East Jefferson General Hospital

OBJECTIVES: The aim of this study was to evaluate the safety and effectiveness of percutaneous mechanical thrombectomy using the FlowTriever System (Inari Medical, Irvine, California) in a prospective trial of patients with acute intermediate-risk pulmonary embolism (PE). BACKGROUND: Catheter-directed thrombolysis has been shown to improve right ventricular (RV) function in patients with PE. However, catheter-directed thrombolysis increases bleeding risk and many patients with PE have relative and absolute contraindications to thrombolysis. METHODS: Patients with symptomatic, computed tomography-documented PE and RV/left ventricular (LV) ratios ≥0.9 were eligible for enrollment. The primary effectiveness endpoint was core laboratory-assessed change in RV/LV ratio. The primary safety endpoint comprised device-related death, major bleeding, treatment-related clinical deterioration, pulmonary vascular injury, or cardiac injury within 48 h of thrombectomy. RESULTS: From April 2016 to October 2017, 106 patients were treated with the FlowTriever System at 18 U.S. sites. Two patients (1.9%) received adjunctive thrombolytics and were analyzed separately. Mean procedural time was 94 min; mean intensive care unit stay was 1.5 days. Forty-three patients (41.3%) did not require any intensive care unit stay. At 48 h post-procedure, average RV/LV ratio reduction was 0.38 (25.1%; p < 0.0001). Four patients (3.8%) experienced 6 major adverse events, with 1 patient (1.0%) experiencing major bleeding. One patient (1.0%) died, of undiagnosed breast cancer, through 30-day follow-up. CONCLUSIONS: Percutaneous mechanical thrombectomy with the FlowTriever System appears safe and effective in patients with acute intermediate-risk PE, with significant improvement in RV/LV ratio and minimal major bleeding. Potential advantages include immediate thrombus removal, absence of thrombolytic complications, and reduced need for post-procedural critical care.

OBJECTIVES: The aim of this study was to determine the lowest optimal tissue plasminogen activator (tPA) dose and delivery duration using ultrasound-facilitated catheter-directed thrombolysis (USCDT) for the treatment of acute intermediate-risk (submassive) pulmonary embolism. BACKGROUND: Previous trials of USCDT used tPA over 12 to 24 h at doses of 20 to 24 mg for acute pulmonary embolism. METHODS: Hemodynamically stable adults with acute intermediate-risk pulmonary embolism documented by computed tomographic angiography were randomized into this prospective multicenter, parallel-group trial. Patients received treatment with 1 of 4 USCDT regimens. The tPA dose ranged from 4 to 12 mg per lung and infusion duration from 2 to 6 h. The primary efficacy endpoint was reduction in right ventricular-to-left ventricular diameter ratio by computed tomographic angiography. A major secondary endpoint was embolic burden by refined modified Miller score, measured on computed tomographic angiography 48 h after initiation of USCDT. RESULTS: One hundred one patients were randomized, and improvements in right ventricular-to-left ventricular diameter ratio were as follows: arm 1 (4 mg/lung/2 h), 0.40 (24%; p = 0.0001); arm 2 (4 mg/lung/4 h), 0.35 (22.6%; p = 0.0001); arm 3 (6 mg/lung/6 h), 0.42 (26.3%; p = 0.0001); and arm 4 (12 mg/lung/6 h), 0.48 (25.5%; p = 0.0001). Improvement in refined modified Miller score was also seen in all groups. Four patients experienced major bleeding (4%). Of 2 intracranial hemorrhage events, 1 was attributed to tPA delivered by USCDT. CONCLUSIONS: Treatment with USCDT using a shorter delivery duration and lower-dose tPA was associated with improved right ventricular function and reduced clot burden compared with baseline. The major bleeding rate was low, but 1 intracranial hemorrhage event due to tPA delivered by USCDT did occur.

BACKGROUND: The objective of this review was to merge current treatment guidelines and best practice recommendations for management of neuropathic pain into a comprehensive algorithm for primary physicians. The algorithm covers assessment, multidisciplinary conservative care, nonopioid pharmacological management, interventional therapies, neurostimulation, low-dose opioid treatment, and targeted drug delivery therapy. METHODS: Available literature was identified through a search of the US National Library of Medicine's Medline database, PubMed.gov. References from identified published articles also were reviewed for relevant citations. RESULTS: The algorithm provides a comprehensive treatment pathway from assessment to the provision of first- through sixth-line therapies for primary care physicians. Clear indicators for progression of therapy from firstline to sixth-line are provided. Multidisciplinary conservative care and nonopioid medications (tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, gabapentanoids, topicals, and transdermal substances) are recommended as firstline therapy; combination therapy (firstline medications) and tramadol and tapentadol are recommended as secondline; serotonin-specific reuptake inhibitors/anticonvulsants/NMDA antagonists and interventional therapies as third-line; neurostimulation as a fourth-line treatment; low-dose opioids (no greater than 90 morphine equivalent units) are fifth-line; and finally, targeted drug delivery is the last-line therapy for patients with refractory pain. CONCLUSIONS: The presented treatment algorithm provides clear-cut tools for the assessment and treatment of neuropathic pain based on international guidelines, published data, and best practice recommendations. It defines the benefits and limitations of the current treatments at our disposal. Additionally, it provides an easy-to-follow visual guide of the recommended steps in the algorithm for primary care and family practitioners to utilize.

We sought to prospectively assess the diagnostic performance of a high-resolution positron emission tomography (PET) scanner using mild breast compression (positron emission mammography [PEM]). Data were collected on concomitant medical conditions to assess potential confounding factors. At four centers, 94 consecutive women with known breast cancer or suspicious breast lesions received 18F-fluorodeoxyglucose (FDG) intravenously, followed by PEM scans. Readers were provided clinical histories and x-ray mammograms (when available). After excluding inevaluable cases and two cases of lymphoma, PEM readings were correlated with histopathology for 92 lesions in 77 women: 77 index lesions (42 malignant), 3 ipsilateral lesions (3 malignant), and 12 contralateral lesions (3 malignant). Of 48 cancers, 16 (33%) were clinically evident; 11 (23%) were ductal carcinoma in situ (DCIS), and 37 (77%) were invasive (30 ductal, 4 lobular, and 3 mixed; median size 21 mm). PEM depicted 10 of 11 (91%) DCIS and 33 of 37 (89%) invasive cancers. PEM was positive in 1 of 2 T1a tumors, 4 of 6 T1b tumors, 7 of 7 T1c tumors, and 4 of 4 cases where tumor size was not available (e.g., no surgical follow-up). PEM sensitivity for detecting cancer was 90%, specificity 86%, positive predictive value (PPV) 88%, negative predictive value (NPV) 88%, accuracy 88%, and area under the receiver-operating characteristic curve (Az) 0.918. In three patients, cancer foci were identified only on PEM, significantly changing patient management. Excluding eight diabetic subjects and eight subjects whose lesions were characterized as clearly benign with conventional imaging, PEM sensitivity was 91%, specificity 93%, PPV 95%, NPV 88%, accuracy 92%, and Az 0.949 when interpreted with mammographic and clinical findings. FDG PEM has high diagnostic accuracy for breast lesions, including DCIS.

PURPOSE: To assess the efficacy and safety of the anti-VEGF receptor-2 (VEGFR-2) antibody ramucirumab as first-line therapy in patients with advanced hepatocellular carcinoma and explore potential circulating biomarkers. EXPERIMENTAL DESIGN: Adults with advanced hepatocellular carcinoma and no prior systemic treatment received ramucirumab 8 mg/kg every two weeks until disease progression or limiting toxicity. The primary endpoint was progression-free survival (PFS); secondary endpoints included objective response rate (ORR) and overall survival (OS). Circulating biomarkers were evaluated before and after ramucirumab treatment in a subset of patients. RESULTS: Forty-two patients received ramucirumab. Median PFS was 4.0 months [95% confidence interval (CI), 2.6-5.7], ORR was 9.5% (95% CI, 2.7-22.6; 4/42 patients had a partial response), and median OS was 12.0 months (95% CI, 6.1-19.7). For patients with Barcelona Clinic Liver Cancer (BCLC) stage C disease, median OS was 4.4 months (95% CI, 0.5-9.0) for patients with Child-Pugh B cirrhosis versus 18.0 months (95% CI, 6.1-23.5) for patients with Child-Pugh A cirrhosis. Treatment-related grade ≥ 3 toxicities included hypertension (14%), gastrointestinal hemorrhage and infusion-related reactions (7% each), and fatigue (5%). There was one treatment-related death (gastrointestinal hemorrhage). After treatment with ramucirumab, there was an increase in serum VEGF and placental growth factor (PlGF) and a transient decrease in soluble VEGFR-2. CONCLUSION: Ramucirumab monotherapy may confer anticancer activity in advanced hepatocellular carcinoma with an acceptable safety profile. Exploratory biomarker studies showed changes in circulating VEGF, PlGF, and sVEGFR-2 that are consistent with those seen with other anti-VEGF agents.

The rapid spread of SARS-CoV-2, the new coronavirus (CoV), throughout the globe poses a daunting public health emergency. Different preventive efforts have been undertaken in response to this global health predicament; amongst them, vaccine development is at the forefront. Several sophisticated designs have been applied to create a vaccine against SARS-CoV-2, and 44 candidates have already entered clinical trials. At present, it is unclear which ones will meet the objectives of efficiency and safety, though several vaccines are gearing up to obtain emergency approval in the U.S. and Europe. This manuscript discusses the advantages and disadvantages of various vaccine platforms and evaluates the safety and efficacy of vaccines in advance stages. Once a vaccine is developed, the next challenge will be acquisition, deployment, and uptake. The present manuscript describes these challenges in detail and proposes solutions to the vast array of translational challenges. It is evident from the epidemiology of SARS-CoV-2 that the virus will remain a threat to everybody as long as the virus is still circulating in a few. We need affordable vaccines that are produced in sufficient quantity for use in every corner of the world.

ABSTRACT In 1995, the U.S. Fish and Wildlife Service implemented an adaptive harvest management program (AHM) for the sport harvest of midcontinent mallards ( Anas platyrhynchos ). The program has been successful in reducing long‐standing contentiousness in the regulatory process, while integrating science and policy in a coherent, rigorous, and transparent fashion. After 20 years, much has been learned about the relationship among waterfowl populations, their environment, and hunting regulations, with each increment of learning contributing to better management decisions. At the same time, however, much has been changing in the social, institutional, and environmental arenas that provide context for the AHM process. Declines in hunter numbers, competition from more pressing conservation issues, and global‐change processes are increasingly challenging waterfowl managers to faithfully reflect the needs and desires of stakeholders, to account for an increasing number of institutional constraints, and to (probabilistically) predict the consequences of regulatory policy in a changing environment. We review the lessons learned from the AHM process so far, and describe emerging challenges and ways in which they may be addressed. We conclude that the practice of AHM has greatly increased an awareness of the roles of social values, trade‐offs, and attitudes toward risk in regulatory decision‐making. Nevertheless, going forward the waterfowl management community will need to focus not only on the relationships among habitat, harvest, and waterfowl populations, but on the ways in which society values waterfowl and how those values can change over time. © 2015 The Authors. Wildlife Society Bulletin published by The Wildlife Society.

Noncosmetic applications of liposuction have continued to appear since its introduction into the United States in 1982. Although the most common use is in removing lipomas, liposuction has also been used for benign symmetric lipomatosis, flap undermining, flap defatting, gynecomastia, pseudogynecomastia, breast reduction, buffalo hump, hypertrophic insulin lipodystrophy, lymphedema, evacuating hematomas, emergency neck defatting for airway restoration, and axillary hyperhidrosis. Other uses remain to be discovered.

The aims of this study were to: (a) examine the consistency of the published Wisconsin Card Sorting Test (WCST) factor structures; (b) determine the factor structure of the WCST in a large, heterogeneous sample; and (c) compare the WCST factor analytically with other neuropsychological procedures. Two WCST factors (concept formation/perseveration and Failure-to-Maintain-Set [FMS]) were consistently reported in the literature. Our analysis of data from 473 clinical cases replicated the two factors previously reported and revealed a third on which nonperseverative errors (NPE) was the sole salient variable. This pattern was maintained in three of four diagnostically distinct subgroups. These factors are potentially clinically meaningful, with each seeming to reflect one of three qualitatively different performance styles. In the construct validation factor analysis, WCST scores loaded independently of other neuropsychological variables, indicating that the WCST contributes uniquely to neuropsychological evaluation. Nevertheless, despite the rational interpretation of the factors, the cognitive processes underlying WCST performance remain poorly understood. Future directions for the application of these factor analytic findings are discussed.

This mixed-methods study uses interviews, participant observations, and the CWEQII empowerment tool to identify structures and attributes of structures that promote control over nursing practice (CNP). Nearly 3,000 staff nurses completed the Essentials of Magnetism (EOM), an instrument that measures CNP, one of the eight staff nurse-identified essential attributes of a productive work environment. Strategic sampling is used to identify 101 high CNP-scoring clinical units in 8 high-EOM scoring magnet hospitals. In addition to 446 staff nurses, managers, and physicians on these high-scoring units, chief nursing officers, chief operating officers, and representatives from other professional departments are interviewed; participant observations are made of all unit/departmental/hospital council and interdisciplinary meetings held during a 4 to 6 day site visit. Structures and components of viable shared governance structures that enabled CNP are identified through constant comparative analysis of interviews and observations, and through analysis of quantitative measures.

To ensure quality of services for individuals with mental retardation/developmental disability, professionals must measure consumer outcomes related to lifestyle. In this study variables contributing to quality of life for 60 adults with severe or profound disabilities who resided in ICF/MR community-based homes for 4 to 5 persons were examined. Using the Quality of Life Index, we studied interrelations among personal lifestyle characteristics of adults and community-home program characteristics with quality of life factors. The R2 effect size (.571) involving total scores on the Quality of Life Index as the criterion variable was large and statistically significant.

This article considers the gross inequality between the health status and life expectation of Indigenous1 and non-Indigenous Australians and the current policy responses to it from a human rights perspective. It outlines a proposal for a human rights-based campaign for achieving health and life expectation equality within a generation (approximately 25 years).This article is based on work first published in the Social Justice Report 2005 of the Aboriginal and Torres Strait Islander Social Justice Commissioner (ATSISJC 2006) and now re-printed as a standalone publication titled Achieving Aboriginal and Torres Strait Islander Health Equality Within a Generation — A Human Rights Approach (ATSIS)C 2007b).2 It also draws on other work on Indigenous health completed by my office in the past year (ATSIS)C 2007a).

How clinical nurses can operationalize the walk aspect of the talk, the values and beliefs inherent in control of nursing practice and a patient-centered culture.To “walk the talk”—putting values into action, leading by example, practicing what you preach—is a best practice related to 2 of the 8 attributes or work processes identified by staff nurses as essential to a healthy work environment. These 2 attributes, control of nursing practice and a culture in which concern for the patient is paramount, are the focus of this article. Another commonality of these 2 essential attributes is that they are the only 2 of the 8 that have as many departmental/hospital-wide implications as they do unit-focused implications. Nurses cannot control practice or engage in activities related to a patient-centered culture at the unit level unless parallel sanction and endorsement for these activities exist at the organizational level. After clarifying and illustrating the walk-the-talk metaphor and the constructs control of nursing practice and shared governance, we present the results of research that pertain to control of nursing practice and a patient-centered culture. We then suggest ways in which clinical nurses can operationalize the walk aspect of the talk, the values and beliefs inherent in control of nursing practice and a patient-centered culture.The cultural metaphor walk the talk is not new, but its use in both popular and professional literature and in everyday colloquial usage is increasing.1,2 In the study that provided the data for this article, the term was freely used by all—staff nurses, managers, physicians, and other professionals—in all hospitals and in all regions of the United States. It was used in conjunction with 3 of the 8 essentials of a healthy work environment: nurse manager support, control of nursing practice, and a patient-centered culture. The following 2 examples illustrate use of this metaphor with respect to a patient-centered culture and control of nursing practice. The first excerpt from a 2001 staff nurse interview3 illustrates the metaphor with respect to culture.The second example illustrates use of the walk-the-talk metaphor in the control of nursing practice. One of the study hospitals that had been invited to participate in the structure-identification studies declined because of a busy schedule of upcoming activities. A week after the invitation was declined, the investigator was informed that the administrative group had been hasty in their decision and that the request was being sent to the shared governance research council for disposition. The council contacted the investigators, sought additional information, endorsed the study, and expedited the institutional review board’s review process. The chief nursing executive explained that the council structure was still relatively new and that nurses and administrators were still learning how to make decisions together, how to walk the talk and “practice what we preach.”4In the spring and summer of 2006, we conducted a nationwide study4–7 in 8 strategically selected magnet hospitals. The purpose of the study was to ascertain the organizational structures and leadership practices that staff nurses identify as necessary for a healthy work environment, specifically, structures and practices that promote control of nursing practice and a patient-centered culture. To achieve this purpose, we needed to elicit the answers from staff nurses working in patient-centered cultural environments with confirmed control of nursing practice. The Essentials of Magnetism (EOM),8–10 a tool used to measure the extent to which staff nurses confirm that they have healthy work environments, has subscales to measure control of nursing practice and patient-centered culture as well as the other 6 essentials. It has been administered to staff nurses in hundreds of hospitals, mostly magnet hospitals, since its development in 2003. The results of these EOM evaluations were used to select the hospital sample for this study.We selected the 8 magnet hospitals, according to the 8 census-tract regions of the United States, that had the highest or second-highest EOM scores. To obtain the interview sample, we selected the clinical units with the highest EOM scores within each hospital. The “experts” that we interviewed on these units consisted of 244 staff nurses nominated by their peers and managers, 105 nurse managers, and 97 physicians nominated by staff nurses or managers. The number of staff nurses interviewed varied by the size of the unit but usually consisted of 2 or 3 staff nurses, 1 nurse manager, and 1 physician per unit. We interviewed the chief operating officer, the chief nursing officer, and 4 to 6 representatives from professional departments such as respiratory therapy, physical therapy, dietary, and pharmacy in each hospital to obtain the perspectives of these personnel of the nursing department and the degree of interdepartmental collaboration. We also conducted “participant-observation,” a qualitative research technique,11,12 in all central and unit council meetings during the 4-day on-site visit.The American Nurses Credentialing Center, which governs magnet designation, refers to control of nursing practice as “shared” or “unit-based” decision making related to an environment in which administrators use a participative management style.13 The Institute of Medicine,14 in the institute’s delineation of 5 evidence-based management practices needed for a healthy work environment, define it as “involving workers in decision making pertaining to work design and work flow.” Staff nurses in magnet hospitals define control of nursing practice as a work process through which nurses at all levels in the organization have input and make decisions on issues of importance that affect nurses, the context of nursing practice at unit, departmental, and hospital levels, and the quality of patient care provided.15 The input includes access to power and exchange of information, views, and judgments; the decision making is interdependent and shared; and the issues of importance include practices, standards, policies, and selection of equipment.Nurses wrote of control of nursing practice as follows:Staff nurses in both the United States15,16 and Canada,17 now4,18,19 and in the past,20 concur with well-established precepts of a profession in distinguishing between clinical autonomy and control of nursing practice. Clinical autonomy is individual, patient-centered decision making with the patient as the primary and often sole beneficiary. In much of the nursing literature,18,19 clinical autonomy and control of nursing practice are combined, referred to simply as decision making, and are discussed as though they were the same attribute. The American Association of Critical-Care Nurses standards for maintaining and sustaining a healthy work environment21 group the 2 dimensions of autonomy under a single standard, effective decision making, but particularly note the principle of unique and combined spheres of practice that is so critical in selecting the appropriate type of decision making: independent or interdependent. Control of practice, articulated by Flexner22 almost 100 years ago in his characteristics of a profession, is the self-regulation and self-determination of professional issues, practices, and standards by professionals. The following excerpt from an interview with a staff nurse illustrates the application of this definition to nursing. (All excerpts in this article are from interviews with staff nurses unless noted otherwise. NM indicates excerpts from interviews with nurse managers; MD, excerpts from interviews with physicians.)As in any form of self-regulation or self-determination, a structure is needed to facilitate smooth and accountable operation. In nursing, control of nursing practice is operationalized through shared governance or similar structures. Born on the heels of the participative management and decentralization themes of the early 1980s, shared governance is a nursing management innovation that legitimizes nurses’ control of nursing practice while extending the influence (input and decision making) of nurses at all levels, to administrative areas previously controlled by management.23 Shared governance is a structural configuration of councils and committees that provide formal mechanisms that ensure nurses’ responsibility, right, and power to make decisions and to control nursing practice.Whether termed shared leadership, clinical governance, collaborative governance, shared decision making, or simply the nursing council, the structure alone will not “bake the The structure by best management practices that make shared governance through of such as and and have noted or that shared governance structures that are not and are not by best management practices will not nurses to control practice. and that shared governance are by staff as with staff nurses on councils and committees but the to have control professional practice, leading to and to for to and of decision making were also in a nationwide of staff nurses working in hospitals that had shared governance in shared governance is not identified as a of or as a of it is that shared governance or a similar structure is for as a magnet hospital. staff nurses in magnet hospitals not confirm the of shared governance structures. In 3 of magnet hospitals in 2 staff nurses that shared governance structures were not and and not the nurses to control nursing practice. the as shared governance structures and what best practices make shared governance structures effective in nurses to control nursing are the we to the we interviewed in the study interviewed identified 2 shared governance and and 5 practices that nurses to control nursing practice within the shared governance and were of the structures were other shared The structures the was by the were usually according to such as practice, quality evidence-based practice, and In hospitals, the councils were according to professional such as staff nurse manager, and practice were into of and not all central councils were at the unit level. with hospitals had with a focus such as nurse practice council or staff nurse evidence-based practice council, and central councils were often at the unit the leadership in council activities were as and nurses’ control of practice. through the of the was usually with or and much in and were not the only or the chief for in control of nursing practice, but they were a nurses that they in a because they had a professional to do 5 best practices that control of nursing practice were the walk aspect of walk the and that shared governance structures nurses’ control of nursing practice. Nurses in hospital walk the talk as the access to power is usually referred to as The it as and you that you had to and that you had the power to make decisions that affect nursing practice, and that you were not only to use that but were to do Shared governance structures were as a of formal governance structures and control of nursing practice are and Staff nurse not to of or from the of had the of this power will power is the to influence action, and control power was as a a had had was this by a at the magnet hospital in A and used in all 8 hospitals, is that power is power has an quality that can and shared to the and of all A staff nurse as the of research by and we that to a of shared governance structures. we all staff nurses on the units with EOM in the sample by the of a tool used to measure the extent to which nurses that they are In this is as access to The tool is used to measure 4 of support, and access to both formal and Staff nurses in these 8 magnet hospitals in any other sample of staff nurses in the literature and within a of nurses in practice and were the chief of The chief of power in the of the 8 hospitals was the and that staff nurses with physicians and other in such as patient care The interdependent of these of had the and power of all professional of power was an shared governance the shared governance structures in and of in which the shared governance structure was in the not in any single were by in 3 of the 8 hospitals. with nurses in the other hospitals, nurses in these 3 hospitals had particularly with respect to the power through collaborative with as noted The was also as being the all are in council, you can the and implications and make decisions to and with each and to and in were 2 of the by that will or the and of a shared governance structure and the of the structure in control of nursing practice. The first and to is a best management practice of staff so that nurses can the unit to meetings and to meetings are The second the of nurses and making it for to in not only the of the shared governance structure but also results in a of with the of to a group of to refers to of the shared governance structure and of the not the physicians, and from other departments the and of nurses the context of the practice of nursing in an these will use the making it and In the of in and of and of shared governance councils is both and is also a in which the work of can and One nurse as practice and their activities are often to a nurse group meetings or group decision from the of these the and and for the decision making essential to quality of patient a shared governance structure and a clinical and many of the best practices with control of nursing practice are leadership and is much that staff nurses can do to their beliefs professional and into you in the form of self-regulation and self-determination for profession, you that nurses have not only the but the professional right, responsibility, and to control the context of nursing practice in the organization in which they you this talk by are a new shared governance structure not work from the and self-regulation are processes that and issues, in council input on issues, results of and the and of and 1 of the 8 hospitals we had a formal for of issues and their disposition. nurse identified a or had a or a a form and it to the council In this it was that the nurse a as to the or decision related to the within 2 shared governance structures to affect nurses’ control of nursing practice, and by nurses at all levels is a we are all nurses as a professional responsibility, but is a of in and patient care to in a nurses will to as unit representatives to this and of can participate by and in their unit council, by work such as the best for patient by standards, or by best practice on the and is is that the of all are and that of are and that both the or and the or decision are by is for staff nurses to access to but they can of the of power you use the power is with and being and accountable for decisions that that One nurse as they will in what they are you were not in the of peers and the and a to accountable for decisions Nurses in hospital explained the is the of and that or and the 3 or levels of to an or clinical unit, the culture is referred to as a the focus of this article. are the of the the of the unit, and or beliefs that cannot but are and example of an on of the units in study was that all were the of a and by all physicians and nurses on the unit. are the beliefs of what to are the standards by which we make decisions that influence aspect of the talk is how we make and values are the and to by in a work group that the are the ways of and include both the and the shared of and the and with or can a from and to or on how and the and values In are to or not to by The of the culture on the and of the of the work the to the culture to new and on how well and the values and are by group The and of the culture on the degree of and on the degree of of the values processes to ensure a values and the values and to new and and values and culture of was with the and was as almost you can it you walk into a as a magnet hospital by the American Nurses Credentialing is on the structures the of with an work environment that were from results of the study and on the for of nursing the of Magnetism and the of for the have to since first study in the staff nurses in magnet hospitals have the of a patient-centered culture in their work environment. In a of of the staff nurses in magnet hospitals and of the staff nurses in 8 hospitals that they in a culture of in which for the patient was In in a of nurses in magnet and hospitals, of the nurses in magnet hospitals and of in answers for the same In 2006, in a of nurses in magnet and hospitals, of nurses in the magnet hospitals and of in hospitals that concern for the patient was in in magnet hospitals to that the and of culture from the magnet hospital as an of have and the of though identified in the study, culture was not as a of because culture is an to In a to care unit with decision making in 4 and care a research conducted and data for 5 a 5 to a for on each of the 4 units that the had identified the care unit used to measure culture measure only the of the of is by In we used the work of and on a culture of to measure cultural values in hospitals. the between and quality care and to a we the following is but quality patient care first in this In a of of nurses in magnet hospitals and of nurses in hospitals to this In the were and in 2006, they were and in both magnet and hospitals, the of nurses a patient-centered culture are to in the of what is is that for all 3 the in the between and in these values an that in hospitals with a culture of the of a patient-centered culture has the of in after staff nurses in magnet hospitals identified the 8 work processes or attributes of which was a culture in which concern for the patient is essential for a healthy work we the EOM tool to measure all 8 We the values of a culture of as well as the care The patient-centered culture of the EOM tool not measure all 3 or levels of it only values and the 3 the study staff nurses, nurse managers, and physicians from the patient care units on which staff nurses had previously confirmed a patient-centered culture were are the 5 cultural values of the unit on which you it to to this the of the work with that of these working on units in We the of for the aspect of walk the talk, by to a nurse the work group on this the or do that you that they was to these were of are ways of these the of the unit related to the cultural number of was because and we the into on the of the and provided by the A of not the and were a of identified values in in to the were by and will used to provide of related to the In this article, we have used a number of excerpts to illustrate both the walk and the talk in to the from this number of values were from on-site chief nursing and the at the of the on-site was not interviews from all units had been and in to the of the unit 1 the values in 8 magnet hospitals as by staff nurses, nurse managers, physicians on units previously confirmed by staff nurses to have a patient-centered culture of The values are in of the that the was The is on 1 also the hospital values as in hospital by on-site and chief nursing on the of the hospitals. The a of and between unit and hospital of of the staff nurses and and of the physicians the It was by on all units in all hospitals. of this the for the and The patient is the first and nurse on this unit is at the of the as we are a a in the of that have been in were used to this care is the but we for and quality was also but not as often as or quality A of professional in being to that level of care on a was as a of quality was as a unit on all units in all hospitals. the of the nurses and and of the physicians identified this as a in this were to the “unit-based” that consisted of nurses and other nursing but also and the also the the and such as the physical in in what the was also was as a by of all so by physicians by nurses and and as of and a group of a of and that between was by of the often by staff nurses by the to this as and each other and with was a by of the on units in all hospitals. was nurses, managers, and and and as and in a and as by was a by of the so by nurses and by physicians characteristics and attributes of the were of this of of the the values clinical autonomy and patient both of which decision making of The 2 values are because that is the only in this study, but in other as clinical as making decisions in the best of the 2 the to or and for the do or what they autonomy and were by all 3 of but physicians autonomy often nurse Staff nurses patient often physicians on autonomy the of as to the values that were by in each of the 8 study hospitals, and were by on units in 2 or 3 of the hospitals. that we care for and and in to and in the to in a of and for the It on schedule so that you and and nurses’ and and and are to provide to example was provided by staff on the as had the by the were into the values on all units in the 8 magnet hospitals were and in were and and and In the were and and clinical autonomy and patient Staff nurses identified patient as a and autonomy often and often the other 2 The have been into 2 other values that were patient and that were staff this had been the 2 patient-centered values first and autonomy and have for of the the that these 8 magnet hospitals had in which the was concern for the hospital values and as provided in hospital are in in of within the but not between hospital values and unit for in how values are and between hospital and units is almost for the 4 the 5 and are the 2 unit and and autonomy and the unit and hospital had 2 hospital and the hospital and unit had In unit values are and hospital values are the 8 hospitals had many in the they also had unique making each hospital and to the the hospital hospitals were were research and the of on and to the hospital and to the hospitals were by particularly to the to and to the In of these hospitals, nurses of their to provide care for or to nurses for such was to identify related to hospital values as was with the unit that hospital values were The values were the central in the and on the to the in the hospital or and often on the of to a values not that the values were or A parallel was by of the at the Institute in The was used in conjunction with into hospital In to for physical and for with that were to a the of the hospital The that this was so the the values for of the or other In we can that of the hospital values to the unit indicates that managers, and the and a unit appropriate values and of in is the extent to which a of and shared values is in values that the of a and into the is what the the nurse managers, and the staff in hospitals have for or units is the extent to which values are or the the can values into ways of to use the walk the their nurses we practice nursing this unit we do it this is a used to the of a In to being in the development of values and staff also in their to and in values and The following excerpt from an it we not of the through which hospital values are operationalized or indicates that of the is as clinical nurses to to present the for the decisions they to use evidence-based management results to and note that in to make evidence-based decisions the cultural for the to the and for the nurses in magnet hospitals have noted that in to and quality patient the values by the of Magnetism and of the culture of the To the values by the into have to measure the of hospital culture and on the of such research is to and it we and data on the that a cultural of the in their into and was and staff development do well to have their and the excerpts that these used to values such as autonomy and which are at the of of nursing practice and a patient-centered culture promote both the quality of nurses’ work environments and the quality of patient Control of nursing practice nurses to the context of nursing use of evidence-based practices nurses to the quality of care provided to is the that and the group and the essential to quality the talk is a best practice through which the values of unit and hospital culture are and control of nursing practice by nurses can The 8 attributes of a healthy work environment identified by staff nurses in magnet hospitals of the hospital and unit culture and quality in patient care are to the talk is also of the of nurse identified by staff nurses as In the article in this we present the results of studies related to the 2 essentials of a healthy work environment: nurse manager and of

enteriae type 1 in 1984, however, a few cases of bacillary dysentery are still being reported from parts of West Bengal.Prophylaxis with chemotherapeutic agents to prevent travelers' diarrhea is currently a controversial issue.In this instance, antimicrobial prophylaxis would have been ineffective because of the multiple drug resistance displayed by the strain of S. dysenteriaerecovered from the two patients.A more tangible prophylactic measure, at least in situations such as this, would be to educate travelers entering high-risk areas on the implicit necessity of exercising caution about where and what they eat and drink.Before the onset of symptoms, these two patients had eaten fruit and other items purchased from a wayside vendor; this food was probably the source of infection.Travelers should also be aware of the importance of early treatment with nalidixic acid (or norfloxacin or ciprofloxacin if available) or furazolidone if illness develops.

Structures that foster clinical competency include annual reviews, educational support, recognition, review sessions, and best-practice teams.“By your actions they will know you.”“My goal is to provide the best care possible to each of my patients, based on knowledge that flows from my brain to my fingertips with compassion.”“The signs were subtle, but I knew this patient was going to get into more trouble, so I bugged them [physicians] until they did something.”“We take pride in being superbly competent; it’s “in the water” here—part of our culture. And the hospital backs up this expectation by providing resources, educational programs, tuition and fees, and time so that you can go. The physicians in PACU [postanesthesia care unit] provided review courses for our national specialty certification exams.”“I wish there was some way that I could learn and could help others meet all our responsibilities at once.The preceding excerpts from interviews with staff nurses in magnet hospitals reflect the key messages reported in this article. (Unless otherwise stated, all excerpts are from staff nurses who were interviewed for this study. The professional role of the speaker is cited for physicians [MDs] and nurse managers [NMs].) Competency is multifaceted and evident through actions. Clinically competent peers is all about competent performance, not the potential for performance. Both performance and potential are important for quality patient care, but here we focus solely on what others see or hear that leads to the judgment or conclusion that nurses on the front line in acute care hospitals are clinically competent.We describe what clinical nurses have to say about 2 elements that staff nurses identify as essential to a healthy work environment: clinically competent peers and support for education. This article is based on the last of the 3 structure-identification studies (Table 1) in which we interviewed 244 staff nurses, 105 managers, and 97 physicians on 101 clinical units in 8 magnet hospitals selected because staff nurses on these units had previously reported satisfying, productive work environments. In other words, we interviewed experts to find out what works. What are the structures and best practices that foster competent performance? That support education?Working with other nurses who are clinically competent has long been cited by staff nurses as a key feature of a satisfying and productive unit work environment, that is, an environment in which personal needs can be met and in which clinical nurses at the front line can give quality patient care. The AACN Standards for Establishing and Sustaining Healthy Work Environments1 define such an environment as one that is healthy. Since 1984, when the characteristics of an excellent work environment were first measured using the 65-item Nursing Work Index constructed from the original magnet hospital criteria,2 thousands of staff nurses in magnet, community, county, Veterans Affairs, and academic hospitals have consistently cited clinically competent peers as the No. 1 attribute of a satisfying unit work environment in which nurses can give high-quality patient care.3 In 2001, when the criteria of a magnetic work environment were shortened to those 37 attributes most often selected by thousands of staff nurses who completed the Nursing Work Index, staff nurses in 14 magnet hospitals cited clinically competent peers as the most important of the 8 attributes essential to a healthy work environment.4 We labeled these 8 attributes the Essentials of Magnetism (EOM) and designed the EOM tool to measure them.5 Each of the 8 essentials has a subscale and a score; the aggregate score of the 8 essentials is a measure of a healthy work environment. Using the same instrument, home health nurses in 9 states selected clinically competent peers as the fourth highest essential attribute.6 Competency is also one of the Baldrige criteria for performance excellence.7Support for education, another of the 8 essentials, is based on the “availability” of educational programs, opportunities, and practices that foster development of competency, but an environment that “supports” education is a necessity. The question investigated and answered in this article is, How is support for education manifested? Support for education is also one of the Baldrige criteria for improving performance excellence7; it is included as an aspect of the Professional Development Force of Magnetism8; and it is identified by the American Organization of Nurse Executives9 as 1 of the 9 elements of a healthy work environment.Competent is usually equated with adequacy, with accepted standard of practice. Webster’s dictionary10(p253) defines it as the quality or state of being functionally adequate or having sufficient knowledge, judgment, or skill. The professionals we interviewed—nurses, managers, and physicians—talked about competent performance as more than baseline performance or adequacy. Baseline performance or adequacy produces safe care; competency produces quality care.To find out “what works,” we wanted to be sure that we were interviewing experts, that is, professionals who were knowledgeable about the competency of the nurses and would be able to identify and describe organizational structures and best practices that helped nurses develop and maintain this exquisite competence. At the beginning of each interview, we used a 1 to 10 rating scale (10 = high), similar to the pain rating scales that nurses use daily. We asked, What number would you select to indicate the level of competent performance of the nurses on this unit? The mean rating for all 446 professionals interviewed was 8.7. Physicians rated staff nurses’ competency as 8.9, significantly higher (P=.004) than did nurse managers (8.4). Staff nurses rated their peers’ competency as 8.7. These ratings are very high, even higher than the ones we obtained when we asked the same question of 279 staff nurses in 14 magnet hospitals in interviews in 2001.4Most of the nursing literature is about core competencies and educational programs to promote or develop the capacity for competent performance. After reviewing studies on nursing core competencies from 1990 to 2000, Zhang et al11 identified multiple different, but overlapping, classifications of core competencies and concluded the following:To obtain descriptions of effective performance, we asked each interviewee, How do you know that a nurse is competent; what do you see or hear that tells you that a nurse (one of your peers) is performing competently? The 446 interviewees generated 749 descriptions and examples of competent performance. Using constant comparative analyses,12 we first independently analyzed the descriptions and examples and nominated potential categories. Then we reanalyzed the data as often as necessary to ascertain categorical fit and to broaden the categories into 6 competency performance domains. Responses that fit more than a single domain were assigned on the basis of context; a few that fit no domain were eliminated. Table 2 lists, in order of frequency, the competency domains described by interviewees in all 8 hospitals. The domains are not necessarily new or different. However, the relative importance and performance manifestations may differ from those usually found and reported, and some may be a surprise. The excerpts given here have some similarities to examples cited by Benner13; this situation is not surprising, because we were interviewing nurses who were clinical experts. By analyzing and thoroughly understanding what interviewees were describing in each performance domain, we can learn not only what organizational structures and best practices promote competent performance but also what additional educational programs and practices may be needed for the development of competent performance in each domain.Making independent, quick and correct decisions and acting “out of the box” in the best interests of the patient were responses given by 58% of the staff nurses, 16% of the managers, and 93% of the physicians. This domain includes commitment, a desire and zeal to acquire the knowledge, competence, and self-confidence necessary to make independent decisions (in the nursing unique sphere of practice) and interdependent decisions (in that sphere of practice where nursing overlaps with medicine and other disciplines).Commitment and patient advocacy were the primary aspects of competency in the autonomy domain described by nurses.Interviewees described 5 structures or best practices that enable staff nurses to develop competent performance. Some of the best practices are specific to a domain, whereas others span several or all domains. Table 3 lists, in descending order of frequency, the best practices that promote competency development and performance and also the domains most affected.Autonomous clinical decision making is facilitated through patient-care review sessions. These sessions are regularly scheduled reviews and updates of clinical practice and pathways, are often interdisciplinary, are an inherent aspect of collaborative practice programs,14,15 and are an integral part of the renegotiation of scope of practice16,17 essential to clinical autonomy. Some hospitals had interdisciplinary updates on each patient’s condition and plan of care 3 times per week. Patient-care review sessions often resulted in the formation of evidence-based practice teams. The primary contribution of these teams in enabling clinical competency was through an increase in knowledge. Perceived clinical competence, a necessary precursor to autonomous practice, has been described before18 and was also often cited by interviewees in this study.Responses related to prioritizing and multitasking, the second most cited domain, were given by 59% of the nurse managers, 27% of the staff nurses, and 1% of the physicians. Prioritizing means putting activities in their proper sequence and order as dictated by patients’ care needs. Multitasking is the mental process of prioritizing care/cure activities for multiple patients and doing so calmly, with concern and empathy and without losing sight of any patient’s needs. As in popular literature and context, multitasking is thinking and doing, or thinking and listening, at the same time. Both nurses and managers repeatedly emphasized that the word tasking does not quite capture the essence of this domain: “It’s not just the physical tasks; it’s a whole array of activities, thought, and work processes that have to be juggled and prioritized, and for multiple patients.” Some described multitasking as follows:Acquiring the capability to multitask is undoubtedly a slow and arduous process, particularly for new graduates. But as the following excerpts illustrate, once the capability is acquired, competent performance appears to be a rather startling transition.Experienced nurses also encounter difficulties in multitasking and prioritizing, but from different sources. Experienced nurses are the ones who are most often called on to take care of the most difficult and acutely ill patients, patients being treated with new technologies, and to assume the increasing array of professional responsibilities and activities—acting as preceptors to new staff members, attending council meetings, and participating in interdisciplinary meetings to develop protocols. A relatively new concept, identified and labeled by researchers in Minnesota as complexity compression,19 is a way of analyzing the competencies demanded by multitasking and, more importantly, of devising methods for mentoring and teaching new and experienced nurses how to develop this competency. Complexity compression is defined as “what nurses’ experience when expected to assume additional responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame.”19Complexities described by our interviewees varied among clinical units. Nurses in intensive care units most often cited patient care and system complexities such as increased patient acuity, limited system resources of critically ill patients, sensory overload for the nurses, technology bombardment, and rapid institution of multiple, new therapies (drugs, robotics). Nurses in other units described complexities due to multiple patients; rapid assessments, triaging, and treatment demanded by multiple and almost constant patient admissions and discharges; and increasing age and numbers of patients with latent or active comorbidities. Comorbidities make high demands on competency because “you have to be alert as to when latent might become active, so that you can do the proper thing in a timely fashion.” Nurses on all units noted “planned and unplanned additional responsibilities” such as emergency admissions, orientation of new nurses, increased expectations of involvement in research and evidence-based practice teams, council activities, interdisciplinary meetings, and working with physicians and others on development of critical pathways, autonomous decision-making reviews, and reviews of collaborative or nursing orders. As one interviewee stated, “With increasing professionalism comes increasing demands on your time, your expertise, your knowledge, your judgment, and your areas of competency.”The compression aspect of complexity compression almost always boils down to time. For new nurses, the compression is primarily the time it takes to develop, execute, and prioritize plans of care for multiple patients. For more experienced nurses, the compression factor is the time and mental alertness required to weave demands of patient care with multiple professional activities. For all, the continued short length of patients’ stays means that a larger number of work processes such as patient teaching must be done in shorter periods. Other compression factors are shortages in staffing, which are often due to increased acuity of the patients, or shortages of “the right kind of staff—not numbers, but skill and preparation.”Of all the structures and best practices needed to facilitate competence development and competency performance, the one cited most often as missing was how to teach and mentor nurses to prioritize and multitask. This competency domain is the only one for which no structures or practices were identified or described by interviewees in at least half of the 8 hospitals. Several pre-service interventions that could be taught to students in schools of nursing have been described. Multitasking for multiple patients and how to decide what to delegate can be taught by having students identify and translate patients’ needs into active and inert tasks or activities on the basis of expected resistance.20 This strategy could also be used for graduate nurses and residents. In an interdigital professional competency model,21 students can be taught to develop care plans and activities for 3 patients and then interdigitize these plans and activities on a priority basis.In 3 hospitals, interviewees described some methods used by their in-service education department to teach multitasking and prioritizing. A preceptor described a “thinking out loud” technique that she uses to teach nurses how to multiprocess, prioritize, and plan care and cure activities for the patients for whom the preceptor and the newcomer are responsible. In another hospital that has a well-developed nurse residency program, residents present their patient assignment and how they prioritized and managed it for critique and analysis by their peers. This approach could also be used in orientation sessions. Two nurse managers in intensive care units described what they called a program for teaching multitasking to new hires. They send new nurses out to the general medical-surgical unit before orientation to the intensive care unit; the nurses in the general medical-surgical unit “know how to prioritize and multitask, and hopefully they can teach it. It’s better to learn this in a less acute environment.”We suggest development of analytical seminars or critique sessions to identify the complexities extant and prevalent on units. The knowledge and needed to these complexities could then be and could be used to and prioritize the multitask needs of the patients and programs have been designed to teach critical could be used to develop similar programs to teach prioritizing and of of the responses fit the domain of they were almost among nurses, managers, and physicians. How does a nurse with a patient and the patient’s the nurse to their answered to the patient’s level of How does the nurse with and other there of an to these the that leads to a judgment that a nurse is clinically competence but it 2 or more and competence is how the the and and aspect of competence is the and approach the nurse uses in the and for the competent nurse out the patient’s and but does not overload with In the structure-identification on physicians particularly noted that they when nurses them in not competence also includes or or another aspect of competence, to patients the nurse is competent and in of the A competent nurse to the the patient’s the and peers and in a professional of of the responses were in the skill domain, more from staff nurses and physicians than from managers include in a different and patients and teaching are also included in this was that the annual competency reviews and care of patients also maintain this of responses for the knowledge domain was similar to that for more from staff nurses and physicians than from managers competency is primarily by asked and how are interviewees of knowledge and potential competence from personal attributes such as national and of and level of education. certification expectations or others to a of knowledge and competent interviewees and is the single best of clinical all interviewees that structures review of national certification and were in increasing competence that to more competent of of staff nurses, of managers, and 1% of physicians responses that were as the patient The number of examples and descriptions in this not be as of importance of this in the patient domain is on the basis of a patient’s physical and and by what the patient the patient are or and does or she is or she and does or she patient-care review sessions and evidence-based practice teams described as best practices for autonomous clinical decision making were also described as best practices for the patient and staff nurses were more in their descriptions of competency domains than were physicians and nurse managers or nurses and nurse managers, for multitasking, where nurses and managers were in The is that nurses and of clinical data and then to or by or by the data to multiple patient’s nurse Physicians may have a limited understanding of the scope of the work of nurses and may not the additional activities, and that into a multiple patient responsibilities for and the and of the these in all experts that an organizational that and demands clinical competency a this of competent performance included the expectation that nurses make for care. This is one in which additional education and mentoring would be to develop competent performance. Nurses cited examples of making without of This is in to the of et who that nurses are making for care to physicians because the nurses they have been in their by physicians when doing so in the The our and those of et may be the of in quality practice environments. The nurse interviewees in our were very in these magnet hospitals, to nurses’ making about care were a of the judgment and in the nurses’ competence, rather than a to nurses’ in the The of was in the system in almost all of the participating hospitals in our and may be to others in teaching nurses how to make than a program to develop and mentor others in prioritizing and multitasking, the number and quality of educational programs by the 8 hospitals in the were and as The mean rating of support for education on the rating scale by the 446 interviewees was with a of This very high rating and analysis and descriptions of educational programs are in Table The programs are in order of frequency, but the in the first and the last cited programs was very to which the educational programs were among the 8 hospitals. hospitals had preceptor programs for new and new hires. the hospitals, 1 had a nurse residency program, and 2 others had education units. These units were to a clinical that quality patient care, an environment where students and are accepted as of the clinical and the collaborative and Some interviewees emphasized the and educational of and others did not these The and support for education varied from one hospital that nurse to and to programs described as by almost nurse and to other hospitals that nurses for 1 or 2 courses a hospital an program for nurses to become nurses that was to and that had all of on of the best practices that support education, in order of frequency, are in Table The educational support described most often by interviewees in all hospitals to be competent so that I can and seminars without as I my peers or my patients.” educational programs were described as a way of to meet our educational needs while that we have The nurse managers in that sufficient competent and staff were present to care for patients on the unit so that staff could meetings and programs scheduled work these to provide educational support, interviewees also that we have a to and to develop and increase our clinical competency through education and structure-identification studies which this article is based are all about what an needs to do to the capability and performance of the staff nurse Staff nurses also have the of of the and that in these healthy work the nurses do We found among the 446 interviewees on all competency performance educational programs and the best practices competency and in a few physicians more or less on some competency domains than did The competency domain of prioritizing and multitasking was the only one described in which educational or mentoring were The here will be to staff and nurse in to the attributes of 2 Essentials of clinically competent peers and support for education. In the article in this we and for the essential of clinical autonomy.

BACKGROUND: Sex disparities in acute ischemic stroke outcomes are well reported with IV thrombolysis. Despite several studies, there is still a lack of consensus on whether endovascular thrombectomy (EVT) outcomes differ between men and women. OBJECTIVE: To compare sex differences in EVT outcomes at 90-day follow-up and assess whether progression in functional status from discharge to 90-day follow-up differs between men and women. METHODS: From the Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) prospective cohort study (2016-2018), adult men and women (≥18 years) with anterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery M1/M2) treated with EVT up to 24 hours from last known well were matched using propensity scores. Discharge and 90-day modified Rankin Scale (mRS) scores were compared between men and women. Furthermore, we evaluated the improvement in mRS scores from discharge to 90 days in men and women using a repeated-measures, mixed-effects regression model. RESULTS: Of 285 patients, 139 (48.8%) were women. Women were older with median (IQR) age 69 (57-81) years vs 64.5 (56-75), p=0.044, had smaller median perfusion deficits (Tmax >6 s) 109 vs 154 mL (p<0.001), and had better collaterals on CT angiography and CT perfusion but similar ischemic core size (relative cerebral blood flow <30%: 7.6 (0-25.2) vs 11.4 (0-38) mL, p=0.22). In 65 propensity-matched pairs, despite similar discharge functional independence rates (women: 42% vs men: 48%, aOR=0.55, 95% CI 0.18 to 1.69, p=0.30), women exhibited worse 90-day functional independence rates (women: 46% vs men: 60%, aOR=0.41, 95% CI 0.16 to 1.00, p=0.05). The reduction in mRS scores from discharge to 90 days also demonstrated a significantly larger improvement in men (discharge 2.49 and 90 days 1.88, improvement 0.61) than in women (discharge 2.52 and 90 days 2.44, improvement 0.08, p=0.036). CONCLUSION: In a propensity-matched cohort from the SELECT study, women had similar discharge outcomes as men following EVT, but the improvement from discharge to 90 days was significantly worse in women, suggesting the influence of post-discharge factors. Further exploration of this phenomenon to identify target interventions is warranted. TRIAL REGISTRATION NUMBER: NCT02446587.

An interdisciplinary process for the reduction of medication errors was implemented at East Jefferson General Hospital in Metairie, Louisiana, a suburb of New Orleans. The Medication Administration Review and Safety Committee expanded the error reporting system with a comprehensive concurrent chart review process. Safe administration of medications through a systems approach has led to a reduction of documentation deficiencies, a new follow-up process, and an increase in reported errors.

BACKGROUND: It is unknown whether endovascular thrombectomy (EVT) is cost effective in large ischemic core infarcts. METHODS: In the prospective, multicenter, cohort study of imaging selection study (SELECT), large core was defined as computed tomography (CT) ASPECTS<6 or computed tomography perfusion (CTP) ischemic core volume (rCBF<30%) ≥50 cc. A Markov model estimated costs, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) of EVT compared with medical management (MM) over lifetime. The willingness to pay (WTP) per QALY was set at $50 000 and $100 000 and the net monetary benefits (NMB) were calculated. Probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEAC) for EVT were assessed in SELECT and other pivotal trials. RESULTS: From 361 patients enrolled in SELECT, 105 had large core on CT or CTP (EVT 62, MM 43). 19 (31%) EVT vs 6 (14%) MM patients achieved modified Rankin Scale (mRS) score 0-2 (OR 3.27, 95% CI 1.11 to 9.62, P=0.03) with a shift towards better mRS (cOR 2.12, 95% CI 1.05 to 4.31, P=0.04). Over the projected lifetime of patients presenting with large core, EVT led to incremental costs of $33 094 and a gain of 1.34 QALYs per patient, resulting in ICER of $24 665 per QALY. EVT has a higher NMB compared with MM at lower (EVT -$42 747, MM -$76 740) and upper (EVT $155 041, MM $57 134) WTP thresholds. PSA confirmed the results and CEAC showed 77% and 92% acceptability of EVT at the WTP of $50 000 and $100 000, respectively. EVT was associated with an increment of $29 225 in societal costs. The pivotal EVT trials (HERMES, DAWN, DEFUSE 3) were dominant in a sensitivity analysis at the same inputs, with societal cost-savings of $37 901, $86 164 and $22 501 and a gain of 1.62, 2.36 and 2.21 QALYs, respectively. CONCLUSIONS: In a non-randomized prospective cohort study, EVT resulted in better outcomes in large core patients with higher QALYs, NMB and high cost-effectiveness acceptability rates at current WTP thresholds. Randomized trials are needed to confirm these results. CLINICAL TRIAL REGISTRATION: NCT02446587.

Removal of residual biliary tract stones through the T-tube tract is discussed, with emphasis upon specific problems encountered in a series of 44 cases. Basket retrieval or fragmentation is the method of choice, due to its lack of mortality and minimal morbidity. Solvents such as heparin or saline may be helpful in dissolving soft stones. The remainder may require repeat surgery. It is suggested that large T-tubes be used in preference to small ones, especially if there is any suspicion that residual stones are present.

Abstract Rationale GM-CSF (granulocyte–macrophage colony–stimulating factor) has emerged as a promising target against the hyperactive host immune response associated with coronavirus disease (COVID-19). Objectives We sought to investigate the efficacy and safety of gimsilumab, an anti–GM-CSF monoclonal antibody, for the treatment of hospitalized patients with elevated inflammatory markers and hypoxemia secondary to COVID-19. Methods We conducted a 24-week randomized, double-blind, placebo-controlled trial, BREATHE, at 21 locations in the United States. Patients were randomized 1:1 to receive two doses of intravenous gimsilumab or placebo 1 week apart. The primary endpoint was all-cause mortality rate at Day 43. Key secondary outcomes were ventilator-free survival rate, ventilator-free days, and time to hospital discharge. Enrollment was halted early for futility based on an interim analysis. Measurements and Main Results Of the planned 270 patients, 225 were randomized and dosed; 44.9% of patients were Hispanic or Latino. The gimsilumab and placebo groups experienced an all-cause mortality rate at Day 43 of 28.3% and 23.2%, respectively (adjusted difference = 5% vs. placebo; 95% confidence interval [−6 to 17]; P = 0.377). Overall mortality rates at 24 weeks were similar across the treatment arms. The key secondary endpoints demonstrated no significant differences between groups. Despite the high background use of corticosteroids and anticoagulants, adverse events were generally balanced between treatment groups. Conclusions Gimsilumab did not improve mortality or other key clinical outcomes in patients with COVID-19 pneumonia and evidence of systemic inflammation. The utility of anti–GM-CSF therapy for COVID-19 remains unclear.