VA Heartland Network

BACKGROUND: Having sufficient healthcare access helps individuals proactively manage their health challenges, leading to positive long-term health outcomes. In the U.S., healthcare access is a public health issue as many Americans lack the physical or financial resources to receive the healthcare services they need. Mental healthcare is especially difficult due to lingering social stigmas and scarcity of services. Subsequently, those with mental health impairment tend to be complex patients, which may convolute delivery of services. OBJECTIVE: To quantify the prevalence of barriers to healthcare access among U.S. adults with and without mental health challenges (MHC) and evaluate the relationship between MHC and no usual source of care (NUSC). METHODS: A cross-sectional study was conducted with data from the 2017-2018 National Health Interview Survey. MHC was categorized into three levels: no (NPD), moderate (MPD) and severe (SPD) psychological distress. Eight barriers were quantified; one was used as the primary outcome: NUSC. Multivariable logistic regression was used to quantify associations between these characteristics. RESULTS: The sample included 50,103 adults. Most reported at least one barrier to healthcare access (95.6%) while 13.3% reported NUSC. For each barrier, rates were highest among those with SPD and lowest for those with NPD. However, in the multivariable model, SPD and MPD were not associated with NUSC (OR, 0.92; 95% CI, 0.83-1.01; 0.88; 0.73-1.07). Male sex (1.92; 1.78-2.06), Hispanic race/ethnicity (1.59; 1.42-1.77), and worry to afford emergent (1.38; 1.26-150) or normal (1.60; 1.46-1.76) healthcare were associated with NUSC. Having a current partner (0.88; 0.80-0.96), dependent(s) (0.77; 0.70-0.85) and paid sick leave (0.60; 0.56-0.65) were protective. CONCLUSIONS: The most prevalent barriers to healthcare access link to issues with affordability, and MHC exist more often when any barrier is reported. More work is needed to understand the acuity of burden as other social and environmental factors may hold effect.

Minocycline, a clinically used tetracycline for over 40 years, crosses the blood-brain barrier and prevents caspase up-regulation. It reduces apoptosis in mouse models of Huntington's disease and familial amyotrophic lateral sclerosis (ALS) and is in clinical trial for sporadic ALS. Because apoptosis also occurs after brain and spinal cord (SCI) injury, its prevention may be useful in improving recovery. We analyzed minocycline's neuroprotective effects over 28 days following contusion SCI and found significant functional recovery compared to tetracycline. Histology, immunocytochemistry, and image analysis indicated statistically significant tissue sparing, reduced apoptosis and microgliosis, and less activated caspase-3 and substrate cleavage. Since our original report in abstract form, others have published both positive and negative effects of minocycline in various rodent models of SCI and with various routes of administration. We have since found decreased tumor necrosis factor-alpha, as well as caspase-3 mRNA expression, as possible mechanisms of action for minocycline's ameliorative action. These results support reports that modulating apoptosis, caspases, and microglia provide promising therapeutic targets for prevention and/or limiting the degree of functional loss after CNS trauma. Minocycline, and more potent chemically synthesized tetracyclines, may find a place in the therapeutic arsenal to promote recovery early after SCI in humans.

In order to understand the mechanism for insoluble neurotoxic protein polymerization in Alzheimer's disease (AD) brain neurons, we examined protein and gene expression for transglutaminase (TGase 2; tissue transglutaminase (tTG)) in hippocampus and isocortex. We found co-localization of tTG protein and activity with tau-positive neurofibrillary tangles, whereas mRNA and sequence analysis indicated an absolute increase in tTG synthesized. Although apoptosis in AD hippocampus is now an established mode of neuronal cell death, no definite underlying mechanism(s) is known. Since TGase-mediated protein aggregation is implicated in polyglutamine ((CAG)(n)/Q(n) expansion) disorder apoptosis, and expanded Q(n) repeats are excellent TGase substrates, a role for TGase in AD is possible. However, despite such suggestions almost 20 years ago, the molecular mechanism remained elusive. We now present one possible molecular mechanism for tTG-mediated, neurotoxic protein polymerization leading to neuronal apoptosis in AD that involves not its substrates (like Q(n) repeats) but rather the unique presence of alternative transcripts of tTG mRNA. In addition to a full-length (L) isoform in aged non-demented brains, we found a short isoform (S) lacking a binding domain in all AD brains. Our current results identify intron-exon "switching" between L and S isoforms, implicating G-protein-coupled signaling pathways associated with tTG that may help to determine the dual roles of this enzyme in neuronal life and death processes.

The catastrophic 2005 hurricane season alerted Americans to the need for a more effective response to mass casualty incidents. To address the needs of the nephrology community, the Kidney Community Emergency Response Coalition (KCERC) was formed, with representatives from more than 50 governmental agencies and private organizations. After completing phase 1 of its work, the KCERC issued recommendations for patients, dialysis units, and providers. During phase 2, the KCERC will promote implementation of those recommendations. During a disaster, the KCERC will host a daily conference call on which dialysis facilities, the End-Stage Renal Disease Networks, and emergency response officials will coordinate disaster response. Predisaster preparation for kidney patients should stress identification of alternative dialysis facilities, education about the renal emergency diet, and plans for early evacuation from the disaster area and for evacuating with medical documents and medications. Dialysis facilities are required to have a disaster plan; regular revision and rehearsal are essential. Critical issues for dialysis facilities include identification of partner facilities, a robust communications plan that takes into account the limitations of telephones and broadband access, staff shortages in the face of a possible influx of new patients, the delivery of service in the face of compromised utilities (water, power), and the recovery of a dialysis facility that experiences flooding or structural damage. A timeline to safety for dialysis patients can be visualized; if specific tasks are accomplished at each disaster stage, then it is likely that the health of these vulnerable patients can be protected.

BACKGROUND: Access to health information is crucial to persons living with a spinal cord injury or disorder (SCI/D). Although previous research has provided insights on computer and Internet use among persons with SCI/D, as well as how and where persons with SCI/D gather health information, few studies have focused on U.S. veterans with SCI/D. OBJECTIVE: To characterize health information seeking among veterans with SCI/D and to examine the association between technology use and the characteristics of veterans with SCI/D. DESIGN: Cross-sectional. SETTING: Veterans Health Administration (VHA). PARTICIPANTS: Sample of 290 veterans with SCI/D who utilize services at 2 VHA SCI/D Centers. METHODS: Postal mail survey. MAIN OUTCOME MEASUREMENTS: Extent of computer, Internet, and text messaging use, information source use, and e-Health literacy rates. RESULTS: The survey response rate was 38%. The majority of respondents were male (97.2%), younger than 65 years (71.0%), and white (71.7%). Of the respondents, 64.8% indicated that they use a computer, 62.9% reported use of the Internet, and 26.2% reported use of text messaging. The mean overall e-Health Literacy Scale score was 27.3 (standard deviation = 7.2). Similar to findings reported in studies focused outside the veteran population, the most frequent source that veterans turned to for information about SCI/D was a health professional (85.1%); this was also the most frequent source that veterans indicated they would turn to first to get information about SCI/D (75.9%). Other frequently reported sources of information included other persons with SCI/D (41.0%), Internet resources (31.0%), and family and friends (27.9%). CONCLUSIONS: Fairly high levels of computer and Internet use exist among veterans with SCI/D. Veterans with SCI/D also have a strong preference for people-particularly health professionals, and to a lesser extent peers and family and friends-as sources of information about SCI/D. These findings highlight the importance of combining technology and human interaction to meet the information needs of this population.

BACKGROUND AND OBJECTIVES: The Centers for Medicare & Medicaid Services (CMS) requires that dialysis centers inform new patients of their transplant options and document compliance using the CMS-2728 Medical Evidence Form (Form-2728). This study compared reports of transplant education for new dialysis patients reported to CMS with descriptions from transplant educators (predominantly dialysis nurses and social workers) of their centers' quantity of and specific educational practices. The goal was to determine what specific transplant education occurred and whether provision of transplant education was associated with center-level variation in transplant wait-listing rates. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Form-2728 data were drawn for 1558 incident dialysis patients at 170 centers in the Heartland Kidney Network (Iowa, Kansas, Missouri, and Nebraska) in 2009-2011; educators at these centers completed a survey describing their transplant educational practices. Educators' own survey responses were compared with Form-2728 reports for patients at each corresponding center. The association of quantity of transplant education practices used with wait-listing rates across dialysis centers was examined using multivariable negative binomial regression. RESULTS: According to Form-2728, 77% of patients (n=1203) were informed of their transplant options within 45 days. Educators, who reported low levels of transplant knowledge themselves (six of 12 questions answered correctly), most commonly reported giving oral recommendations to begin transplant evaluation (988 informed patients educated, 81% of centers) and referrals to external transplant education programs (959 informed patients educated, 81% of centers). Only 18% reported having detailed discussions about transplant with their patients. Compared with others, centers that used more than three educational activities (incident rate ratio, 1.36; 95% confidence interval, 1.07 to 1.73) had higher transplant wait-listing rates. CONCLUSIONS: While most educators inform new patients that transplant is an option, dialysis centers with higher wait-listing rates use multiple transplant education strategies.

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

Thrombin, the ultimate protease in the blood coagulation cascade, mediates its known cellular effects by unique proteolytic activation of G-protein-coupled protease-activated receptors (PARs), such as PAR1, PAR3, and PAR4, and a "tethered ligand" mechanism. PAR1 is variably expressed in subpopulations of neurons and largely determines thrombin's effects on morphology, calcium mobilization, and caspase-mediated apoptosis. In spinal cord motoneurons, PAR1 expression correlates with transient thrombin-mediated [Ca(2+)](i) flux, receptor cleavage, and elevation of rest [Ca(2+)](i) activating intracellular proteases. At nanomolar concentrations, thrombin retracts neurites via PAR1 activation of the monomeric, 21 kDa Ras G-protein RhoA, which is also involved in neuroprotection at lower thrombin concentrations. Such results suggest potential downstream targets for thrombin's injurious effects. Consequently, we employed several G-protein-specific modulators prior to thrombin exposure in an attempt to uncouple both heterotrimeric and monomeric G-proteins from motoneuronal PAR1. Cholera toxin, stimulating Gs, and lovastatin, which blocks isoprenylation of Rho, reduced thrombin-induced calcium mobilization. In contrast, pertussis toxin and mastoparan, inhibiting or stimulating G(o)/G(i), were found to exacerbate thrombin action. Effects on neuronal rounding and apoptosis were also detected, suggesting therapeutic utility may result from interference with downstream components of thrombin signaling pathways in human motor neuron disorders, and possibly other neurodegenerative diseases. Published 2001 John Wiley & Sons, Inc.

BACKGROUND: Emerging evidence suggests electronic health record (EHR)-related information overload is a risk to patient safety. In the US Department of Veterans Affairs (VA), EHR-based 'inbox' notifications originally intended for communicating important clinical information are now cited by 70% of primary care practitioners (PCPs) to be of unmanageable volume. We evaluated the impact of a national, multicomponent, quality improvement (QI) programme to reduce low-value EHR notifications. METHODS: The programme involved three steps: (1) accessing daily PCP notification load data at all 148 facilities operated nationally by the VA; (2) standardising and restricting mandatory notification types at all facilities to a recommended list; and (3) hands-on training for all PCPs on customising and processing notifications more effectively. Designated leaders at each of VA's 18 regional networks led programme implementation using a nationally developed toolkit. Each network supervised technical requirements and data collection, ensuring consistency. Coaching calls and emails allowed the national team to address implementation challenges and monitor effects. We analysed notification load and mandatory notifications preintervention (March 2017) and immediately postintervention (June-July 2017) to assess programme impact. RESULTS: Median number of mandatory notification types at each facility decreased significantly from 15 (IQR: 13-19) to 10 (IQR: 10-11) preintervention to postintervention, respectively (P<0.001). Mean daily notifications per PCP decreased significantly from 128 (SEM=4) to 116 (SEM=4; P<0.001). Heterogeneity in implementation across sites led to differences in observed programme impact, including potentially beneficial carryover effects. CONCLUSIONS: Based on prior estimates on time to process notifications, a national QI programme potentially saved 1.5 hours per week per PCP to enable higher value work. The number of daily notifications remained high, suggesting the need for additional multifaceted interventions and protected clinical time to help manage them. Nevertheless, our project suggests feasibility of using large-scale 'de-implementation' interventions to reduce unintended safety or efficiency consequences of well-intended electronic communication systems.

A total of 70% of all United States end-stage renal disease (ESRD) patients—more than 350,000— are on some form of dialysis.1 Although dialysis is life-saving, the sur-vival, quality-of-life, and cost-saving ben-efits of receiving a transplant over remain-ing on lifetime dialysis have been clearly established.2-7 After 5 years, only 35% of dialysis patients are still living, com-pared with 70% to 80% of patients who receive a deceased or living-donor trans-plant.1 Thus, to promote ongoing quality improvement, the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage (CfC) for ESRD Facilities mandate that accredited dialysis centers provide evidence of transplant education, track patients' transplant referrals and status on the waiting list, and communi-cate with transplant facilities regularly (Table I).8 To accomplish these CMS mandates, some responsibility for transplant education falls on the shoulders of dialysis providers. Compared with education in a transplant center, educating patients about transplant in a dialysis center has a different set of advan-tages and difficulties. Since kidney patients are at dialysis centers weekly or monthly, educators have multiple opportunities for transplant conversations, often over many years. Thus, education can occur when patients are most healthy and interested in learning about it. Dialysis providers also can educate all potential transplant candidates, not just those who present at the transplant center. However, dialysis providers also may have insufficient time or training to administer transplant education,9 may not have access to transplant education materials,10-12 work in dialysis centers unsupportive of transplant discussion, or have a fi nan-cial disincentive to refer for transplant.13 For example, patients at for-profi t dialysis centers have been shown to receive less transplant-related education than patients at non-profit dialysis centers.14 Previous research has shown that dial-ysis patients' knowledge about transplant is poor,15-17 and that patients presenting for transplant evaluation lack knowledge about the benefits of transplant over remaining on dialysis.15, 18 Patients commonly have con-cerns about involving and risking a living donor's health, or fear that the transplanted kidney may fail.19-21 Many patients are also unaware that living donors report positive benefits from donating, including getting to help a loved one and having increased self-worth.22, 23 Multiple randomized controlled trials have shown that improved education about deceased and living donation can sig-nificantly increase patients' knowledge and informed transplant decision-making.24-28 However, with dialysis patients varying in their level of readiness regarding pursu-ing deceased or living-donor transplant, transplant education must be tailored by a patient's level of transplant readiness to support each individual in making an informed transplant choice. Precontemplation: Not considering or not ready to pursue deceased or living-donor transplant. Contemplation: Considering pursuing deceased or living-donor transplant. Preparation: Planning to pursue deceased or living-donor transplant. Action: Have contacted the transplant center and are being evaluated or hav-ing living donors evaluated. Maintenance: Have already contacted the transplant center and have been list-ed or found a matching living donor. Transplant education commonly rec-ommends that patients take actions such as calling a transplant center to initiate evaluation or asking loved ones to con-sider being living donors. These recom-mendations assume that a patient is very close to pursuing transplant and may cause patients who have not yet decided to feel pressured or stop learning. The TTM theory posits that informed transplant deci-sion-making occurs when patients get the opportunity to voice and receive answers to their questions matched to their level of readiness to consider whether transplant could improve their health or quality of life. For these reasons, the ET program assesses a patient's level of transplant readiness and then provides factual infor-mation and recommendations tailored to each patient's stage in their transplant deci-sion-making. There is no one right answer about whether to pursue deceased- or living-donor transplant. ET, therefore, recom-mends that all eligible dialysis patients “explore the option of transplant” and make an informed choice. The program has many advantages for both dialysis provid-ers and the patients they serve (Table II). The program helps patients think about what might motivate them to pursue trans-plant, addresses commonly held concerns about transplant and involving a living donor, shares real-life transplant stories of donors and recipients, and presents a series of small actions that an interested patient could take, if they were interested, to pursue transplant. All medical content of ET has been approved by medical experts in dialysis and transplantation. The ET program won the National Association of Transplant Professionals' (NATCO) Quality of Care Award in 2009. Meeting One: Could getting a trans-plant add anything to this patient's quality of life? Meeting Two: What would it be like to undergo transplant evaluation and surgery? Meeting Three: What would it be like to involve a living donor? Meeting Four: What is the right Transplant Action Plan for this patient? A total of 18 ESRD networks support the federal government in assuring appro-priate care for dialysis patients who receive treatment in certified Medicare facilities in all 50 states. Dr. Waterman partnered with CMS ESRD Network 12, the Heartland Kidney Network, in conducting a transplant education Quality Improvement Initiative in 2009. The Heartland Kidney Network over-sees 273 facilities providing care for more than 13,000 dialysis patients in Missouri, Kansas, Nebraska, and Iowa. The purpose of this initiative was to enhance dialysis providers' transplant knowledge and abil-ity to educate their own patients about deceased and living donation. Of the 273 dialysis centers in the Heartland Network, 201 (74%) sent representatives to the train-ing, with 294 dialysis providers becom-ing trained to administer ET to patients in their facilities. Clinic administrators, nurses, social workers, dieticians, admin-istrative assistants, and dialysis technicians all attended the trainings. During the One-Day Provider Training, dialysis providers discussed bar-riers they were facing in delivering trans-plant education in their facilities. Barriers mentioned included patients being over-whelmed coping with dialysis, having fear and misinformation about transplan-tation, and not understanding they were potential transplant candidates. Provider barriers discussed included having lim-ited medical training in and knowledge about transplant, and lack of time for education. During the training, providers learned how to tailor education based on a patients' readiness to pursue transplant and improved their transplant knowledge and relationships with local transplant centers. They also learned how to administer the four ET meetings with patients and how to track what transplant education occurred in the case of an audit. Providers who completed the training received copies of all the ET print and video materials for dissemination to their patients. Of dialysis providers who attended the training, 94% would recommend it to another health professional. After the training, dialysis providers revealed several strategies they used to suc-cessfully disseminate ET education in their facilities. Some clinic administrators allot-ted more staff time to conducting trans-plant education. Multidisciplinary teams were created to share transplant education responsibilities across shifts and patients in order to reduce the education burden placed on any particular staff member. Providers planned to start small and educate 1 to 5 patients with previously expressed inter-est in transplant to learn how the program would be received. Education about living donation was given to patients already listed on the waiting list to remind them about the possibility and benefits of a living-donor transplant. Finally, patients on home treat-ment modalities were mailed brochures and videos along with their monthly labs to share with their families. In an environment focused on pro-viding excellent dialysis care, transplant education can become a lower priority. However, since transplants within the fi rst 6 months of initiating dialysis result in the best health outcomes,34, 35 one Healthy People 2010 proposed goal is to “increase the proportion of dialysis patients wait-listed and/or receiving a deceased donor kidney transplant within one year of ESRD start.”36 Transplant educators need to meet all patients where they are in their transplant decision-making and educate them about all their ESRD treatment options. This training was conducted under Net-work contract #HHSM-500-2006-NW012C with Centers for Medicare and Medicaid Services, Baltimore, Md. The content pre-sented does not necessarily refl ect CMS policy, and the author assumes full respon-sibility for the accuracy and completeness of the ideas presented. For more informa-tion on the “Explore Transplant” education-al program, call (888) 454-9445 or write to exploretransplant@dom.wustl.edu.

Over the past decade, direct oral anticoagulants (DOACs) have contributed to a major paradigm shift in thrombosis management, replacing vitamin K antagonists as the most commonly prescribed anticoagulants in many countries. While DOACs provide distinct advantages over warfarin (eg, convenience, simplicity, and safety), they are frequently associated with inappropriate prescribing and adverse events. These events have prompted regulatory agencies to mandate oversight, which individual institutions may find difficult to comply with given limited resources. Veterans Health Administration (VHA) has leveraged technology to develop the DOAC Population Management Tool (PMT) to address these challenges. This tool has empowered VHA to update a 60-year standard of care from one-to-one provider-to-patient anticoagulation monitoring to a population-based management approach. The DOAC PMT allows for the oversight of all patients prescribed DOACs and leads to intervention only when clinically indicated. Using the DOAC PMT, facilities across VHA have maximized DOAC oversight while minimizing resource usage. Herein, we discuss how the DOAC PMT was conceived, developed, and implemented, along with the challenges encountered throughout the process. Additionally, we share the impact of the DOAC PMT across VHA, and the potential of this approach beyond anticoagulation and VHA.

Although hospice care for dying patients on dialysis has been recommended in clinical practice guidelines and policy statements of professional nephrology organizations, only a minority of dying patients on dialysis currently receive hospice services. This retrospective qualitative study investigated a variety of factors contributing to the low referral rate for patients with end stage renal disease (ESRD). Interviews (N=338) were conducted with dialysis facility professionals (RN staff nurses, social workers, nurse managers) in ESRD networks 1, 5, and 12 using a standardized telephone survey. The sample (N=448) consisted of patients who discontinued dialysis and died between September 2005 and February 2006. The study illuminated a striking variation by discipline in the understanding of Medicare ESRD benefits and Medicare hospice benefits as they apply to patients with ESRD. Social workers were more knowledgeable that patients on dialysis were eligible for the Medicare hospice benefit while continuing dialysis with a non-kidney-related terminal diagnosis than RN staff nurses or nurse managers (79% of social workers, 64% of nurse managers, and 48% of RN staff nurses were knowledgeable [p < 0.001]). Nurses were significantly more likely than social workers to be uncertain about the process of hospice referral (28% of nurse managers, 17% of RN staf nurses, and 9% of social workers [p < 0.001]). Additionally, the study found that depending on geographic region, hospice programs varied in accepting patients who wish to continue dialysis treatment. This study identified multiple barriers to referral to hospice care ofpatients with ESRD who are dying. It illustrates that hospice organizations, dialysis facilities, and dialysis unit nurses need education regarding the eligibility for Medicare hospice benefits in conjunction with a patient receiving the Medicare ESRD benefit.

Although the central nervous system (CNS) of mammals has had poor prospects for regeneration, recent studies suggest this might improve from blocking "secondary cell loss" or apoptosis. In this regard, intravenous activated protein C (aPC) improved neurologic outcomes in a rat compression spinal cord injury (SCI) model. Protein C activation occurs when the serine protease thrombin binds to the cell surface proteoglycan thrombomodulin (TM) forming a complex that halts coagulation. In culture, rTM blocks thrombin's activation of protease-activated receptors (PARs), that mediate thrombin killing of neurons and glial reactivity. Both PAR1 and prothrombin are rapidly upregulated after contusion SCI in rats, prior to peak apoptosis. We now report neuroprotective effects of intraperitoneal soluble recombinant human rTM on open-field locomotor rating scale (BBB) and spinal cord lesion volume when given 1 h after SCI. BBB scores from four separate experiments showed a 7.6 +/- 1.4 absolute score increase (p < 0.05) at 3 days, that lasted throughout the time course. Histological sections at 14 days were even more dramatic where a twofold reduction in lesion volume was quantified in rTM-treated rats. Thionin staining revealed significant preservation of motor neuronal profiles both at, and two segments below, the lesion epicenter. Activated caspase-3 immunocytochemistry indicated apoptosis was quite prominent in motor neurons in vehicle (saline) controls, but was dramatically reduced by rTM. Microglia, increased and activated after injury, were reduced with rTM treatment. Taken together, these and previous results support a prominent role for coagulation-inflammation signaling cascades in the subacute changes following SCI. They identify a neuroprotective role for rTM by its inhibition of thrombin generation and blockade of PAR activation.

Abstract In this paper we report on what “sustainable agriculture” means to farmers who seek to develop more sustainable farming systems. Group interviews were conducted with two groups of sustainable farmers in Kansas to learn how they developed their respective approaches, the kinds of parameters they have used to evaluate success and progress, and what other evaluation tools would be helpful to them. For the farmers we interviewed, the central meaning of sustainable agriculture is its holistic approach to assets management. It also means an alternative perspective on what constitutes success in farming. While economic considerations are important, they are balanced by other considerations such as environmental quality, quality of life, and the contributions the farmers can make to their communities. Sustainable agriculture also means an approach to agriculture that entails “thinking risks” as much as financial risks. Lastly, sustainable agriculture means whole farm planning; the farmers we interviewed were more interested in applying whole-farm planning principles based on their local knowledge, than in evaluation tools based on the expert knowledge of researchers and other scientists. The implications of what sustainable agriculture means to these farmers for research and educational programs are discussed.

BACKGROUND: Flaws in the science supporting pesticide risk assessment and regulation stand in the way of progress in mitigating the human health impacts of pesticides. Critical problems include the scope of regulatory testing protocols, the near-total focus on pure active ingredients rather than formulated products, lack of publicly accessible information on co-formulants, excessive reliance on industry-supported studies coupled with reticence to incorporate published results in the risk assessment process, and failure to take advantage of new scientific opportunities and advances, e.g. biomonitoring and "omics" technologies. RECOMMENDED ACTIONS: Problems in pesticide risk assessment are identified and linked to study design, data, and methodological shortcomings. Steps and strategies are presented that have potential to deepen scientific knowledge of pesticide toxicity, exposures, and risks. We propose four solutions: (1) End near-sole reliance in regulatory decision-making on industry-supported studies by supporting and relying more heavily on independent science, especially for core toxicology studies. The cost of conducting core toxicology studies at labs not affiliated with or funded directly by pesticide registrants should be covered via fees paid by manufacturers to public agencies. (2) Regulators should place more weight on mechanistic data and low-dose studies within the range of contemporary exposures. (3) Regulators, public health agencies, and funders should increase the share of exposure-assessment resources that produce direct measures of concentrations in bodily fluids and tissues. Human biomonitoring is vital in order to quickly identify rising exposures among vulnerable populations including applicators, pregnant women, and children. (4) Scientific tools across disciplines can accelerate progress in risk assessments if integrated more effectively. New genetic and metabolomic markers of adverse health impacts and heritable epigenetic impacts are emerging and should be included more routinely in risk assessment to effectively prevent disease. CONCLUSIONS: Preventing adverse public health outcomes triggered or made worse by exposure to pesticides will require changes in policy and risk assessment procedures, more science free of industry influence, and innovative strategies that blend traditional methods with new tools and mechanistic insights.

OBJECTIVE: To assess the perceptions and preferences of telemedicine among patients with autoimmune rheumatic diseases during the COVID-19 pandemic. METHODS: We conducted an online survey among patients with autoimmune rheumatic diseases. Attitudes about telemedicine (i.e., telemedicine acceptability), evaluated using the validated Telemedicine Perception Questionnaire (TMPQ), and visit satisfaction were assessed for different telemedicine experiences and types of autoimmune rheumatic disease. RESULTS: Of 3,369 invitations, 819 responses were received. Participants had a mean ± SD age of 58.6 ± 11.6 years and were mostly White (n = 759, or 92.7%) and female (n = 702, or 85.7%). Of the 618 participants who said that telemedicine was available to them, 449 (72.7%) reported having a telemedicine visit, with 303 (67.5%) reporting attending a telemedicine video visit. On a 0 to 10 scale, the mean ± SD visit satisfaction score was 7.3 ± 1.8, with 25.8% of respondents being very satisfied (scores of 9 or 10). Video visits and higher TMPQ scores were associated with higher satisfaction. Compared to those who did not experience a telemedicine visit, patients who did were more likely to prefer telemedicine (video or phone) for routine visits (73.7% versus 44.3%; P < 0.001), reviewing test results (64.8% versus 53.8%; P < 0.001), when considering changing medications (40.5% versus 26.8%; P < 0.001), and when starting a new injectable medication (18.9% versus 12.7%; P = 0.02). CONCLUSION: During the COVID-19 pandemic, patients with autoimmune rheumatic diseases frequently had telemedicine visits, with the majority held via video, and were satisfied with these visits. These results suggest that because patients prefer telemedicine for certain visit reasons, maximizing effective use of telemedicine will require personalized patient scheduling.

There seems to be a unique interplay between 2019 novel coronavirus (SARS-CoV-2) and cardiovascular diseases, although it is predominantly a respiratory illness. Patients with pre-existing cardiovascular co-morbidities appear to be at highest risk for mortality from coronavirus disease 2019 (COVID-19) along with the elderly; COVID-19 also contributes to cardiovascular complications, including acute coronary syndromes, arrhythmias, myocarditis, acute heart failure, and, in the most severe cases, cardiogenic shock and death. Several medications proposed in the treatment of COVID-19 require cardiac monitoring owing to their cardiac-specific adverse effects. Ultimately, the COVID-19 pandemic has jeopardized the safety of heart transplantation and has placed transplant recipients on immunosuppressive therapies at significant risk. In this article, the authors summarize the rapidly emerging data on the cardiovascular implications of SARS-CoV-2 and COVID-19.

BACKGROUND: A data collection tool was developed and nationally deployed to clinical pharmacists (CPs) working in advanced practice provider roles within the Department of Veterans Affairs to document interventions and associated clinical outcomes. Intervention and short-term clinical outcome data derived from the tool were used to populate a validated clinical outcomes modeling program to predict long-term clinical and economic effects. OBJECTIVE: To predict the long-term effect of CP-provided pharmacotherapy management on outcomes and costs for patients with type 2 diabetes. METHODS: Baseline patient demographics and biomarkers were extracted for type 2 diabetic patients having > 1 encounter with a CP using the tool between January 5, 2013, and November 20, 2014. Treatment biomarker values were extracted 12 months after the patient's initial visit with the CP. The number of visits with the CP was extracted from the electronic medical record, and duration of visit time was quantified by Current Procedural Terminology codes. Simulation modeling was performed on 3 patient cohorts-those with a baseline hemoglobin A1c of 8% to < 9%, 9% to < 10%, and ≥ 10%-to estimate long-term cost and clinical outcomes using modeling based on pivotal trial data (the Archimedes Model). A sensitivity analysis was conducted to assess the extent to which our results were dependent on assumptions related to program effectiveness and costs. RESULTS: A total of 7,310 patients were included in the analysis. Analysis of costs and events on 2-, 3-, 5-, and 10-year time horizons demonstrated significant reductions in major adverse cardiovascular events (MACEs), myocardial infarctions (MIs), episodes of acute heart failure, foot ulcers, and foot amputations in comparison with a control group receiving usual guideline-directed medical care. In the cohort with a baseline A1c of ≥ 10%, the absolute risk reduction was 1.82% for MACE, 1.73% for MI, 2.43% for acute heart failure, 5.38% for foot ulcers, and 2.03% for foot amputations. The incremental cost-effectiveness ratios for cost per quality-adjusted life-year during the 2-, 3-, 5-, and 10-year time horizons were cost-effective for the cohorts of patients with a baseline A1c of 9% to < 10% and ≥ 10%. CONCLUSIONS: CPs acting as advanced practice providers reduced A1c from baseline for veterans with type 2 diabetes compared with modeled usual care. Archimedes modeling of the A1c reductions projects a decreased incidence of diabetes complications and overall health care spending when compared with modeled usual care. DISCLOSURES: There was no outside funding source or sponsor for this project. None of the authors report any conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the views or policies of the U.S. Department of Veterans Affairs. Preliminary data from this project were previously presented in abstract form at the Academy of Managed Care Pharmacy 27th Annual Meeting and Expo; April 8-10, 2015; in San Diego, California.

We believe that the current practice in HAI reporting of using estimation approaches rather than quality control approaches to data supply chain validation might be supportable for research. However, we believe that it should not be the standard recommended practice for program managers who need to ensure that their data supply chain produces data of sustainably reliable quality over time to ensure maximum protection of the public’s health. Therefore, we strongly recommend an immediate, synergistic alignment of the state-of-the-art validation acceptance-sampling methods and science currently used widely in industry with the needs and logistics of the tasks involved in collecting, sampling, evaluating, and reporting HAI data. We believe that the American public deserves to have its best technology and its “A Team” on the field in this effort and that involving the ASQ, its Healthcare Division, its quality scientists, and its intellectual capital resources could dramatically improve the HAI quality reporting system. Our people and our healthcare system deserve no less!

PD-L1 is a transmembrane glycoprotein with an extracellular as well as an intracellular cytoplasmic domain. Physiologically, it plays a pivotal role in regulating T-cell activation and tolerance. Many tumor cells have exploited this regulatory mechanism by overexpressing PD-L1 in an effort to escape immunologic surveillance. In this review, we parse the literature regarding the prognostic value of tumoral PD-L1 expression before discussing the various methodologies as well as the pearls and pitfalls associated with each for predicting response to anti-PD-1/PD-L1 therapies. Special attention is given to cutaneous entities in which PD-L1 expression has been documented with an emphasis on cutaneous malignancies that have seen the broadest applications of anti-PD-L1/PD-1 therapies. Currently, immunohistochemistry is the method that is most commonly used for detection of PD-L1. However, with the wide array of immunohistochemistry protocols and staining platforms available in the market, there seems to be different cutoffs not just for different entities but also for the same entity. This review is an attempt to address the need for standardization and validation of existing protocols for PD-L1 detection.