BACKGROUND:Assuring quality care is critical to the well-being and recovery of individuals receiving inpatient psychiatric treatment, yet a comprehensive map of quality inpatient care does not exist.AIMS:To isolate and describe quality elements of inpatient psychiatric treatment.METHODS:A survey queried psychiatric inpatient nursing leaders on what they considered to be critical elements of quality. The survey was emailed to 40 American Psychiatric Nurses Association members, and 39 individuals responded. In the survey, participants were asked to comment on the importance of six dimensions of quality as well as quality indicators used on their units.RESULTS:Data from this survey indicate how thought leaders conceptualized quality of inpatient care. A unifying philosophy of care was endorsed as a quality element as was structure that affords staff available time on the unit-engaging with patients. While staffing levels were viewed as important, the respondents commented on the nuances between staffing and quality. Participants endorsed the importance of involving individuals in their treatment planning as well as tapping into patients' perspectives on the treatment experience.CONCLUSIONS:The participants' responses compliment the quality literature and reinforce the need to develop a comprehensive map of quality elements. These elements interact in complex way, for instance, staffing, engagement, and teamwork is tied to the organizational structure and philosophy of care, which in turn facilitates consumer involvement in care. Thus, gauging the impact of quality on outcomes will demand consideration of the interaction of factors not just the linear relationship of one element to an outcome.

Frontal polymerization, which involves a self-propagating polymerizing reaction front, has been considered as a rapid, energy-efficient, and environmentally friendly methodology to manufacture lightweight, high-performance thermoset polymers, and composites. Previous work has reported that the introduction of thermally conductive elements can enhance the front velocity. As follow-up research, the present work investigates this problem more systemically using both numerical and experimental approaches by investigating the front shape, front width, and heat exchange when aluminum and cooper metal strips are embedded in the resin. The study reveals that the enhancement in the front velocity is mainly due to a preheating effect associated with the conductive element. Moreover, the numerical parametric study for the system size shows that the front speed increases as the system size decreases, ultimately approaching a prediction provided by a homogenized model for polymer-metal composites.

Polythiophenes (PTs) constitute a diverse array of promising materials for conducting polymer applications. However, many of the synthetic methods to produce PTs have been optimized only for the prototypical alkyl-substituted example poly(3-hexylthiophene) (P3HT). Improvement of these methods beyond P3HT is key to enabling the widespread application of PTs. In this work, P3HT and two ether-substituted PTs poly(2-dodecyl-2H,3H-thieno[3,4-b][1,4]dioxine) (PEDOT-C12) and poly(3,4-bis(hexyloxy)thiophene) (PBHOT) are synthesized by the FeCl3-initiated oxidative method under different conditions. Polymerization was carried out according to a common literature procedure (“reverse addition”) and a modified method (“standard addition”), which differ by the solvent system and the order of addition of reagents to the reaction mixture. Gel-permeation chromatography (GPC) was performed to determine the impact of the different methods on the molecular weights (Mw) and degree of polymerization (Xw) of the polymers relative to polystyrene standards. The standard addition method produced ether-substituted PTs with higher Mw and Xw than those produced using the reverse addition method for sterically unhindered monomers. For P3HT, the highest Mw and Xw were obtained using the reverse addition method. The results show the oxidation potential of the monomer and solution has the greatest impact on the yield and Xw obtained and should be carefully considered when optimizing the reaction conditions for different monomers.

Pneumatically actuated soft robots have recently shown promise for their ability to adapt to their environment. Previously, these robots have been controlled with electromechanical components, such as valves and pumps, that are typically bulky and expensive. Here, we present an approach for controlling the gaits of soft-legged robots using simple pneumatic circuits without any electronic components. This approach produces locomotive gaits using ring oscillators composed of soft valves that generate oscillating signals analogous to biological central pattern generator neural circuits, which are acted upon by pneumatic logic components in response to sensor inputs. Our robot requires only a constant source of pressurized air to power both control and actuation systems. We demonstrate this approach by designing pneumatic control circuits to generate walking gaits for a soft-legged quadruped with three degrees of freedom per leg and to switch between gaits to control the direction of locomotion. In experiments, we controlled a basic walking gait using only three pneumatic memory elements (valves). With two oscillator circuits (seven valves), we were able to improve locomotion speed by 270%. Furthermore, with a pneumatic memory element we designed to mimic a double-pole double-throw switch, we demonstrated a control circuit that allowed the robot to select between gaits for omnidirectional locomotion and to respond to sensor input. This work represents a step toward fully autonomous, electronics-free walking robots for applications including low-cost robotics for entertainment and systems for operation in environments where electronics may not be suitable.

Purpose: Multiple robotic-assisted surgeries are often performed within a single operating day; however, the impact of this practice on patient outcomes has not been examined. We aim to determine whether outcomes for robotic-assisted laparoscopic prostatectomy (RALP) differed when performed sequentially. Materials and methods: A multi-institutional, retrospective cohort study was conducted involving a total of 8 academic centers between years 2015 and 2018. Participants were adult males undergoing RALP for localized prostate cancer on operative days in which 2 RALP cases were performed sequentially by the same resident-attending team. The primary outcome of the study was presence of positive surgical margin (PSM). Secondary outcomes were lymph node yield, operative time, and estimated blood loss. The primary analysis was a random effects meta-analysis model for PSM. Results: Overall, 898 RALP cases (449 sequential pairs) were included in the study. There was no significant difference in PSM rate (27.2% vs. 30.3%, P = 0.338) between first and second case groups, respectively. Utilizing random effects meta-analysis, the second case cohort had no increased risk of PSM (OR (0.76)1.23(1.97), P = 0.40). Higher blood loss was noted in the second case cohort (186.7 ml vs. 221.7 ml, P = 0.002). Additionally, factors associated with PSM were increasing prostate specific antigen, higher percent tumor involvement, extraprostatic extension, and seminal vesicle invasion. Conclusion: Case sequence was not associated with PSM, lymph node yield, or operative time for RALP. Disease specific factors and institutional experience are associated with increased risk for positive surgical margin which can aid providers in scheduling of patients. (C) 2020 Elsevier Inc. All rights reserved.

For medieval authors who sought to retell the story of Proserpina, Claudian may have been regarded as a greater authority on the topic than the ‘great clerk’ Ovid himself.1 Even overtly ‘Ovidian’ versions of the story can sometimes reveal a hidden debt to Claudian’s De raptu Proserpinae. To this point, John Gower’s retelling in the Confessio amantis borrows from the Ovidius moralizatus by Petrus Berchorius. However, line V.1283 also contains a narrative detail that I believe has its classical antecedent in Claudian’s unfinished epic. The line in question recounts how the goddess Ceres, just prior to her daughter’s abduction by Pluto, instructs Proserpina to acquire the skills of weaving and spinning. Gower’s concise 26-line retelling of the story (with my emphasis at line V.1283) reads:

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy II (PD43)1 Apr 2020PD43-02 THE IMPACT OF CASE ORDER ON POSITIVE SURGICAL MARGINS FOR PROSTATE CANCER: A MULTI-INSTITUTIONAL ANALYSIS Laura Bukavina, MD MPH* Kirtishri Mishra, MD Amr Mahran, MD MS Sarah Markt, ScD MPH Fredrick Schumacher, PhD MPH Britt Conroy, MD PhD JD MS Robert Abouassaly, MD MS Gregory MacLennan, MD Garrett Smith, MD Elizabeth Ferry, MD Daniel Wong, MS Yair Lotan, MD Claus Roehrborn, MD David Sharp, MD Chaparala Hemant, MD Nayan Shah, BS Kareem Alazem, MD Ali Moinzadeh, MD, Burlington, MA Brittany Adamic, MD Gregory Zagaya, MD Puneet Kang, BS Holly Lawry, BS Benjamin Lee, MD Adam Callaway, MD MPH Jason Jankowski, andMD Lee PonskyMD Laura BukavinaLaura Bukavina More articles by this author , Kirtishri MishraKirtishri Mishra More articles by this author , Amr MahranAmr Mahran More articles by this author , Sarah MarktSarah Markt More articles by this author , Fredrick SchumacherFredrick Schumacher More articles by this author , Britt ConroyBritt Conroy More articles by this author , Robert AbouassalyRobert Abouassaly More articles by this author , Gregory MacLennanGregory MacLennan More articles by this author , Garrett SmithGarrett Smith More articles by this author , Elizabeth FerryElizabeth Ferry More articles by this author , Daniel WongDaniel Wong More articles by this author , Yair LotanYair Lotan More articles by this author , Claus RoehrbornClaus Roehrborn More articles by this author , David SharpDavid Sharp More articles by this author , Chaparala HemantChaparala Hemant More articles by this author , Nayan ShahNayan Shah More articles by this author , Kareem AlazemKareem Alazem More articles by this author , Ali MoinzadehAli Moinzadeh More articles by this author , Brittany AdamicBrittany Adamic More articles by this author , Gregory ZagayaGregory Zagaya More articles by this author , Puneet KangPuneet Kang More articles by this author , Holly LawryHolly Lawry More articles by this author , Benjamin LeeBenjamin Lee More articles by this author , Adam CallawayAdam Callaway More articles by this author , Jason JankowskiJason Jankowski More articles by this author , and Lee PonskyLee Ponsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000930.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Our aim was to evaluate whether sequential surgeries result in worse outcomes, such as positive surgical margins (PSM), in patients undergoing robotic-assisted laparoscopic prostatectomy (RALP), by comparing the second surgery to the first. METHODS: We retrospectively analyzed 898 RALP cases (449 sequential pairs) across eight institutions, from 1/1/2015-07/1/2018. Pooling the data across eight institutions, we calculated odds ratio (OR) and 95% confidence intervals (95% CI) using multivariable logistic regression models, adjusting for age, BMI, PSA, Grade, Tumor Involvement, EPE, and SVI, modeling PSM as the dependent variable, and case sequence as the independent variable of interest. Due to potential heterogeneity between institutions, we then conducted a meta-analysis to calculate a random-effects OR . RESULTS: A total of 898 RALP cases were included in this study, across 8 institutions. There were no differences between the first and the second cases of the day in PSA (6.2 ng/mL vs 6.3 ng/ml) total lymph node yield (12.0 vs. 11.0), seminal vesicle invasion (49% vs 52%), operative time (216.0 mins vs 220.0 mins), BMI (28.4 kg/m2 vs 28.6 kg/m2), prostate volume (45.1 g vs 45.2 g) and positive surgical margin rate (n=121 vs n=135). The second case of the day more likely to have higher prostatic involvement (p= 0.02), as well as higher blood loss (p= 0.25). In multivariable models, there were no differences in positive surgical margin (PSM) between the first and the second cases of the day. However, SVI (OR 1.92), EPE (OR 2.05), tumor involvement (OR 1.03), PSA (OR 1.02) as well as individual institution were statistically significantly associated with an increased risk of positive surgical margin. CONCLUSIONS: Data from our multi-institutional study suggests no statistically significant difference in lymph node yield, operative time, or PSM between the first and the second RALP of the day. Despite the lack of statistical significance by conventional parameters, there is a strong trend for increased rate of PSM in the second prostatectomy of the day in select patients. Disease specific factors such as EPE, SVI, PSA, tumor involvement as well as institutional experience are all associated with increased risk for positive surgical margin. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e899-e900 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Laura Bukavina More articles by this author Kirtishri Mishra More articles by this author Amr Mahran More articles by this author Sarah Markt More articles by this author Fredrick Schumacher More articles by this author Britt Conroy More articles by this author Robert Abouassaly More articles by this author Gregory MacLennan More articles by this author Garrett Smith More articles by this author Elizabeth Ferry More articles by this author Daniel Wong More articles by this author Yair Lotan More articles by this author Claus Roehrborn More articles by this author David Sharp More articles by this author Chaparala Hemant More articles by this author Nayan Shah More articles by this author Kareem Alazem More articles by this author Ali Moinzadeh More articles by this author Brittany Adamic More articles by this author Gregory Zagaya More articles by this author Puneet Kang More articles by this author Holly Lawry More articles by this author Benjamin Lee More articles by this author Adam Callaway More articles by this author Jason Jankowski More articles by this author Lee Ponsky More articles by this author Expand All Advertisement PDF downloadLoading ...

Background: Evaluating women with symptoms suggestive of coronary artery disease (CAD) remains challenging. A blood-based precision medicine test yielding an age/sex/gene expression score (ASGES) has shown clinical validity in the diagnosis of obstructive CAD. We assessed the effect of the ASGES on the management of women with suspected obstructive CAD in a community-based registry. Materials and Methods: The prospective PRESET (A Registry to Evaluate Patterns of Care Associated with the Use of Corus® CAD in Real World Clinical Care Settings) Registry (NCT01677156) enrolled 566 patients presenting with symptoms suggestive of stable obstructive CAD from 21 United States primary care practices from 2012 to 2014. Demographics, clinical characteristics, and referrals to cardiology or further functional and/or anatomical cardiac studies after ASGES testing were collected for this subgroup analysis of women from the PRESET Registry. Patients were followed for 1-year post-ASGES testing. Results: This study cohort included 288 women with a median age 57 years. The median body mass index was 29.2, with hyperlipidemia and hypertension present in 48% and 43% of patients, respectively. Median ASGES was 8.5 (range 1-40), with 218 (76%) patients having low (≤15) ASGES. Clinicians referred 9% (20/218) low ASGES versus 44% (31/70) elevated ASGES women for further cardiac evaluation (odds ratio 0.14, p < 0.0001, adjusted for patient demographics and clinical covariates). Across the score range, higher ASGES were associated with a higher likelihood of posttest cardiac referral. At 1-year follow-up, low ASGES women experienced fewer major adverse cardiac events than elevated ASGES women (1.3% vs. 4.2% respectively, p = 0.16). Conclusions: Incorporation of ASGES into the diagnostic workup demonstrated clinical utility by helping clinicians identify women less likely to benefit from further cardiac evaluation.

PURPOSE The evaluation of obstructive coronary artery disease (CAD) is inefficient and costly. Previous studies of an age/sex/gene expression score (ASGES) in this diagnostic workup have shown a 96% negative predictive value, as well as an 85% decreased likelihood of cardiac referral among low-score outpatients at 45 days. The objective was to explore the one-year cost implications of ASGES use among symptomatic outpatients. DESIGN A prospective PRESET Registry (NCT01677156) enrolled stable, nonacute adult patients presenting with symptoms suggestive of obstructive CAD at 21 U.S. primary care practices. METHODOLOGY Demographics, clinical factors, and ASGES (defined as low <=15 or elevated >15), as well as management plans post-ASGES, were collected. The economic endpoint analysis was based on the cost of cardiovascular-related tests, procedures, office visits, emergency room visits, and hospitalizations during one year after testing. RESULTS The analysis included 566 patients, 51% of whom were women and the median age was 56. Forty-five percent had a low ASGES. The mean cost of cardiovascular care for patients in the year following ASGES was $1,647 for patients with a low ASGES versus $2,709 for those with an elevated score (39% reduction, P=.03 by Wilcoxon rank test). This relationship remained after multivariate analysis that adjusted for patient demographics and clinical covariates (P<.001). CONCLUSION The ASGES helped identify patients with low current likelihood of obstructive CAD. These patients had lower costs of cardiovascular care during one year of follow-up. Early reductions in cardiac referrals at 45 days among these patients persisted at one year.

Background: Innovation driven by authoritative evidence is critical to the survival of England’s NHS. Clinical Commissioning Groups (CCGs) are central in NHS efforts to do more with less. Although decisions should be based on the ‘best available evidence’, this is often problematic, with frequent mismatches between the evidence ‘pushed’ by producers and that used in management work. Our concern, then, is to understand practices and conditions (which we term ‘capabilities’) that enable evidence use in commissioning work. We consider how research gets into CCGs (‘push’), how CCGs use evidence (‘pull’) and how this can be supported (toolkit development). We aim to contribute to evidence-based NHS innovation, and, more generally, to improved health-care service provision. Method: Supported by the National Institute for Health Research (NIHR), we conducted semistructured ethnographic interviews in eight CCGs. We also conducted observations of redesign meetings in two of the CCGs. We used inductive and deductive coding to identify evidence used and capabilities for use from the qualitative data. We then compared across cases to understand variations in outcomes as a function of capabilities. To help improvements in commissioning, we collated our findings into a toolkit for use by stakeholders. We also conducted a small-scale case study of the production of evidence-based guidance to understand evidence ‘push’. Results: Fieldwork indicated that different evidences inform CCG decision-making, which we categorise as ‘universal’, ‘local’, ‘expertise-based’ and ‘trans-local’. Fieldwork also indicated that certain practices and conditions (‘capabilities’) enable evidence use, including ‘sourcing and evaluating evidence’, ‘engaging experts’, ‘effective framing’, ‘managing roles and expectations’ and ‘managing expert collaboration’. Importantly, cases in which fewer capabilities were recorded tended to report more problems, relative to cases in which needed capabilities were applied. These latter cases were more likely to effectively use evidence, achieve objectives and maintain stakeholder satisfaction. We also found that various understandings of end-users are inscribed into products by evidence producers, which seems to reflect the evolving landscape of the production of authoritative evidence. Conclusions: This was exploratory research on evidence use capabilities in commissioning decisions. The findings suggest that commissioning stakeholders need support to identify, understand and apply evidence. Support to develop capabilities for evidence may be one means of ensuring effective, evidence-based innovations in commissioning. Our work with evidence producers also shows variation in their perceptions of end users, which may inform the ‘push’/’pull’ gap between research and practice. There were also some limitations to our project, including a smaller than expected sample size and a time frame that did not allow us to capture full redesign projects in all CCGs. Future work: With these findings in mind, future work may look more closely at how information comes to be treated as evidence and at the relationships of capabilities to project outcomes. Going forward, knowledge, especially that related to generalisability, may be built by means of a longer time and the study of redesign projects in different settings. Funding: The NIHR Health Services and Delivery Research programme.

Purpose: Each of the participating patient-centered medical home (PCMH) received coaching and participated in learning collaborative for improving teamwork. The objective of the study was to assess the impact of trainings on patient-centered teamwork. Methods: The Teamwork Perception Questionnaire (TPQ) was administered once in spring 2014 and then in fall 2015. The TPQ consists of 35 questions across 5 domains: mutual support, situation monitoring, communication, team structure, and leadership. Based on our objective we compared the frequencies of strongly agree/agree by domain. The difference was tested using chi-square test. We compared the scores on each domain (strongly agree/agree = 1; maximum score = 7) via Wilcoxon rank sum test. Results: The response rate for this survey was n = 29 (80.6%) in spring 2014, and n = 31 (86.1%) in fall 2015. We found that the practice members significantly (P<.05) strongly agreed/agreed more in fall 2015 than spring 2014 for characteristics-" staff relay relevant information in a timely manner" (64.5% vs 83.9%) and "staff follow a standardized method of sharing information when handing off patients" (67.7% vs 90.3%) under communication domain and for characteristic-" staff within my practice share information that enables timely decision making" (74.2% vs 90.3%). However, there was no statistical significant difference observed in the scores for the overall TPQ at the 2 time points. Conclusion: Despite the statistical insignificance, the observations in PCMHs across the spectrum of practices participating in the Maryland Multi-Payer Program demonstrated enhanced teamwork specifically in communication and in leadership. This we believe will continue to result in enhanced patient access to care and safety.

Background: Because of diagnostic uncertainty, patients with symptoms suggestive of obstructive coronary artery disease (CAD) are referred at high rates to cardiologists and advanced cardiac testing. This evaluation process may also expose patients to appreciable costs and health risks. A previously validated, blood-based test incorporating age, sex and genomic expression into an algorithmic score (1-40) has shown clinical validity in assessing the likelihood of obstructive CAD (≥50% luminal diameter stenosis by quantitative coronary angiography) early in the cardiac workup. This test has also shown clinical utility in association with decision making around cardiac referrals and helping clinicians determine the current likelihood of obstructive CAD in symptomatic patients. Hypothesis: We hypothesized that use of the age/sex/gene expression score (ASGES) test would influence cost of care in the diagnosis and management of symptomatic patients with suspected obstructive CAD. Methods: The prospective PRESET Registry (NCT01677156) enrolled stable, non-acute adult patients presenting with symptoms suggestive of obstructive CAD to 21 US primary care practices from September 2012 to August 2014. Primary care clinicians provided pre- and post-ASGES diagnosis and evaluation plans for each patient. Demographics, clinical factors, and ASGES results (predefined as low [ASGES ≤ 15] or elevated [ASGES > 15]) were collected, as were management plans post-ASGES testing, including referrals to cardiology or further functional/anatomic testing. The economic analysis for cost of care after ASGES testing was based on the cost of cardiovascular-related tests, invasive procedures, office visits, emergency room visits, and hospital admissions during 1-year follow-up. Results: This sub-analysis cohort included 560 patients, with 50% females and median age 56 years. Patients had a median ASGES score of 18, with 246 (44%) patients with ASGES < 15. The mean cost of care for patients in the year following ASGES testing was $234 (SD ±$707) in the low ASGES versus $1,296 (SD ±$5230) in the elevated ASGES group (p=0.03 by Wilcoxon rank test). Multivariate analysis incorporating patient demographics and clinical covariates showed that low ASGES was associated with a 51% reduction in cost of follow-up care compared to elevated ASGES group (p<0.001 by log-linear regression). Conclusion: In this community-based cardiovascular registry, the ASGES influenced costs in the evaluation of patients with suspected obstructive CAD. Low score patients had approximately half the cardiovascular costs of elevated score patients in one year follow-up. Our work provides evidence supporting the economic value of using precision medicine in the delivery of cardiovascular care.

Diagnosing obstructive coronary artery disease (CAD) is challenging in elderly adults, and current diagnostic approaches for CAD expose these individuals to risks from contrast dye and invasive procedures.