

Aeration in foods has been widely utilised in the food industry to develop novel foods with enhanced sensorial characteristics. Specifically, aeration at the micron-sized scale has a significant impact on the microstructure where micro-bubbles interact with the other microstructural features in chocolates. This study aims to determine the effect of micro-aeration on the mechanical properties of chocolate products, which are directly correlated with textural attributes such as hardness and crumbliness. Uniaxial compression tests were performed to determine the mechanical properties such as Poisson's ratio, Young's modulus and macroscopic yield strength together with fracture tests to estimate the fracture toughness. In vivo mastication tests were also conducted to investigate the link between the fracture properties and fragmentation during the first two chewing cycles. The uniaxial stress-strain data were used to calibrate a viscoplastic constitutive law. The results showed that micro-aeration significantly affects mechanical properties such as Young's modulus, yield and fracture stresses, as well as fracture toughness. In addition, it enhances the brittle nature of the chocolate, as evidenced by lower fracture stress but also lower fracture toughness leading to higher fragmentation, in agreement with observations in the in vivo mastication tests. As evidenced by the XRT images and the stress-strain measurements micro-aeration hinders the re-arrangement of the microscopic features inside the chocolate during the material's deformation. The work provides a new insight of the role of bubbles on the bulk behaviour of complex multiphase materials, such as chocolates, and defines the mechanical properties which are important input parameters for the development of oral processing simulations.

Loss of the WNT9a ligand aggravates the rheumatoid arthritis-like symptoms in hTNF transgenic mice

Agonists and antagonists of the canonical Wnt signaling pathway are modulators of pathological aspects of rheumatoid arthritis (RA). Their activity is primarily modifying bone loss and bone formation, as shown in animal models of RA. More recently, modulation of Wnt signaling by the antagonist Sclerostin has also been shown to influence soft-tissue-associated inflammatory aspects of the disease pointing towards a role of Wnt signaling in soft-tissue inflammation as well. Yet, nothing is known experimentally about the role of Wnt ligands in RA. Here we provide evidence that altering Wnt signaling at the level of a ligand affects all aspects of the rheumatoid arthritic disease. WNT9a levels are increased in the pannus tissue of RA patients, and stimulation of synovial fibroblasts (SFB) with tumor necrosis factor (TNF) leads to increased transcription of Wnt9a. Loss of Wnt9a in a chronic TNF-dependent RA mouse model results in an aggravation of disease progression with enhanced pannus formation and joint destruction. Yet, loss of its activity in the acute K/BxN serum-transfer induced arthritis (STIA) mouse model, which is independent of TNF signaling, has no effect on disease severity or progression. Thus, suggesting a specific role for WNT9a in TNF-triggered RA. In synovial fibroblasts, WNT9a can activate the canonical Wnt/β-catenin pathway, but it can also activate P38- and downregulate NFκB signaling. Based on in vitro data, we propose that loss of Wnt9a creates a slight proinflammatory and procatabolic environment that boosts the TNF-mediated inflammatory response.

Variation in Target Attainment of Beta-Lactam Antibiotic Dosing Between International Pediatric Formularies

As antimicrobial susceptibility of common bacterial pathogens decreases, ensuring optimal dosing may preserve the use of older antibiotics in order to limit the spread of resistance to newer agents. Beta-lactams represent the most widely prescribed antibiotic class, yet most were licensed prior to legislation changes mandating their study in children. As a result, significant heterogeneity persists in the pediatric doses used globally, along with quality of evidence used to inform dosing. This review summarizes dosing recommendations from the major pediatric reference sources and tries to answer the questions: Does beta-lactam dose heterogeneity matter? Does it impact pharmacodynamic target attainment? For three important severe clinical infections-pneumonia, sepsis, and meningitis-pharmacokinetic models were identified for common for beta-lactam antibiotics. Real-world demographics were derived from three multicenter point prevalence surveys. Simulation results were compared with minimum inhibitory concentration distributions to inform appropriateness of recommended doses in targeted and empiric treatment. While cephalosporin dosing regimens are largely adequate for target attainment, they also pose the most risk of neurotoxicity. Our review highlights aminopenicillin, piperacillin, and meropenem doses as potentially requiring review/optimization in order to preserve the use of these agents in future.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Dementia care providers’ delivery of family caregiver support during COVID-19

Family caregiver support is a cornerstone of dementia care. Yet the transition to virtual care during COVID raised questions about the ability of dementia care teams to maintain caregiver support services. We surveyed Veterans Affairs clinicians about dementia caregiver support delivery following the COVID surge in the six New England states. 38 out of 68 (55%) clinicians from 6 states responded in June and July 2020. We found: 1) Clinicians continued providing the same types of support services for family caregivers before and after COVID, with over 50% of providers interacting with caregivers daily or multiple times per week. The most prevalent services were caregiver needs assessments, information and referrals, and assistance with accessing services. Two-thirds reported continuing to offer caregiver skills training and counseling, including peer support groups. 2) Caregiver support modality changed, most frequently through the combined use of phone and video, followed by only phone, and rarely, by only video. 3) Providers indicated that phone, more than video, increased to replace in-person interactions, because of multiple factors: caregivers (who continued to call for support on an as-needed basis but declined video encounters), providers (who began to provide group support via phone), and service factors (ad hoc versus scheduled encounters). Results suggest clinicians continued providing caregiver support despite suspension of in-person interactions, but future research is needed to assess the impacts of caregiver support delivery mostly by phone and factors underlying the limited use of video in delivering caregiver support.

Whole-Person, Whole-Team Approach to Quality Improvement: Why Person-Centered Care Matters

The Department of Veterans Affairs (VA) began its culture transformation journey in 2006, supporting its nursing homes in providing high-quality, person-centered care in person-centered environments. We implemented a quality improvement intervention to support frontline staff from low-performing VA nursing homes in providing high-quality care using a whole-person, whole-team approach. The intervention consisted of a bundle with four components: 1) specialized frontline staff huddles that encouraged high-quality frontline staff communication and collaboration, 2) micro-root cause analyses and targeted interventions to promote resident sleep and reduce resident falls through individualized care, 3) in-depth frontline conversations regarding residents’ distress behaviors and mobility, and 4) targeted, team-based, person-centered performance improvement projects. The intervention was implemented at 8 low-performing VA nursing homes (August 2018 - April 2019) via in-person and virtual sessions and facilitated through CLC-based champions and intervention team-based coaches. We monitored the intervention’s impact using pre-post Centers for Medicare and Medicaid Services quality star ratings. We also conducted 17 post-intervention interviews with key informants at 7 participating nursing homes and conducted a content analysis of the data. Pre intervention, all 8 nursing homes had a history of being 1 or 2 stars in overall quality. Post intervention, 3 homes increased 1 star; 1 home increased 2 stars; 2 homes increased 3 stars; 2 homes increased 4 stars. Post intervention, participants perceived improved delivery of person-centered care (e.g., providing individualized sleep hygiene, de-implementing alarms). Our findings suggest a whole-person, whole-team intervention can effectively and efficiently improve both person-centered care and care quality.

IRX3 and IRX5 Inhibit Adipogenic Differentiation of Hypertrophic Chondrocytes and Promote Osteogenesis

Maintaining the correct proportions of different cell types in the bone marrow is critical for bone function. Hypertrophic chondrocytes (HCs) and osteoblasts are a lineage continuum with a minor contribution to adipocytes, but the regulatory network is unclear. Mutations in transcription factors, IRX3 and IRX5, result in skeletal patterning defects in humans and mice. We found coexpression of Irx3 and Irx5 in late-stage HCs and osteoblasts in cortical and trabecular bone. Irx3 and Irx5 null mutants display severe bone deficiency in newborn and adult stages. Quantitative analyses of bone with different combinations of functional alleles of Irx3 and Irx5 suggest these two factors function in a dosage-dependent manner. In Irx3 and Irx5 nulls, the amount of bone marrow adipocytes was increased. In Irx5 nulls, lineage tracing revealed that removal of Irx3 specifically in HCs exacerbated reduction of HC-derived osteoblasts and increased the frequency of HC-derived marrow adipocytes. β-catenin loss of function and gain of function specifically in HCs affects the expression of Irx3 and Irx5, suggesting IRX3 and IRX5 function downstream of WNT signaling. Our study shows that IRX3 and IRX5 regulate fate decisions in the transition of HCs to osteoblasts and to marrow adipocytes, implicating their potential roles in human skeletal homeostasis and disorders.

Wnt signaling and Loxl2 promote aggressive osteosarcoma

Osteosarcoma (OS) is the most frequent primary malignant bone tumor in urgent need of better therapies. Using genetically modified mouse models (GEMMs), we demonstrate that Wnt signaling promotes c-Fos-induced OS formation via the actions of the collagen-modifying enzyme Loxl2. c-Fos/AP-1 directly regulates the expression of the Wnt ligands Wnt7b and Wnt9a in OS cells through promoter binding, and Wnt7b and Wnt9a in turn promote Loxl2 expression in murine and human OS cells through the transcription factors Zeb1 and Zeb2. Concordantly, inhibition of Wnt ligand secretion by inactivating the Wnt-less (Wls) gene in osteoblasts in c-Fos GEMMs either early or in a therapeutic setting reduces Loxl2 expression and progression of OS. Wls-deficient osteosarcomas proliferate less, are less mineralized and are enriched in fibroblastic cells surrounded by collagen fibers. Importantly, Loxl2 inhibition using either the pan-Lox inhibitor BAPN or a specific inducible shRNA reduces OS cell proliferation in vitro and decreases tumor growth and lung colonization in murine and human orthotopic OS transplantation models. Finally, OS development is delayed in c-Fos GEMMs treated with BAPN or with specific Loxl2 blocking antibodies. Congruently, a strong correlation between c-FOS, LOXL2 and WNT7B/WNT9A expression is observed in human OS samples, and c-FOS/LOXL2 co-expression correlates with OS aggressiveness and decreased patient survival. Therefore, therapeutic targeting of Wnt and/or Loxl2 should be considered to potentiate the inadequate current treatments for pediatric, recurrent, and metastatic OS.

Muscle defects due to perturbed somite segmentation contribute to late adult scoliosis

Scoliosis is an abnormal bending of the body axis. Truncated vertebrae or a debilitated ability to control the musculature in the back can cause this condition, but in most cases the causative reason for scoliosis is unknown (idiopathic). Using mutants for somite clock genes with mild defects in the vertebral column, we here show that early defects in somitogenesis are not overcome during development and have long lasting and profound consequences for muscle fiber organization, structure and whole muscle volume. These mutants present only mild alterations in the vertebral column, and muscle shortcomings are uncoupled from skeletal defects. None of the mutants presents an overt musculoskeletal phenotype at larval or early adult stages, presumably due to compensatory growth mechanisms. Scoliosis becomes only apparent during aging. We conclude that adult degenerative scoliosis is due to disturbed crosstalk between vertebrae and muscles during early development, resulting in subsequent adult muscle weakness and bending of the body axis.

β-Catenin safeguards the ground state of mousepluripotency by strengthening the robustness of the transcriptional apparatus

Mouse embryonic stem cells cultured with MEK (mitogen-activated protein kinase kinase) and GSK3 (glycogen synthase kinase 3) inhibitors (2i) more closely resemble the inner cell mass of preimplantation blastocysts than those cultured with SL [serum/leukemia inhibitory factor (LIF)]. The transcriptional mechanisms governing this pluripotent ground state are unresolved. Release of promoter-proximal paused RNA polymerase II (Pol2) is a multistep process necessary for pluripotency and cell cycle gene transcription in SL. We show that β-catenin, stabilized by GSK3 inhibition in medium with 2i, supplies transcriptional coregulators at pluripotency loci. This selectively strengthens pluripotency loci and renders them addicted to transcription initiation for productive gene body elongation in detriment to Pol2 pause release. By contrast, cell cycle genes are not bound by β-catenin, and proliferation/self-renewal remains tightly controlled by Pol2 pause release under 2i conditions. Our findings explain how pluripotency is reinforced in the ground state and also provide a general model for transcriptional resilience/adaptation upon network perturbation in other contexts.

Diffuse glioneuronal tumour with oligodendroglioma-like features and nuclear clusters (DGONC) - a molecularly defined glioneuronal CNS tumour class displaying recurrent monosomy 14

AIMS

DNA methylation-based central nervous system (CNS) tumour classification has identified numerous molecularly distinct tumour types, and clinically relevant subgroups among known CNS tumour entities that were previously thought to represent homogeneous diseases. Our study aimed at characterizing a novel, molecularly defined variant of glioneuronal CNS tumour.

PATIENTS AND METHODS

DNA methylation profiling was performed using the Infinium MethylationEPIC or 450 k BeadChip arrays (Illumina) and analysed using the 'conumee' package in R computing environment. Additional gene panel sequencing was also performed. Tumour samples were collected at the German Cancer Research Centre (DKFZ) and provided by multinational collaborators. Histological sections were also collected and independently reviewed.

RESULTS

Genome-wide DNA methylation data from >25 000 CNS tumours were screened for clusters separated from established DNA methylation classes, revealing a novel group comprising 31 tumours, mainly found in paediatric patients. This DNA methylation-defined variant of low-grade CNS tumours with glioneuronal differentiation displays recurrent monosomy 14, nuclear clusters within a morphology that is otherwise reminiscent of oligodendroglioma and other established entities with clear cell histology, and a lack of genetic alterations commonly observed in other (paediatric) glioneuronal entities.

CONCLUSIONS

DNA methylation-based tumour classification is an objective method of assessing tumour origins, which may aid in diagnosis, especially for atypical cases. With increasing sample size, methylation analysis allows for the identification of rare, putative new tumour entities, which are currently not recognized by the WHO classification. Our study revealed the existence of a DNA methylation-defined class of low-grade glioneuronal tumours with recurrent monosomy 14, oligodendroglioma-like features and nuclear clusters.

Favourable growth conditions for the preparation of bulk AlN single crystals by PVT

A high seed temperature (2251 °C) reveals the highest deep UV transparency (α_265nm = 27 cm⁻¹), a high structural perfection (EPD = 9 × 10³ cm⁻²) and a suitable growth rate (R = 200 μm h⁻¹).

1053. De-Implementing Low-Value Antibiotic Prescribing Across Levels of Care

Background

Performing urinalyses and urine cultures in asymptomatic patients is one of the most common reasons for inappropriate antibiotic use. However, de-implementing this practice has been difficult, especially for clinical scenarios deemed to be high risk for infectious complications, such as among patients with delirium or those undergoing orthopedic implant surgery.

Methods

Using the dual-process theory framework “Developing De-Implementation Strategies Based on Un-Learning and Substitution,” an educational intervention citing new IDSA guidelines and providing a pneumonic “ABCs of ASB” was created and delivered didactically to providers. The goal was to increase performance of evidence-based prevention actions in place of low-value urine screening and treating of asymptomatic patients. Clinical providers and staff (MD, RN, APRN, trainees) in 3 different levels of care (acute inpatient, long-term, and outpatient) were included. A web-based anonymous and confidential pre- and post-question format was delivered to assess influence on provider behavior.

Results

Responses from a range of 250–279 unique providers were collected. For scenario #1 (patient with delirium and a positive urine culture and no other infectious symptoms), the option to give antibiotics was reduced by 45% pre to 4% post, Chi-square P < 0.01). For scenario #2 (patient having a knee replacement and positive preoperative urine culture, no other symptoms) the option to give antibiotics was reduced by the same magnitude (~50%) but a lower absolute number (67% pre and 33% post, chi-square P < 0.01). Changes in predicted behavior were similar across levels of care.

Conclusion

Substituting evidence-based practices in place of low-value practices is an appealing framework for influencing provider behavior. Our work demonstrates that education can successfully reduce the intention to use antibiotics for asymptomatic patients with positive urine cultures.

Disclosures

All authors: No reported disclosures.

Cell death induced autophagy contributes to terminal differentiation of skin and skin appendages

In the adult mammalian skin, cells are constantly renewing, differentiating and moving upward, to finally die in a yet not fully understood manner. Here, we provide evidence that macroautophagy/autophagy has a dual role in the skin. In addition to its known catabolic protective role as an evolutionary conserved upstream regulator of lysosomal degradation, we show that autophagy induced cell death (CDA) occurs in epithelial lineage-derived organs, such as the inter-follicular epidermis, the sebaceous- and the Harderian gland. By utilizing GFP-LC3 transgenic and ATG7-deficient mice, we show that CDA is initiated during terminal differentiation at a stage when the cells have become highly resistant to apoptosis. In these transitional cells, the Golgi compartment expands, which accounts for the formation of primary lysosomes, and the nucleus starts to condense. During CDA a burst of autophagosome formation is observed, first the endoplasmic reticulum (ER) is phagocytosed followed by autophagy of the nucleus. By this selective form of cell death, most of the cytoplasmic organelles are degraded, but structural proteins remain intact. In the absence of autophagy, consequently, parts of the ER, ribosomes, and chromatin remain. A burst of autophagy was stochastically observed in single cells of the epidermis and collectively in larger areas of ductal cells, arguing for a coordinated induction. We conclude that autophagy is an integral part of cell death in keratinocyte lineage cells and participates in their terminal cell fate.

Abbreviations: Atg7: autophagy related 7; BECN1: beclin 1; CDA: cell death-induced autophagy; Cre: Cre-recombinase; DAPI: 4′,6-diamidino-2-phenylindole; ER: endoplasmatic reticulum; GFP: green fluorescent protein; HaGl: haderian gland; IVL: involucrin; KRT14: keratin 14; LD: lipid droplet; LSM: laser scanning microscope; MAP1LC3/LC3: microtubule-associated protein 1 light chain 3; PN: perinuclear space; RB: residual body; rER: rough endoplasmatic reticulum; SB: sebum; SG-SC: stratum granulosum – stratum corneum; SGl: sebaceous gland; SQSTM1: sequestosome 1; TEM: transmission electron microscopy; TUNEL: terminal deoxynucleotidyl transferase dUTP nick end labelling.

A Second Career for Chondrocytes-Transformation into Osteoblasts

PURPOSE OF REVIEW

The goal of the review is to summarize the current knowledge on the process of chondrocyte-to-osteoblast transdifferentiation during endochondral bone formation and its potential implications in fracture healing and disease.

RECENT FINDINGS

Lineage tracing experiments confirmed the transdifferentiation of chondrocytes into osteoblasts. More recent studies lead to the discovery of molecules involved in this process, as well as to the hypothesis that these cells may re-enter a stem cell-like phase prior to their osteoblastic differentiation. This review recapitulates the current knowledge regarding chondrocyte transdifferentiating into osteoblasts, the developmental and postnatal events where transdifferentiation appears to be relevant, and the molecules implicated in this process.

Genetic interactions between Ror2 and Wnt9a, Ror1 and Wnt9a and Ror2 and Ror1: Phenotypic analysis of the limb skeleton and palate in compound mutants

Mutations in the human receptor tyrosine kinase ROR2 are associated with Robinow syndrome (RRS) and brachydactyly type B1. Amongst others, the shortened limb phenotype associated with RRS is recapitulated in Ror2^-/- mutant mice. In contrast, Ror1^-/- mutant mice are viable and show no limb phenotype. Ror1^-/- ;Ror2^-/- double mutants are embryonic lethal, whereas double mutants containing a hypomorphic Ror1 allele (Ror1^hyp ) survive up to birth and display a more severe shortened limb phenotype. Both orphan receptors have been shown to act as possible Wnt coreceptors and to mediate the Wnt5a signal. Here, we analyzed genetic interactions between the Wnt ligand, Wnt9a, and Ror2 or Ror1, as Wnt9a has also been implicated in skeletal development. Wnt9a^-/- single mutants display a mild shortening of the long bones, whereas these are severely shortened in Ror2^-/- mutants. Ror2^-/- ;Wnt9a^-/- double mutants displayed even more severely shortened long bones, and intermediate phenotypes were observed in compound Ror2;Wnt9a mutants. Long bones were also shorter in Ror1^hyp/hyp ;Wnt9a^-/- double mutants. In addition, Ror1^hyp/hyp ;Wnt9a^-/- double mutants displayed a secondary palate cleft phenotype, which was not present in the respective single mutants. Interestingly, 50% of compound mutant pups heterozygous for Ror2 and homozygous mutant for Ror1 also developed a secondary palate cleft phenotype.

Abstract P4-12-05: First implementation of the International Consortium of Health Outcomes Measurement standard for breast cancer at a major German university hospital using a web-based tool to measure patient reported outcomes

Purpose:

Collecting patient reported outcome (PRO) data in a systematic way enables an objective evaluation of treatments and its related outcomes. By using the disease specific questionnaires developed by the International Consortium of Health Outcome Measurement (ICHOM) this allows for comparison between physicians, hospitals and even different countries.

Methods

In November 2016 we implemented a web-based system to collect PRO data at the breast center at Charité University hospital using the ICHOM data set. All new patients who are seen at the breast center are enrolled and are answering a predefined set of questions using a tablet computer. Once they start their treatment at Charité automated emails are sent to the patient at predefined treatment points. Those emails contain a web-based link through which they can access their questionnaires.

Results

Until now we have enrolled 834 patients and initiated 2470 questionnaires. 9.44% of patients were under 40 years of age, 49.7% between 40 and 60, 39.6% between 60-80 and 1.3% over the age of 80 years. The average return rate of questionnaires is 72% without any additional intervention. When asked about preference regarding paper versus online 7.9% of the patients 50 to 60 years of age would prefer paper, 18% in the 60-70 years of age group and 21.2 % in the age group over 70 years.

Conclusion

Measuring PRO in breast cancer patients in an automated electronic version is possible across all age ranges while simultaneously achieving a high return rate.

Citation Format: Karsten MM, Speiser D, Hartmann C, Lippold K, Kirchberger V, Blohmer J-U. First implementation of the International Consortium of Health Outcomes Measurement standard for breast cancer at a major German university hospital using a web-based tool to measure patient reported outcomes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-12-05.