Cysteine protease and its inhibitor in experimentally produced squamous cell carcinomas in hairless mouse skin

Squamous cell carcinomas (SCC) were experimentally produced in hairless mouse skin, and cysteine protease and its inhibitor were simultaneously purified from extracts of 1 g of tissue of SCC and normal skin. Activity of cysteine proteinases, Mr greater than 50,000 and Mr 28,000, increased in SCC compared to those in normal skin. SCC also showed elevation of cysteine proteinase inhibitor activity and Mr 13,000 and Mr 82,000 inhibitors were purified. Mr 13,000 inhibitor was found to have biochemical properties which were the same as those of the inhibitor present in normal skin. Mr 82,000 inhibitor was not detectable in normal skin and it differed from a serum inhibitor with a similar Mr in terms of activity and stability at acidic pH. The findings suggest that the increased activity of both cysteine proteases and endogenous inhibitors may be involved in the regulatory mechanisms of malignant cell metabolism and tissue remodeling associated with SCC development.     

A Team-Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania

Introduction

Millions of patients worldwide suffer disability and death due to complications related to surgery. Many of these complications can be reduced by the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC), a simple tool that can enhance teamwork and communication and improve patient safety. Despite the evidence on benefits of its use, introducing and sustaining the use of the checklist are challenging. We present a team-based approach employed in a low-resource setting in Tanzania, which resulted in high checklist utilization and compliance rates.

Methods

We reviewed reported data from facility registers supplemented by direct observation data by mentors to evaluate the use of the WHO SSC across 40 health facilities in two regions of Tanzania between January and December 2018. We analyzed the self-reported monthly data on total number of major surgeries performed and proportion of surgeries where the checklist was used. We also analyzed the use of the SSC during direct observation by external mentors and completion rates of the SSC in a random selection of patient files during two mentorship visits between June and December 2018.

Results

During the review period, the average self-reported checklist utilization rate was 79.3% (11,564 out of 14,580 major surgeries). SSC utilization increased from 0% at baseline in January 2018 to 98% in December 2018. The proportion of checklists that were completely and correctly filled out increased between the two mentor visits from 82.1 to 92.8%, but the gain was significantly greater at health centers than at hospitals (p < 0.05). Health centers (which had one or two surgical teams) self-reported a higher checklist utilization rate than hospitals (which had multiple surgical teams), i.e., 99.4% vs 68.8% (p < 0.05).

Conclusion and recommendations

Our findings suggest that Surgical Safety Checklist implementation is feasible even in lower-resource settings. The self-reported SSC utilization rate is higher than reported in other similar settings. We attribute this finding to the team-based approach employed and the ongoing regular mentorship. We recommend use of this approach to scale-up checklist use in other regions in the country as recommended in the Ministry of Health of Tanzania’s National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

     

A profile of cardiovascular disease in northern Ontario: public health planning implications

Cardiovascular disease (CVD) is a leading cause of death in Northern Ontario and therefore considered an important issue. To this end, this paper examines CVD trends in Northern Ontario and the prevalence of known risk factors that give an insight into these trends. Ontario Health Survey 1990, Ontario Health Survey 1996, Canadian Institute for Health Information (1990-95) and Vital Statistics (1990-95) were examined. It was determined that CVD rates in Northern Ontario significantly exceeded those of the province. Further, high prevalence of modifiable risk factors, such as smoking, fat intake, physical inactivity and obesity are all experienced in Northern Ontario when compared to the province. Planning implications, as they relate to collaboration, delivery of services, determinants of health, multiple risk factors and monitoring and evaluation are also discussed.     

A Difference-in-Difference Analysis of Changes in Quality,Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot

BACKGROUND

Research on the effects of patient-centered medical homes on quality and cost of care is mixed, so further study is needed to understand how and in what contexts they are effective.

OBJECTIVE

We aimed to evaluate effects of a multi-payer pilot promoting patient-centered medical home implementation in 15 small and medium-sized primary care groups in Colorado.

DESIGN

We conducted difference-in-difference analyses, comparing changes in utilization, costs, and quality between patients attributed to pilot and non-pilot practices.

PARTICIPANTS

Approximately 98,000 patients attributed to 15 pilot and 66 comparison practices 2 years before and 3 years after the pilot launch.

MAIN MEASURES

Healthcare Effectiveness Data and Information Set (HEDIS) derived measures of diabetes care, cancer screening, utilization, and costs to payers.

KEY RESULTS

At the end of two years, we found a statistically significant reduction in emergency department use by 1.4 visits per 1000 member months, or approximately 7.9 % (p = 0.02). At the end of three years, pilot practices sustained this difference with 1.6 fewer emergency department visits per 1000 member months, or a 9.3 % reduction from baseline (p = 0.01). Emergency department costs were lower in the pilot practices after two (13.9 % reduction, p < 0.001) and three years (11.8 % reduction, p = 0.001). After three years, compared to control practices, primary care visits in the pilot practices decreased significantly (1.5 % reduction, p = 0.02). The pilot was associated with increased cervical cancer screening after two (12.5 % increase, p < 0.001) and three years (9.0 % increase, p < 0.001), but lower rates of HbA1c testing in patients with diabetes (0.7 % reduction at three years, p = 0.03) and colon cancer screening (21.1 % and 18.1 % at two and three years, respectively, p < 0.001). For patients with two or more comorbidities, similar patterns of association were found, except that there was also a reduction in ambulatory care sensitive inpatient admissions (10.3 %; p = 0.05).

CONCLUSION

Our findings suggest that a multi-payer, patient-centered medical home initiative that provides financial and technical support to participating practices can produce sustained reductions in utilization with mixed results on process measures of quality.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3521-1) contains supplementary material, which is available to authorized users.KEY WORDS: patient-centered care, primary care redesign, health care costs, quality improvementAdvocates for primary care reform have promoted patient-centered medical home (PCMH) models as a way to strengthen primary care. PCMH structures and processes, which are intended to help practices deliver patient-centered, proactive, coordinated care can be coupled with financial support and accountability for a defined population of patients.¹ PCMHs are intended to transform the business model of primary care while improving quality of care and reducing costs, largely by reducing emergency department and hospital utilization. Medicare, Medicaid and commercial payers have launched dozens of PCMH pilots across the nation.^2,3 Two recent systematic reviews found mixed evidence that PCMH initiatives affect utilization, quality, and costs within two years.^4,5 Many studies have found evidence of improved quality based on selected process measures and reduction in emergency department visits, but the evidence for cost savings is limited. A study of Geisinger Health System’s PCMH pilot found an 18 % reduction in hospital admissions after two years of a PCMH initiative.⁶ Similarly, Group Health of Puget Sound’s pilot medical home yielded 6 % fewer hospitalizations compared with other Group Health clinics in the first year and savings of $10.30 per patient per month in the second year.⁷ While some recent evaluations have not identified significant effects of PCMH initiatives on health care utilization and cost,^8–10 the heterogeneity of PCMH interventions and contexts may lead to differential effectiveness, the patterns of which could illuminate facilitators and barriers to effective transformation.¹¹ In addition, few studies of PCMH pilots have evaluated outcomes beyond two years, even though the literature suggests that practice transformation takes time to unfold.⁸ We examined the cumulative effects of a PCMH intervention after two and three years, and endeavored to document details of both the initiative and context to enable comparison with similar studies.     

Aging rat vestibular ganglion: I. Quantitative light microscopic evaluation

This study was undertaken to quantify age-related changes in the rat vestibular ganglion. Cell number, diameter, and proximal-distal distribution based on size were evaluated. Serial 5-microns plastic sections of the vestibular ganglion from 15 female Wistar rats were examined. Rats were divided into three age groups: young (Y, 3 to 5 months, n = 5), old (0, 24 to 26 months, n = 3), and very old (VO, 28 to 31 months, n = 7). Quantitative analysis indicated no significant differences (P less than .05) in the estimated number of ganglion cells (mean: Y = 1,690, 0 = 2,257, VO = 1,678), ganglion cell profile diameters (mean: Y = 22.5 microns, n = 2,886; O = 23.7 microns, n = 2,313; VO = 22.8 microns, n = 4,061), or proximal-distal localization (proximal: 22.3 microns, 24.4 microns, 22.7 microns; middle: 22.6 microns, 23.1 microns, 22.4 microns; distal: 23.3 microns, 23.4 microns, 23.7 microns; Y, O, and VO, respectively). When pooled, the old animals tended to have slightly larger cell profiles than the other groups. We noted a dramatic age-related increase of aging pigment within the ganglion cell profiles, making the old and very old animals easily distinguishable from the young. In most of the cell profiles, the aging pigment was more or less uniformly distributed throughout the cytoplasm. However, in some, aging pigment was accumulated at one pole of the cell profile. While no typical degenerating cellular profiles were found in any of the sections, several of the ganglion cell profiles from the old animals revealed dense cytoplasm, possibly indicating an early stage of degeneration.     

Survival data and prognostic factors seen in Pakistani patients with esophageal cancer.

BACKGROUND: Esophageal cancer is common in Pakistan. An attempt has been made for the first time to look at the survival data and prognostic factors associated with esophageal cancer in this region. PATIENTS AND METHODS: We did a retrospective review of 263 cases seen at the Aga Khan University Hospital in Karachi. Data analysis was done using the Kaplan-Meier method and the Cox proportional hazard model. RESULTS: Squamous cell carcinoma was noted in 81% of the cases, whereas adenocarcinoma was the second most common. At the time of diagnosis, early-stage disease was found in 25%, locally advanced in 41% and metastatic in 34% of all cases. Mean age at diagnosis was 56 years, with 59% males and 41% females. Survival data were available in 89 cases. Median survival was 7 months. On univariate analysis, the following factors were of prognostic significance: obstruction, histology, albumin level at diagnosis, age and platelet count. On multivariate analysis, three factors were found prognostic: presence or absence of obstruction, squamous cell carcinoma versus adenocarcinoma and platelet count. CONCLUSIONS: We found that patients with squamous cell carcinoma and absence of thrombocytopenia and obstruction had a better overall survival. However, this is a limited retrospective analysis; we therefore recommend that these prognostic factors be evaluated in larger studies.     

First line nurse managers: optimizing the span of control

Span of control, the number of people reporting to a manager, is an important management concept. It determines the structure of an organization and has financial, human resource, and quality of care implications. In nursing, the first line manager fills one of the most critical roles in the administration of nursing services. For this manager to perform her responsibilities effectively, an optimal span of control is necessary. Span of control is influenced by a number of factors. By understanding these factors, we can influence them to optimize the span of control of the nurse manager.     

The challenges of evaluating health systems networks: Lessons learned from an early evaluation of the Child Health Network for the Greater Toronto Area

This article describes the first system-wide evaluation of the Child Health Network (CHN) for the Greater Toronto Area (GTA), a partnership of 29 community and hospital care providers. The CHN performance evaluation sought to identify the impact of the network on the delivery of maternal, newborn and child health services in the GTA. CHN members identified seven criteria to be evaluated (appropriate care, accessibility, effectiveness, satisfaction, integrated and coordinated care, accountability and affordability) and then collaborated in selecting measurable indicators for each criterion. Data were compiled from administrative data sets, or collected as needed. This undertaking succeeded in providing a comprehensive assessment of the network's performance, identification of strategies to improve outcomes and network sustainability, as well as practical information that will inform the important new field of network evaluation.     

Monitoring right-sided chest leads during chest pain in patients with obstructive lung disease

Isolated nondominant right coronary artery stenosis causing significant angina and right ventricular infarction has been reported previously, but the importance of monitoring right-sided precordial leads during chest pain in patients with obstructive lung disease has not been documented.