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During a read this post here typical year, where is better to buy renova over a million people visit Yellowstone National Park, where the Old Faithful geyser regularly blasts a jet of boiling water high in the air. Now, an international team of astronomers has discovered a cosmic equivalent, a distant galaxy that erupts roughly every 114 days.Using data from facilities including NASA's Neil Gehrels Swift Observatory and Transiting Exoplanet Survey Satellite (TESS), the scientists have studied 20 repeated outbursts of an event called ASASSN-14ko. These various telescopes and instruments are sensitive where is better to buy renova to different wavelengths of light. By using them collaboratively, scientists obtained more detailed pictures of the outbursts."These are the most predictable and frequent recurring multiwavelength flares we've seen from a galaxy's core, and they give us a unique opportunity to study this extragalactic Old Faithful in detail," said Anna Payne, a NASA Graduate Fellow at the University of Hawai'i at M?. Noa.

"We think a supermassive black hole at the galaxy's center creates the bursts as it partially consumes an orbiting giant star."Payne presented the findings on Tuesday, Jan. 12, at the virtual 237th meeting of the American Astronomical Society. A paper on the source and these observations, led by Payne, is undergoing scientific review.Astronomers classify galaxies with unusually bright and variable centers as active galaxies. These objects can produce much more energy than the combined contribution of all their stars, including higher-than-expected levels of visible, ultraviolet, and X-ray light. Astrophysicists think the extra emission comes from near the galaxy's central supermassive black hole, where a swirling disk of gas and dust accumulates and heats up because of gravitational and frictional forces.

The black hole slowly consumes the material, which creates random fluctuations in the disk's emitted light.But astronomers are interested in finding active galaxies with flares that happen at regular intervals, which might help them identify and study new phenomena and events. advertisement "ASASSN-14ko is currently our best example of periodic variability in an active galaxy, despite decades of other claims, because the timing of its flares is very consistent over the six years of data Anna and her team analyzed," said Jeremy Schnittman, an astrophysicist at NASA's Goddard Space Flight Center in Greenbelt, Maryland, who studies black holes but was not involved in the research. "This result is a real tour de force of multiwavelength observational astronomy."ASASSN-14ko was first detected on Nov. 14, 2014, by the All-Sky Automated Survey for Supernovae (ASAS-SN), a global network of 20 robotic telescopes headquartered at Ohio State University (OSU) in Columbus. It occurred in ESO 253-3, an active galaxy over 570 million light-years away in the southern constellation Pictor.

At the time, astronomers thought the outburst was most likely a supernova, a one-time event that destroys a star.Six years later, Payne was examining ASAS-SN data on known active galaxies as part of her thesis work. Looking at the ESO 253-3 light curve, or the graph of its brightness over time, she immediately noticed a series of evenly spaced flares -- a total of 17, all separated by about 114 days. Each flare reaches its peak brightness in about five days, then steadily dims.Payne and her colleagues predicted that the galaxy would flare again on May 17, 2020, so they coordinated joint observations with ground- and space-based facilities, including multiwavelength measurements with Swift. ASASSN-14ko erupted right on schedule. The team has since predicted and observed subsequent flares on Sept.

7 and Dec. 20.The researchers also used TESS data for a detailed look at a previous flare. TESS observes swaths of the sky called sectors for about a month at a time. During the mission's first two years, the cameras collected a full sector image every 30 minutes. These snapshots allowed the team to create a precise timeline of a flare that began on Nov.

7, 2018, tracking its emergence, rise to peak brightness, and decline in great detail. advertisement "TESS provided a very thorough picture of that particular flare, but because of the way the mission images the sky, it can't observe all of them," said co-author Patrick Vallely, an ASAS-SN team member and National Science Foundation graduate research fellow at OSU. "ASAS-SN collects less detail on individual outbursts, but provides a longer baseline, which was crucial in this case. The two surveys complement one another."Using measurements from ASAS-SN, TESS, Swift and other observatories, including NASA's NuSTAR and the European Space Agency's XMM-Newton, Payne and her team came up with three possible explanations for the repeating flares.One scenario involved interactions between the disks of two orbiting supermassive black holes at the galaxy's center. Recent measurements, also under scientific review, suggest the galaxy does indeed host two such objects, but they don't orbit closely enough to account for the frequency of the flares.The second scenario the team considered was a star passing on an inclined orbit through a black hole's disk.

In that case, scientists would expect to see asymmetrically shaped flares caused when the star disturbs the disk twice, on either side of the black hole. But the flares from this galaxy all have the same shape.The third scenario, and the one the team thinks most likely, is a partial tidal disruption event.A tidal disruption event occurs when an unlucky star strays too close to a black hole. Gravitational forces create intense tides that break the star apart into a stream of gas. The trailing part of the stream escapes the system, while the leading part swings back around the black hole. Astronomers see bright flares from these events when the shed gas strikes the black hole's accretion disk.In this case, the astronomers suggest that one of the galaxy's supermassive black holes, one with about 78 million times the Sun's mass, partially disrupts an orbiting giant star.

The star's orbit isn't circular, and each time it passes closest to the black hole, it bulges outward, shedding mass but not completely breaking apart. Every encounter strips away an amount of gas equal to about three times the mass of Jupiter.Astronomers don't know how long the flares will persist. The star can't lose mass forever, and while scientists can estimate the amount of mass it loses during each orbit, they don't know how much it had before the disruptions began.Payne and her team plan to continue observing the event's predicted outbursts, including upcoming dates in April and August 2021. They'll also be able to examine another measurement from TESS, which captured the Dec. 20 flare with its updated 10-minute snapshot rate."TESS was primarily designed to find worlds beyond our solar system," said Padi Boyd, the TESS project scientist at Goddard.

"But the mission is also teaching us more about stars in our own galaxy, including how they pulse and eclipse each other. In distant galaxies, we've seen stars end their lives in supernova explosions. TESS has even previously observed a complete tidal disruption event. We're always looking forward to the next exciting and surprising discoveries the mission will make."Video. Https://www.youtube.com/watch?.

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Patients are more likely to experience preventable harm during renova hand center san antonio perioperative care than in any other type of healthcare encounter.1 2 For several decades, a hallmark of surgical quality and safety has been the use of checklists to prevent errors (eg, wrong site surgery) and assure that key tasks have been or will be performed. The most widely used approach globally is the Surgical Safety Checklist (SSC) recommended by the WHO.3 It is divided into preinduction (or sign in, consisting renova hand center san antonio of seven items performed by anaesthesia and nursing), preincision (timeout, 10 items performed by the entire team) and postsurgery (sign out, five items by the entire team).4 5 Most hospitals in the developed world perform the SSC or an equivalent timeout prior to surgical incision. However, preinduction briefings, and postcase debriefings in particular, are much less commonly performed.6 7There are widely disseminated arguments recommending the use of checklists in healthcare8 but also recognised limitations.9 Checklist-based preincision timeouts appear to improve surgical outcomes in many settings,4 5 yet, in other hospitals, the introduction of the SSC failed to improve outcomes.10 Like all tools or processes intended to improve safety, ineffective implementation will reduce the desired benefits. For example, there is appreciable evidence showing that surgical teams skip or do not meaningfully respond to timeout checklist items.11 12 Even with a robust implementation, effectiveness can be renova hand center san antonio weakened by contextual factors, failure of leadership or deficient safety culture.Despite numerous studies, gaps in the evidence to guide optimal checklist use persist.

For example, we do not know whether checklist-based timeouts only decrease the occurrence of the undesirable events targeted by the checklist or, as many hypothesise, whether their use also facilitates teamwork and interprofessional communication. Although there is increasing guidance on how to optimally implement checklists at the local level, many questions remain.13 Moreover, we still do not understand the circumstances in which checklist use facilitates the detection, reporting and correction of errors.In this issue of the journal, Muensterer and colleagues14 describe a clever study in which the attending renova hand center san antonio surgeon intentionally introduced errors during the preincision timeout while a medical student in the operating theatre surreptitiously noted whether the error was detected and reported by one or more members of the surgical team. If the error was not verbalised, the attending surgeon corrected the error before the timeout was complete. The single error renova hand center san antonio embedded in each of 120 of 1800 paediatric operations was randomly chosen from among wrong patient name, age, gender, allergy or surgical procedure, side or site.

Overall, only about half (65. 54%) of all renova hand center san antonio errors were detected and reported by a team member prior to surgeon correction. Of these, errors were most commonly reported by the anaesthesiologist (64%) and almost never by residents in training (6%) or medical students (1%).This study also has important limitations. Because the investigators were leading renova hand center san antonio the timeouts as part of a research study, adherence to all of the checklist items was reportedly 100%.

Yet, few organisations consistently attain timeout adherence above 90%.11 Since you are less likely to catch an error if you do not address that item during the timeout, in institutions with lower adherence, the proportion of missed errors may be even higher.The authors, with input from their institutional review board, designed the study to be feasible and compliant with established human subjects protection principles. As such, renova hand center san antonio the attending surgeon always corrected the error after the anaesthesiologistâs component of the timeout but before the nursesâ component. By excluding the part of the timeout when the nurses address their checklist items (eg, instruments are sterile,) followed by a final opportunity as the timeout ends to note any errors or concerns, the study may have underestimated the rate of error reporting.Because the study did not query team members individually after the timeout, we also do not know how many errors were detected but not annunciated. For example, recognised errors that were attributed to âmisspeakingâ and/or had no clinical significance may not have been renova hand center san antonio verbally challenged.

Moreover, as is discussed by the authors, there was an unequivocal hierarchy effectâindividuals with the least âpowerâ (ie, low in hierarchy within the current healthcare culture) were the least likely to report the error.This study highlights two important safety relevant questions on which I will elaborate. First, why and how should we change renova hand center san antonio healthcare culture to facilitate âspeaking upâ?. Second, how can we best design and implement checklists and other safety interventions to yield more consistent and sustained clinician behaviour change?. The continued problem of hierarchical culture in healthcareThe significant influence of hierarchy on the renova hand center san antonio incidence of error reporting in Muensterer et alâs14 study is consistent with substantial prior evidence that lower hierarchy clinical providers are less likely to âspeak upâ, even when they are aware of major safety violations.15â17Failure of a subordinate copilot to challenge or speak up to the captain in the 1977 Tenerife disaster was the impetus for the aviation industryâs adoption of crew resource management (CRM).

Healthcare team-training initiatives like the Agency for Healthcare Research and Qualityâs TeamSTEPPS now include tools such as the âtwo-challenge ruleâ and emphasise speaking up.18 Flattened hierarchies and reliance on expertise rather than seniority, especially during crisis or stress, are an integral component of high-reliability organisations. In contrast, the persistent hierarchical renova hand center san antonio culture of healthcare is anathema to positive safety attitudes and behaviours. This is particularly problematic in operating theatres where surgeons view themselves as âcaptain of the shipâ and where uncivil behaviour is tolerated.19 The insidious effects of hierarchy will impair effectiveness of checklist use and predispose to safety issues in all aspects of routine and emergency care.20 While team-oriented training designed to enhance the ability of lower hierarchy clinicians to âspeak upâ can be effective,21 22 evidence to guide the design and implementation of these interventions is still sparse. Single training renova hand center san antonio exposures have generally had limited effects,17 23 in part likely due to inadequate âpotencyâ to achieve the desired effect24 in a clinical environment contaminated by the hierarchical culture and in part because most interventions have focused on âassertivenessâ training for the less powerful members of the team rather than, or in addition to, sensitivity or receptivity training of the most powerful (eg, surgical attendings).17Discussions of power hierarchy to date have largely focused on cliniciansâ professional roles (ie, nurse vs physician) and level of experience (eg, resident vs attending).

Even with two attending physicians, for example, a surgeon and anaesthesiologist, power dynamics can degrade communication and decrease team performance. In a multicentre study of experienced anaesthesiologists managing simulated crisis events, the anaesthesiologistsâ failure to challenge the surgeon to initiate life-saving interventions (eg, to open the abdomen in the presence of an enlarging retroperitoneal renova hand center san antonio haematoma during laparoscopic surgery, or to halt surgery to cardiovert an unstable patient) was associated with lower overall scenario performance scores as determined by trained blinded anaesthesiologist video raters.25In fact, hierarchy is much more complex and this may explain in part the variable and generally weak results seen in âspeaking upâ intervention studies to date. When considering hierarchical effects on communication assertiveness, one must also consider individual characteristics including gender, race/ethnicity, language, personal cultural background and personality, as well as the personality of those in higher power roles, microclimate factors of the team and care unit, and overall organisational culture.17 22 An interesting direction for future study is the facilitation of more positive communication (eg, expressions of gratitude or encouragement).26In a single-site intervention study to improve the quality of handovers from anaesthesia professionals to postanaesthesia care unit (PACU) nurses,27 simulation-based training emphasised specific dyadic communication behavioursâassertiveness for the nurses when their needs were not being met and âsensitivityâ (or receptiveness) for the anaesthesia professionals when the nurses raised concerns. In poststudy interviews, this behavioural focus was considered an important contributor to the renova hand center san antonio resulting sustained improvement in the quality of actual handovers.

As part of this study, we explicitly taught participants to CUSS. CUSS is a renova hand center san antonio graduated approach to facilitate speaking up. The acronym stands for âIâm Concernedâ, âIâm Uncomfortableâ, âThis is a Safety issueâ and âStop!. Â.

The intended learners were taught these âtriggersâ for eliciting desired behaviours (ie, to stop what they are doing and have a conversation with the initiator) and this approach creates an environment where the initiating individual can receive support from others who overhear the conversationââDoctor, I hear that Maria is CUSSing at you?. How can I help to resolve this situation?. Â Such a graded assertiveness approach to âstop the lineâ, developed in other industries, is increasingly being used throughout healthcare.28Designing and implementing more effective safety tools and processesSSCs are just one tool used to advance overall perioperative system safety. Similarly, in commercial aviation, checklists are one tool used as part of CRM to assure operational safety.

CRM is a philosophy or construct that includes explicit values and principles, procedures supported by purpose-designed checklists and other tools, and regularly scheduled mandatory simulation-based training and assessment that together contribute to an existing safety culture in pilots and across the organisation.29 CRM and most of the existing aviation safety system were iteratively designed by pilots (the front-line workers) in collaboration with other stakeholders (including regulators). Healthcare must employ similar human-centred design approaches to re-engineer our safety systems.For commercial aviation to be completely safe, no planes would fly. Similarly, safety will never be the foremost system objective in healthcare. The primary goal is to efficiently deliver cost-effective care.

Instead, in any high-consequence industry, safety is a desirable by-product (an âemergent featureâ) of a system designed to achieve primary operational goals. In healthcare, sick patients must be treated and there is inherent risk in doing so.30 Achieving societally acceptable levels of safety will stem from a deliberately designed system founded on a strong safety culture and truly committed leadership.With this as background, it is not surprising that so many hospitals struggle to garner reliable and sustained benefit from the use of checklists and other safety tools. To understand what is required, I would like to draw parallels with anaesthesiologyâs experience of implementing another type of checklist.The Food and Drug Administration Anesthesia Machine Pre-Use ChecklistThe earliest checklist used in healthcare to reduce adverse events is the anaesthesia equipment preuse checklist, developed in 1987 by the US Food and Drug Administration (FDA) in collaboration with the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists.31 After more than three decades of use, lessons learnt from the use of the FDA checklist parallel more recent experiences with SSCs, and are instructive to a more general understanding of the role of safety tools in healthcare (see table 1).View this table:Table 1 Lessons learnt from 30 years of personal experience with and reflection about the Anesthesia Equipment Pre-Use Checklist*A checklist alone is insufficient to achieve optimal resultsHospitals that get the best results from an SSC implementation are often well-resourced organisations that already have safety-oriented committed leadership, a strong safety culture, educated and engaged front-line clinicians and an established track record of successfully implementing other safety interventions.32 That said, any hospital, given adequate commitment, resources and expertise, can implement an SSC or other substantive safety intervention successfully. In doing so, it will educate and engage its workers, improve its safety culture and set the stage for further safety and quality improvements.A multimodal approach to safety interventions is more effective.

Hospitals that were able to successfully implement all three components of the SSC saw greater reductions in postoperative complications.33 Similarly, the combination of the SSC with a complementary approach that more fully addresses preoperative and postoperative issues, the Surgical Patient Safety System, was associated with better postoperative outcomes than use of the WHO SSC alone.34 The most effective interventions are those that are based on an integrated conceptual framework and follow human factor principles, especially when the safety goals are multiple or diverse.35In our PACU handover improvement project mentioned earlier,27 the multimodal intervention produced a fourfold improvement in observed clinician behaviours (ie, conduct of actual handovers) that was sustained for at least 3âyears after the intervention ceased. The project began by getting perioperative leadership buy-in, conducting observations of the current handover process and engaging front-line clinicians in all phases of study development. The criteria for an âacceptable handoverâ were chosen by an independent team of clinicians. Front-line clinicians first completed a multimedia introductory webinar that included key principles and a knowledge assessment.

To attend the 2-hour simulation training session, both anaesthesia professionals and PACU nurses were relieved from regular clinical duties (a strong message that this was an organisational priority). A custom patient-specific electronic form was available at every bedside in the PACU to reinforce the training during actual handovers. Performance feedback was provided to individuals, units and perioperative leadership. The number of components needed for successful safety interventions will depend on the behaviour change desired, the existing safety culture, current experience and expertise of the intended end users and the priority articulated by organisational leaders.

Regardless, design and implementation must be based on a solid conceptual framework, consider the full life-cycle of the intervention (from conceptualisation to obsolescence) and employ human factors engineering and implementation science principles and tools.13ConclusionChecklists and other safety tools are potentially valuable tools to advance perioperative safety. However, when used in isolation or implemented incorrectly, checklists have significant limitations. Safety initiatives that take a systems-oriented multimodal approach to design and implementation can, with organisational leadership and determination, produce both targeted and more general safety improvement.Ethics statementsPatient consent for publicationNot required.Many patients admitted to hospital require venous access to infuse medications and fluids. The most commonly used device, the peripheral venous catheter, ranges from 2.5 to 4.5 cm in length, and is typically used for less than 5 days.

The midline, a relatively newer peripheral venous catheter, is up to 20 cm in length, but does not reach the central veins, and may be used for up to 2 weeks. A peripherally inserted central venous catheter (PICC) is a longer catheter that is placed in one of the arm veins and extends to reach the central veins. The PICC is used for longer periods of time compared with peripheral intravenous devices, and initially gained popularity as a convenient vascular access device used in the outpatient and home settings. Its premise has been to provide access that lasts for weeks, that is fairly safe and easily manageable.

Patients often require central venous access when hospitalised, with more than half of patients in intensive care, and up to 20% in those cared for in the non-intensive care wards.1 Common indications for PICC use in the acute care setting include the requirement for multiple and frequent infusions (eg, antibiotics, parenteral nutrition), the administration of medications incompatible with peripheral infusion, invasive haemodynamic monitoring in critically ill patients, very poor venous access and frequent need for blood draws.2 Specially trained healthcare workers place PICCs, often nurses from a vascular access team (VAT), or interventional radiologists. The VAT is comprised of skilled nurses, with either medical/surgical, emergency department or intensive care unit backgrounds. Contrary to other healthcare workers that place PICCs, the VATâs primary function is to place PICCs, and optimise the infusion delivery, through a safe and effective process. Its scope includes assessment for need, peripheral and central device insertion, monitoring of use and removal.3In their study of five hospitals within the Veterans Administration (VA) healthcare systems in the USA, Krein et al4 underscore the importance of a formal VAT to formulate and implement explicit appropriateness criteria, ensure timely insertion and safe management and direct patient education around PICC use.

They found that team structures supporting line placement vary across hospitals from a dedicated team, to individual nurses trained in placement, to hospitals where only interventional radiologists insert PICCs. The presence of a VAT was associated with more defined criteria for PICC use, but a recurrent theme was inadequate interdisciplinary dialogue. Although qualitative data were gathered at five VA hospitals only, the studyâs findings reflect the variation in PICC placement and use, whether in academic or community, small or large hospitals.An important factor in variation in the approach to PICC line placement and management is the availability of resources and expertise at the hospital site. For example, if healthcare workers have suboptimal skills to place peripheral venous catheters, including midlines,5 clinicians may resort to ordering more PICCs unnecessarily to fill that void.

Furthermore, as revealed in Kreinâs study, a hospital that does not have the expertise to learn about alternative devices, such as those with lower risks and shorter dwell times (eg, midlines), may resort to using more PICCs than necessary. Similarly, hospitals without clinicians skilled or comfortable placing other central lines6 may rely more on using PICCs. In addition, the lack of an available VAT to place PICCs using uasound guidance may result in more referrals to interventional radiology for placement, potentially exposing the patient to avoidable radiation during fluoroscopy.7We propose an approach to improve the appropriate and safe use of PICCs by focusing on three elements that address the findings by Krein and colleagues. Establishing a structure powered by a VAT.

Anchoring a standardised process for line selection, insertion and care. And promoting adoption by engagement with the key stakeholders.Establishing a structure to support placement and management of PICCs depends on whether the number of devices placed is enough to support the creation of a dedicated vascular access programme. Leadership plays a critical role to invest the resources for a functional VAT, understanding the financial and quality benefits associated.8 Not realising its value, hospital leaders may view the VAT as a non-revenue-generating service, putting it at risk when considering cost reduction strategies. The value of the VAT expands from mitigating preventable events (eg, deep venous thrombosis, ) to enhancing patient experience (eg, less attempts to place a peripheral device).9 In addition, better outcomes help curb the financial risks (eg, hospital-acquired condition penalties)8 and improve hospital ratings.

The VATâs role encompasses placing PICCs and guaranteeing the proper selection of the intravascular device and its appropriate use.2The second element involves standardising processes for line selection and care, regardless of who is taking care of the device. Implementing policies to address indications, placement and maintenance and using standardised kits help minimise variation. The creation of policies should be achieved through a multidisciplinary approach with VAT, nurses and physicians. The VAT can act as the âgate keeperâ evaluating whether the reason for PICC placement is aligned with indications.

In addition, the VAT plays a critical role supporting nursesâ competencies for venous catheter use (eg, aseptic access and maintenance, addressing complications and mitigating risk)10 to reduce mechanical11 and infectious complications.12 The VAT performs regular rounds to mitigate process gaps (eg, dressing site intactness) and to identify complications (eg, PICC site erythema or drainage, arm swelling), and provides timely feedback on clinical performance. The VAT can also serve as subject matter experts to the ordering physicians for the appropriate device type, based on vessel size and indications for use, how many lumens, site selection and a de-escalation plan for the patient prior to discharge. It also provides services should a device-related complication occur (eg, clotting), and works with clinicians to remedy the issue and salvage the device, thereby preventing a patient from losing their vascular access and/or having to replace it.The last element, and perhaps most significant, is to enhance the adoption of best practices through a partnership with the key stakeholders. PICC-associated outcomes are not only owned by the VAT, rather it is the responsibility of the clinicians, physicians and nurses to achieve those goals (table 1).

Physicians are an essential stakeholder group to engage as they are the ones responsible for ordering the PICC. An identified physician champion who partners and empowers the VAT will help resolve any barriers and be a liaison with the local physician community.13 The ideal physician champion should have the respect of peers, understand process optimisation and promote quality improvement. They need to be well versed on the appropriate indications for PICC use, the associated complications and risks and alternatives to the device. The physician champion engages the leaders of the key disciplines responsible for requesting a PICC, educating them on the appropriate indications for use, the outcomes associated with PICC use, inviting them to be partners and responding to any of their concerns.View this table:Table 1 Disciplines and their support to mitigate PICC harmWhat about the key physician disciplines to engage?.

Physicians can play an active role in enhancing PICC use through avoiding the unnecessary use of infusions. The consultation of infectious diseases specialists for intravenous antibiotic use appropriateness has been associated with less PICC use and lower complications.14 Similarly, having a surgeon support the decision for whether enteral or parenteral nutrition is needed will help reduce unnecessary device use.15 Disciplines like hospitalists or general internists care for a large number of patients and often order PICCs for venous access,16 while nephrologists may advocate avoiding the use of PICCs in the chronic kidney disease population in an effort for vein preservation.17 In hospitals with teaching programmes, the VAT and its physician champion may educate physicians in training on device choice, placement and duration of use, and address with their faculty competencies for line management.18 Engaging these disciplines, elucidating the indications for appropriate use and providing feedback and local data on the potential harm ensure accountability and further attention to PICC safety.In summary, the PICC is one of the primary solutions to achieve vascular access. With up to one in five patients at risk for developing complications,19 it is incumbent on us to ensure that these devices are properly used and maintained. Identifying and overcoming system barriers are key to delivering sustainable safe outcomes.

As a first step, clinical and administrative leaders, realising the financial and quality benefits, need to support the structure reflected by the VAT to enhance PICC care. Second, the VAT must partner with disciplines (particularly nursing) to promote and ensure adequate competencies for placement and maintenance. Finally, clinical disciplines caring for the patient should instil a collaborative environment for better decision-making on when central access is required, and what device provides the safest and most effective delivery of care.Ethics statementsPatient consent for publicationNot required..

Patients are more likely to experience preventable harm during perioperative care than in any other type of healthcare encounter.1 2 For several decades, http://johannameyers.com/buy-zithromax-with-free-samples a hallmark of surgical quality and safety has been where is better to buy renova the use of checklists to prevent errors (eg, wrong site surgery) and assure that key tasks have been or will be performed. The most where is better to buy renova widely used approach globally is the Surgical Safety Checklist (SSC) recommended by the WHO.3 It is divided into preinduction (or sign in, consisting of seven items performed by anaesthesia and nursing), preincision (timeout, 10 items performed by the entire team) and postsurgery (sign out, five items by the entire team).4 5 Most hospitals in the developed world perform the SSC or an equivalent timeout prior to surgical incision. However, preinduction briefings, and postcase debriefings in particular, are much less commonly performed.6 7There are widely disseminated arguments recommending the use of checklists in healthcare8 but also recognised limitations.9 Checklist-based preincision timeouts appear to improve surgical outcomes in many settings,4 5 yet, in other hospitals, the introduction of the SSC failed to improve outcomes.10 Like all tools or processes intended to improve safety, ineffective implementation will reduce the desired benefits. For example, there is appreciable evidence showing that surgical teams skip or do not meaningfully respond to timeout checklist items.11 12 Even with a robust implementation, effectiveness can be weakened by contextual factors, failure of leadership or deficient where is better to buy renova safety culture.Despite numerous studies, gaps in the evidence to guide optimal checklist use persist.

For example, we do not know whether checklist-based timeouts only decrease the occurrence of the undesirable events targeted by the checklist or, as many hypothesise, whether their use also facilitates teamwork and interprofessional communication. Although there is increasing guidance on how to optimally implement checklists at the local level, many questions remain.13 Moreover, we still do not understand the circumstances in which checklist use facilitates the detection, reporting and correction of errors.In this issue of the journal, Muensterer and colleagues14 describe where is better to buy renova a clever study in which the attending surgeon intentionally introduced errors during the preincision timeout while a medical student in the operating theatre surreptitiously noted whether the error was detected and reported by one or more members of the surgical team. If the error was not verbalised, the attending surgeon corrected the error before the timeout was complete. The single error embedded in each of 120 of 1800 paediatric operations was where is better to buy renova randomly chosen from among wrong patient name, age, gender, allergy or surgical procedure, side or site.

Overall, only about half (65. 54%) of all errors were detected and where is better to buy renova reported by a team member prior to surgeon correction. Of these, errors were most commonly reported by the anaesthesiologist (64%) and almost never by residents in training (6%) or medical students (1%).This study also has important limitations. Because the investigators were leading the timeouts as part of a research study, adherence to all of the where is better to buy renova checklist items was reportedly 100%.

Yet, few organisations consistently attain timeout adherence above 90%.11 Since you are less likely to catch an error if you do not address that item during the timeout, in institutions with lower adherence, the proportion of missed errors may be even higher.The authors, with input from their institutional review board, designed the study to be feasible and compliant with established human subjects protection principles. As such, the attending surgeon always corrected the error after the anaesthesiologistâs component of the timeout but where is better to buy renova before the nursesâ component. By excluding the part of the timeout when the nurses address their checklist items (eg, instruments are sterile,) followed by a final opportunity as the timeout ends to note any errors or concerns, the study may have underestimated the rate of error reporting.Because the study did not query team members individually after the timeout, we also do not know how many errors were detected but not annunciated. For example, where is better to buy renova recognised errors that were attributed to âmisspeakingâ and/or had no clinical significance may not have been verbally challenged.

Moreover, as is discussed by the authors, there was an unequivocal hierarchy effectâindividuals with the least âpowerâ (ie, low in hierarchy within the current healthcare culture) were the least likely to report the error.This study highlights two important safety relevant questions on which I will elaborate. First, why and how should we change healthcare culture to facilitate âspeaking upâ? where is better to buy renova. Second, how can we best design and implement checklists and other safety interventions to yield more consistent and sustained clinician behaviour change?. The continued problem of hierarchical culture in healthcareThe significant influence of hierarchy on the incidence of error reporting in Muensterer et alâs14 study is consistent with substantial prior where is better to buy renova evidence that lower hierarchy clinical providers are less likely to âspeak upâ, even when they are aware of major safety violations.15â17Failure of a subordinate copilot to challenge or speak up to the captain in the 1977 Tenerife disaster was the impetus for the aviation industryâs adoption of crew resource management (CRM).

Healthcare team-training initiatives like the Agency for Healthcare Research and Qualityâs TeamSTEPPS now include tools such as the âtwo-challenge ruleâ and emphasise speaking up.18 Flattened hierarchies and reliance on expertise rather than seniority, especially during crisis or stress, are an integral component of high-reliability organisations. In contrast, where is better to buy renova the persistent hierarchical culture of healthcare is anathema to positive safety attitudes and behaviours. This is particularly problematic in operating theatres where surgeons view themselves as âcaptain of the shipâ and where uncivil behaviour is tolerated.19 The insidious effects of hierarchy will impair effectiveness of checklist use and predispose to safety issues in all aspects of routine and emergency care.20 While team-oriented training designed to enhance the ability of lower hierarchy clinicians to âspeak upâ can be effective,21 22 evidence to guide the design and implementation of these interventions is still sparse. Single training exposures have generally had limited effects,17 23 in part likely due to inadequate âpotencyâ to achieve the desired effect24 in a clinical environment contaminated by the hierarchical culture and in part because most interventions have focused on âassertivenessâ training for the less powerful members of the team rather than, or in addition to, sensitivity or receptivity training of the most powerful (eg, surgical attendings).17Discussions of power hierarchy to date where is better to buy renova have largely focused on cliniciansâ professional roles (ie, nurse vs physician) and level of experience (eg, resident vs attending).

Even with two attending physicians, for example, a surgeon and anaesthesiologist, power dynamics can degrade communication and decrease team performance. In a multicentre study of experienced anaesthesiologists managing simulated crisis events, the anaesthesiologistsâ failure to challenge the surgeon to initiate life-saving interventions (eg, to open the where is better to buy renova abdomen in the presence of an enlarging retroperitoneal haematoma during laparoscopic surgery, or to halt surgery to cardiovert an unstable patient) was associated with lower overall scenario performance scores as determined by trained blinded anaesthesiologist video raters.25In fact, hierarchy is much more complex and this may explain in part the variable and generally weak results seen in âspeaking upâ intervention studies to date. When considering hierarchical effects on communication assertiveness, one must also consider individual characteristics including gender, race/ethnicity, language, personal cultural background and personality, as well as the personality of those in higher power roles, microclimate factors of the team and care unit, and overall organisational culture.17 22 An interesting direction for future study is the facilitation of more positive communication (eg, expressions of gratitude or encouragement).26In a single-site intervention study to improve the quality of handovers from anaesthesia professionals to postanaesthesia care unit (PACU) nurses,27 simulation-based training emphasised specific dyadic communication behavioursâassertiveness for the nurses when their needs were not being met and âsensitivityâ (or receptiveness) for the anaesthesia professionals when the nurses raised concerns. In poststudy interviews, this behavioural focus was where is better to buy renova considered an important contributor to the resulting sustained improvement in the quality of actual handovers.

As part of this study, we explicitly taught participants to CUSS. CUSS is where is better to buy renova a graduated approach to facilitate speaking up. The acronym stands for âIâm Concernedâ, âIâm Uncomfortableâ, âThis is a Safety issueâ and âStop!. Â.

What may interact with Renova?

medicines or other preparations that may dry your skin such as benzoyl peroxide or salicylic acid
medicines that increase your sensitivity to sunlight such as tetracycline or sulfa drugs

This list may not describe all possible interactions. Give your health care provider a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

Renova paracentesis pump

There are renova paracentesis pump not enough health workers in California to meet the needs Lasix for dogs cost of the stateâs increasingly diverse, growing, and aging population, and the situation is getting worse. In 2019, 39 percent of Californians identified as Latinx, but only 14 percent of medical school students and 6 percent of active patient care physicians in California were Latinx.Researchers from Mathematica, with support from the California Health Care Foundation, recently reviewed evidence from key health workforce policy interventions to determine their impact on access to health care, the diversity of the health workforce, and providersâ ability to deliver services in a language other than English (âlanguage concordanceâ). The evidence review included academic literature and interviews renova paracentesis pump of key experts in the field. It focused on health professions that require an advanced degree, because it has been particularly challenging to improve access, diversity, and language concordance through these jobs.âThere have been many public and private efforts in California to increase the number and diversity of health professionals, but they have not been sufficient to alleviate the crisis,â said Diane Rittenhouse, a senior fellow at Mathematica.

ÂIn a year with a state budget surplus, this report reviews evidence and presents options for public investment to improve health care access and health workforce diversity.â Mathematicaâs researchers concluded that a blended approach is necessary to achieve better renova paracentesis pump health care access and improve the diversity of the health workforce. For example, loan repayment in exchange for a commitment to serve in a medically underserved area of California is a quick way to improve access to primary care, behavioral health, and dentistry in those areas. Improving the diversity of the workforce, renova paracentesis pump however, requires support for a diverse array of college students to succeed in Californiaâs health professional training programs. Ultimately, underserved rural and urban areas are more likely to retain health professionals who are from those areas, and interventions that seek to engage those professionals will likely have the greatest impact.

Read the renova paracentesis pump report here. For more information on the report or on health workforce challenges in California, please contact Todd Kohlhepp.Despite the important mission of adult education to provide adults with the competencies they need to succeed in the workforce and achieve economic self-sufficiency, policymakers and practitioners have limited evidence on effective strategies for improving adult learnersâ outcomes. The Workforce Innovation and Opportunity Act (WIOA) Title II, the key federal investment helping adults acquire important skills and credentials to succeed in the workplace, encourages adult education programs to use evidence-based renova paracentesis pump strategies to improve services and participant success. A new review of existing research, authored by staff at Mathematica for the Institute of Education Sciences at the U.S.

Department of Education, identifies some promising strategies and a need for more rigorous studies to guide decision making around successful strategies for adult renova paracentesis pump learners. The available evidence provides limited support for the use of particular adult education strategies over others, although bridge classes and integrated education and training programs offer some promise. The authors also note opportunities for the field to prioritize research investments renova paracentesis pump to increase the evidence base. Namely, under WIOA, Title II requires adult education programs to collect data on skill gains, educational progress, employment, and earnings for program participants.

These data offer opportunities to examine adult education strategies that might improve these learner outcomes renova paracentesis pump. The emphasis in WIOA on longer term educational attainment and labor market outcomes also provides opportunities for research on strategies with an increased focus on improving adult learner transitions to postsecondary education or to better jobs and higher earnings, outcomes for which reliable data sources exist.âThis systematic review provides some guidance for the field to make progress on its goals of helping adult learners obtain the competencies they need to be productive workers, family members, and citizens,â noted project director Alina Martinez. This research can help policymakers and local providers target their resources to help adult learners achieve higher earnings and career success.âRead the IES snapshot..

There are not enough health workers in California to meet the needs of this contact form the stateâs increasingly diverse, growing, and aging population, where is better to buy renova and the situation is getting worse. In 2019, 39 percent of Californians identified as Latinx, but only 14 percent of medical school students and 6 percent of active patient care physicians in California were Latinx.Researchers from Mathematica, with support from the California Health Care Foundation, recently reviewed evidence from key health workforce policy interventions to determine their impact on access to health care, the diversity of the health workforce, and providersâ ability to deliver services in a language other than English (âlanguage concordanceâ). The evidence review where is better to buy renova included academic literature and interviews of key experts in the field. It focused on health professions that require an advanced degree, because it has been particularly challenging to improve access, diversity, and language concordance through these jobs.âThere have been many public and private efforts in California to increase the number and diversity of health professionals, but they have not been sufficient to alleviate the crisis,â said Diane Rittenhouse, a senior fellow at Mathematica.

ÂIn a year with a state budget surplus, this report reviews evidence and presents options for public investment to improve health care access and health workforce diversity.â Mathematicaâs researchers concluded that a blended approach is necessary to achieve better health care access and improve where is better to buy renova the diversity of the health workforce. For example, loan repayment in exchange for a commitment to serve in a medically underserved area of California is a quick way to improve access to primary care, behavioral health, and dentistry in those areas. Improving the diversity of the workforce, however, requires support where is better to buy renova for a diverse array of college students to succeed in Californiaâs health professional training programs. Ultimately, underserved rural and urban areas are more likely to retain health professionals who are from those areas, and interventions that seek to engage those professionals will likely have the greatest impact.

Read the report here where is better to buy renova. For more information on the report or on health workforce challenges in California, please contact Todd Kohlhepp.Despite the important mission of adult education to provide adults with the competencies they need to succeed in the workforce and achieve economic self-sufficiency, policymakers and practitioners have limited evidence on effective strategies for improving adult learnersâ outcomes. The Workforce Innovation and Opportunity Act (WIOA) Title II, where is better to buy renova the key federal investment helping adults acquire important skills and credentials to succeed in the workplace, encourages adult education programs to use evidence-based strategies to improve services and participant success. A new review of existing research, authored by staff at Mathematica for the Institute of Education Sciences at the U.S.

Department of Education, identifies some promising strategies and a need for more rigorous studies to guide decision making around successful strategies for adult where is better to buy renova learners. The available evidence provides limited support for the use of particular adult education strategies over others, although bridge classes and integrated education and training programs offer some promise. The authors also note opportunities where is better to buy renova for the field to prioritize research investments to increase the evidence base. Namely, under WIOA, Title II requires adult education programs to collect data on skill gains, educational progress, employment, and earnings for program participants.

These data offer opportunities to examine adult education strategies that might improve these learner outcomes where is better to buy renova. The emphasis in WIOA on longer term educational attainment and labor market outcomes also provides opportunities for research on strategies with an increased focus on improving adult learner transitions to postsecondary education or to better jobs and higher earnings, outcomes for which reliable data sources exist.âThis systematic review provides some guidance for the field to make progress on its goals of helping adult learners obtain the competencies they need to be productive workers, family members, and citizens,â noted project director Alina Martinez. This research can help policymakers and local providers target their resources to help adult learners achieve higher earnings and career success.âRead the IES snapshot..

Renova paper

Credit online pharmacy renova renova paper. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form of permanent alopecia renova paper in this population. The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the renova paper scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries.

During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over. The prevalence renova paper of those with fibroids was compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids. The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, renova paper sex and race matched controls.

Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. ÂThe cause renova paper of the link between the two conditions remains unclear,â she says. However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other renova paper disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

The other authors on renova paper this paper were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit. The New England Journal of Medicine Share Fast Facts This study renova paper clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumorâs DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors.

- Click to Tweet The âmutational burden,â or the number of mutations present in a tumorâs DNA, is a renova paper good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows. The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide renova paper future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells. As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an .

These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced renova paper melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma. The mutational burden of certain tumor types has previously been proposed as an explanation for renova paper why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to renova paper immune checkpoint inhibitors across many different cancer types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different renova paper tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer typeâs mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational renova paper burden of that cancer.

ÂThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive. Itâs one of those things that doesnât sound right when renova paper you hear it,â says Hopkins. ÂBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.â Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare renova paper and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a renova, which seems to encourage a strong immune response despite the cancerâs lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these renova paper drugs havenât yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well renova paper to this class of immunotherapy drugs. ÂThe end goal is precision medicineâmoving beyond whatâs true for big groups of patients to see whether we can use this information to help any given patient,â he says.

Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

Credit. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form of permanent alopecia in this population. The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries.

During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over. The prevalence of those with fibroids was compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids. The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls.

Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. ÂThe cause of the link between the two conditions remains unclear,â she says. However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

The other authors on this paper were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit. The New England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumorâs DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors.

- Click to Tweet The âmutational burden,â or the number of mutations present in a tumorâs DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows. The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells. As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an .

These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma. The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer typeâs mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer.

ÂThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive. Itâs one of those things that doesnât sound right when you hear it,â says Hopkins. ÂBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.â Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a renova, which seems to encourage a strong immune response despite the cancerâs lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs havenât yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. ÂThe end goal is precision medicineâmoving beyond whatâs true for big groups of patients to see whether we can use this information to help any given patient,â he says.

Spartherm renova b

Implementation of accountable care organizations (ACOs) low price renova has spartherm renova b been occurring unevenly across the nation, with rural areas lagging behind their more urban counterparts in ACO establishment (for example, see here, here, and here). To help establish ACOs in more areas of the country, the Centers for Medicare and Medicaid Services (CMS) developed the ACO Investment Model (AIM) to provide participating ACOs with up-front and ongoing monthly payments over 24 months to fund ACO infrastructure investments and staffing. As part spartherm renova b of the Medicare Shared Savings Program (SSP), the payments were to be recouped through any shared savings earned by the ACOs that sufficiently decreased costs relative to a financial benchmark, as specified by SSP regulations. Forty-one new SSP ACOs, primarily located in rural and underserved health care markets, joined AIM in 2016 (exhibit 1).In this blog post, we discuss several noteworthy observations from our evaluation of the AIM ACO implementation and impacts over the three performance years (2016 to 2018), pertaining to:AIM ACOsâ close partnerships with management companies;Strategiesâbeyond local care coordinationâfor reducing spending in dispersed markets.

AndThe extent to which single-sided financial risk may suffice to induce care transformations.The full report is available here.Exhibit 1. AIM accountable care organization geographic locations spartherm renova b in 2018Source. Authorsâ analysis of Centers for Medicare and Medicaid Services data. Notes.

Figure shows primary care service areas (PCSAs) in which AIM ACOsâ assigned beneficiaries resided. We included PCSAs for which at least 0.5 percent of an ACOâs attributed beneficiaries resided. There was one AIM ACO with providers and assigned beneficiaries located in Guam, which is not shown in the figure.Small, Rural ACOs Relied Heavily On Management CompaniesA majority of AIM ACOs (35 of 41, or 85 percent) used specialized consulting firms (or management companies) to assist with setting up and operating the ACO. Management companies typically coordinated reporting, conducted claims-based analytics, and served as the liaison between the ACO participants and CMS officials.

Caravan Health managed 21 of the AIM ACOs, providing a fairly standard set of shared services to all of its client ACOs. Services included training for care coordinators and patient navigators, population health coaching, learning networks and workshops, analytics support through a centralized health information technology platform, and financial reporting. By contrast, a study analyzing data from the National Survey of ACOs, which surveyed ACOs formed between 2012 and 2015, showed that around one-third of ACOs had a management partner.In interviews with leaders from all 41 AIM ACOs, many stated that management companies played an important role by supporting them in navigating ACO start-up, managing ongoing operations, and providing access to services shared with other ACOs. AIM ACO leadership expressed general satisfaction with management company services.

At the same time, some AIM ACOs emphasized the need for greater due diligence when making larger investments in management company offerings. For example, some AIM ACOs found elements of the health information technology system and services selected by their management companies too costly given the capabilities offered.We also found that some AIM ACOs had become less dependent on their management companies over time and had developed sufficient internal capacity and expertise to function more independently. However, for those ACOs still requiring management company services, it is unclear whether ACOs can continue to pay for them without ongoing AIM-type funding. Furthermore, while management companies may have provided important services in the initial years of AIM, 27 of the 35 (77 percent) AIM ACOs with management company affiliations exited SSP by 2020.

CMS and other researchers should continue to investigate the relationships among ACOs and management companiesâand how they evolve.Dispersed, Rural ACOs Sought Alternatives To Local Care Coordination To Reduce SpendingThrough interviews with ACO leadership and staff, we determined that about 90 percent of the 41 AIM ACOs were collections of independent practices rather than large organizations owning many practices. Thus, one might expect these practices to have been centrally located. However, many ACOs were composed of practices that spanned multiple local markets, at least in part as a result of management company involvement. Management companies had the ability toâand didâbring together unrelated entities, sometimes across regions or states to meet the minimum SSP requirement of 5,000 attributed beneficiaries and spread financial risk.

Indeed, only around 30 percent of AIM ACOs were composed of participants that were located in geographically proximate counties. While a common perception has been that local coordination of care among providers within an ACO would be a major driver of ACO financial success, ACOs serving relatively small, dispersed, and rural populations may have needed to use other strategies to improve care and earn shared savings.Looking at different care settings helps to elucidate how AIM ACOs reduced spending. We found statistically significant reductions across a number of spending components (the following reflect results from the final performance year, 2018), including acute inpatient (-4 percent), hospital outpatient and ambulatory surgery centers (-4 percent), skilled nursing facilities (SNFs) (-8 percent), and home health (-8 percent). This breakdown is similar to that found for programwide savings in the first three years of the SSP among physician group ACOs, which similarly exhibited greater relative reductions in areas thought to be greater sources of wasteful care (for example, postacute facility care) and was not clearly attributable to prevention efforts.

Admissions for ambulatory careâsensitive conditions were not reduced, and spending reductions were not concentrated among high-risk patients targeted by case management programs. Our findings for cheap generic renova AIM are similarly consistent with efforts to directly limit certain types of care use and the much stronger incentives physician practices have to do so. Physician practices do not incur offsetting losses in fee-for-service profits when reducing spending on care provided by hospitals, SNFs, or home health agencies. In short, the less of the care continuum provided by an ACO, the stronger its incentives to lower spending.Our evaluation thus highlights that, in spite of a lack of geographic proximity, AIM ACOs overall were able to significantly reduce costs.

Moreover, management company executives and ACO staff stated in interviews that they did not think proximity mattered for ACO success. In interviews, executives from two management companies, which collectively managed 25 of the 41 AIM ACOs, had similar responses when we asked them about the topic of geographic contiguity of providers within a given ACO. They stated that the geographic distribution of providers minimally influenced the ACOsâ abilities to reduce unnecessary care and, ultimately, costs. One management company reported that it implemented a standard set of practice management services, tools, and approaches to transforming clinic workflows, which would have been similar whether the ACO providers were located in the same city or more dispersed.The fact that ACOs may be successful without substantial collaboration in their localities may encourage rural providers that are considering value-based payment models but lack a concentrated local network of potential collaborators.

At the same time, management companies may play important roles in facilitating care transformations by pooling risk and overcoming fixed costsâfor a price.Does One-Sided Risk Provide Sufficient Inducement For Rural Providers To Offer Quality Accountable Care?. When the Medicare Shared Savings Program was redesigned under Pathways to Success, it allowed for newly formed and small ACOs to still start in a one-sided (shared savingsâonly) risk track but required them to move to two-sided risk (both shared savings and losses) more quickly than under the prior program rules. Two-sided financial risk strengthens incentives for ACOs to lower spending. However, among smaller ACOs, uncertainty about spending is amplified and rural providers in particular may struggle to participate in voluntary models that come with a 10 percent chance of having to repay CMS millions of dollars each year.

Our multiyear, mixed-methods evaluation (reports can be found here), which integrated findings from ACO surveys and interviews, as well as claims data analyses, showed that rural providers are capable of reducing some wasteful spending when sufficient investments are made, thereby supporting delivery system improvements that are at least budget neutral. Specifically, AIM ACOs that took on only one-sided financial risk were consistently able to decrease spending and maintain quality for three straight years. We found that AIM resulted in net savings to CMS of $382 million through 2018 (that is, gross savings less earned shared savings and unrecouped payments from CMS)âan average annual reduction of 2.5 percent compared to baseline spending levels.Many of the ACOs we interviewed were hesitant to take on two-sided financial risk, even at the end of AIM. This is not surprising, given only 54 percent of AIM ACOs earned any shared savings.

ACOs rightly viewed one-sided risk-sharing contracts as carrying downside risk, particularly after AIM funding ceasedâif they did not generate savings, they would not recoup the costs of trying. ACO leaders cited a host of concerns about. Size (in terms of attributed patients), their participant networks, operational capacities to handle the analytics they believed would be necessary to manage risk-taking, and other organizational factors. While management companies played key roles in helping new ACOs operate, only seven of the 41 AIM ACOs (17 percent) had accepted two-sided risk arrangements by the end of AIM in 2018.

This suggests that any mitigation of downside risk offered by management companies was prohibitively costly for AIM ACOs without continued investment funding.ConclusionThe ACO Investment Model demonstrated that underresourced providers can successfully reduce enough wasteful spending to offset the costs of delivery system investments, even under an upside-only financial risk model. Management companies played an important supportive role by providing services that individual ACOs lacked the necessary scale in which to invest. Looking forward, they may play additional roles in pooling risk to shield small providers with limited reserves from deleterious penalties, although doing so defeats the purpose of introducing downside risk at the provider level and could weaken incentives to participate if management companies must charge higher fees to cover potential losses.As ACO benchmarks increasingly reflect regional spending under âPathways to Success,â management companies may be inclined to strategically include practices with low spending for their region. Thus, it will be important to track the implications of key features of ACO model designâsuch as benchmarking and risk adjustmentâon ACO formation and evolution.

If geographic centralization is not integral to ACO success, it may open new doors in care deliveryâan important finding in light of the ongoing renova and renewed focus on telehealth.Authorsâ NoteThe authors acknowledge David Nyweide and Catherine Hersey.This work was supported by the Centers for Medicare and Medicaid Services (CMS) (contract number, HHSM50020140026I. Task order number, HHSM500T0004). The statements contained herein are those of the authors and do not necessarily reflect the views or policies of CMS..

Implementation of accountable care organizations (ACOs) has been occurring unevenly across the http://robertroyer.com/2011/08/17/leading-from-behind/ nation, with where is better to buy renova rural areas lagging behind their more urban counterparts in ACO establishment (for example, see here, here, and here). To help establish ACOs in more areas of the country, the Centers for Medicare and Medicaid Services (CMS) developed the ACO Investment Model (AIM) to provide participating ACOs with up-front and ongoing monthly payments over 24 months to fund ACO infrastructure investments and staffing. As part of the Medicare Shared Savings Program (SSP), the payments were to be recouped through any shared savings earned by the ACOs that sufficiently decreased costs relative to a where is better to buy renova financial benchmark, as specified by SSP regulations. Forty-one new SSP ACOs, primarily located in rural and underserved health care markets, joined AIM in 2016 (exhibit 1).In this blog post, we discuss several noteworthy observations from our evaluation of the AIM ACO implementation and impacts over the three performance years (2016 to 2018), pertaining to:AIM ACOsâ close partnerships with management companies;Strategiesâbeyond local care coordinationâfor reducing spending in dispersed markets. AndThe extent to which single-sided financial risk may suffice to induce care transformations.The full report is available here.Exhibit 1.

AIM accountable care organization geographic locations in where is better to buy renova 2018Source. Authorsâ analysis of Centers for Medicare and Medicaid Services data. Notes. Figure shows primary care service areas (PCSAs) in which AIM ACOsâ assigned beneficiaries resided. We included PCSAs for which at least 0.5 percent of an ACOâs attributed beneficiaries resided.

There was one AIM ACO with providers and assigned beneficiaries located in Guam, which is not shown in the figure.Small, Rural ACOs Relied Heavily On Management CompaniesA majority of AIM ACOs (35 of 41, or 85 percent) used specialized consulting firms (or management companies) to assist with setting up and operating the ACO. Management companies typically coordinated reporting, conducted claims-based analytics, and served as the liaison between the ACO participants and CMS officials. Caravan Health managed 21 of the AIM ACOs, providing a fairly standard set of shared services to all of its client ACOs. Services included training for care coordinators and patient navigators, population health coaching, learning networks and workshops, analytics support through a centralized health information technology platform, and financial reporting. By contrast, a study analyzing data from the National Survey of ACOs, which surveyed ACOs formed between 2012 and 2015, showed that around one-third of ACOs had a management partner.In interviews with leaders from all 41 AIM ACOs, many stated that management companies played an important role by supporting them in navigating ACO start-up, managing ongoing operations, and providing access to services shared with other ACOs.

AIM ACO leadership expressed general satisfaction with management company services. At the same time, some AIM ACOs emphasized the need for greater due diligence when making larger investments in management company offerings. For example, some AIM ACOs found elements of the health information technology system and services selected by their management companies too costly given the capabilities offered.We also found that some AIM ACOs had become less dependent on their management companies over time and had developed sufficient internal capacity and expertise to function more independently. However, for those ACOs still requiring management company services, it is unclear whether ACOs can continue to pay for them without ongoing AIM-type funding. Furthermore, while management companies may have provided important services in the initial years of AIM, 27 of the 35 (77 percent) AIM ACOs with management company affiliations exited SSP by 2020.

While a common perception has been that local coordination of care among providers within an ACO would be a major driver of ACO financial success, ACOs serving relatively small, dispersed, and rural populations may have needed to use other strategies to improve care and earn shared savings.Looking at different care settings helps to elucidate how AIM ACOs reduced spending. We found statistically significant reductions across a number of spending components (the following reflect results from the final performance year, 2018), including acute inpatient (-4 percent), hospital outpatient and ambulatory surgery centers (-4 percent), skilled nursing facilities (SNFs) (-8 percent), and home health (-8 percent). This breakdown is similar to that found for programwide savings in the first three years of the SSP among physician group ACOs, which similarly exhibited greater relative reductions in areas thought to be greater sources of wasteful care (for example, postacute facility care) and was not clearly attributable to prevention efforts. Admissions for ambulatory careâsensitive conditions were not reduced, and spending reductions were not concentrated among high-risk patients targeted by case management programs. Our findings for AIM are similarly consistent with efforts to directly limit certain types of care use and the much stronger incentives physician practices have pop over to this web-site to do so.

Physician practices do not incur offsetting losses in fee-for-service profits when reducing spending on care provided by hospitals, SNFs, or home health agencies. In short, the less of the care continuum provided by an ACO, the stronger its incentives to lower spending.Our evaluation thus highlights that, in spite of a lack of geographic proximity, AIM ACOs overall were able to significantly reduce costs. Moreover, management company executives and ACO staff stated in interviews that they did not think proximity mattered for ACO success. In interviews, executives from two management companies, which collectively managed 25 of the 41 AIM ACOs, had similar responses when we asked them about the topic of geographic contiguity of providers within a given ACO. They stated that the geographic distribution of providers minimally influenced the ACOsâ abilities to reduce unnecessary care and, ultimately, costs.

One management company reported that it implemented a standard set of practice management services, tools, and approaches to transforming clinic workflows, which would have been similar whether the ACO providers were located in the same city or more dispersed.The fact that ACOs may be successful without substantial collaboration in their localities may encourage rural providers that are considering value-based payment models but lack a concentrated local network of potential collaborators. At the same time, management companies may play important roles in facilitating care transformations by pooling risk and overcoming fixed costsâfor a price.Does One-Sided Risk Provide Sufficient Inducement For Rural Providers To Offer Quality Accountable Care?. When the Medicare Shared Savings Program was redesigned under Pathways to Success, it allowed for newly formed and small ACOs to still start in a one-sided (shared savingsâonly) risk track but required them to move to two-sided risk (both shared savings and losses) more quickly than under the prior program rules. Two-sided financial risk strengthens incentives for ACOs to lower spending. However, among smaller ACOs, uncertainty about spending is amplified and rural providers in particular may struggle to participate in voluntary models that come with a 10 percent chance of having to repay CMS millions of dollars each year.

As rural providers are not subject to Quality Payment Program adjustments, they face weaker incentives to participate in a risk track that qualifies as an Advanced Alternative Payment Model. That is, opting to decline participation in a two-sided risk model does not mean incurring the costs of complying with the complex Merit-based Incentive Payment System (MIPS). It is possible that one-sided financial risk might suffice to spur development of ACOs that improve care efficiency in areas that previously had little accountable care activity. In fact, the added protection of one-sided financial risk might be necessary to induce ACOs to form in such areas. Our multiyear, mixed-methods evaluation (reports can be found here), which integrated findings from ACO surveys and interviews, as well as claims data analyses, showed that rural providers are capable of reducing some wasteful spending when sufficient investments are made, thereby supporting delivery system improvements that are at least budget neutral.

Specifically, AIM ACOs that took on only one-sided financial risk were consistently able to decrease spending and maintain quality for three straight years. We found that AIM resulted in net savings to CMS of $382 million through 2018 (that is, gross savings less earned shared savings and unrecouped payments from CMS)âan average annual reduction of 2.5 percent compared to baseline spending levels.Many of the ACOs we interviewed were hesitant to take on two-sided financial risk, even at the end of AIM. This is not surprising, given only 54 percent of AIM ACOs earned any shared savings. ACOs rightly viewed one-sided risk-sharing contracts as carrying downside risk, particularly after AIM funding ceasedâif they did not generate savings, they would not recoup the costs of trying. ACO leaders cited a host of concerns about.

Size (in terms of attributed patients), their participant networks, operational capacities to handle the analytics they believed would be necessary to manage risk-taking, and other organizational factors. While management companies played key roles in helping new ACOs operate, only seven of the 41 AIM ACOs (17 percent) had accepted two-sided risk arrangements by the end of AIM in 2018. This suggests that any mitigation of downside risk offered by management companies was prohibitively costly for AIM ACOs without continued investment funding.ConclusionThe ACO Investment Model demonstrated that underresourced providers can successfully reduce enough wasteful spending to offset the costs of delivery system investments, even under an upside-only financial risk model. Management companies played an important supportive role by providing services that individual ACOs lacked the necessary scale in which to invest. Looking forward, they may play additional roles in pooling risk to shield small providers with limited reserves from deleterious penalties, although doing so defeats the purpose of introducing downside risk at the provider level and could weaken incentives to participate if management companies must charge higher fees to cover potential losses.As ACO benchmarks increasingly reflect regional spending under âPathways to Success,â management companies may be inclined to strategically include practices with low spending for their region.

Thus, it will be important to track the implications of key features of ACO model designâsuch as benchmarking and risk adjustmentâon ACO formation and evolution. If geographic centralization is not integral to ACO success, it may open new doors in care deliveryâan important finding in light of the ongoing renova and renewed focus on telehealth.Authorsâ NoteThe authors acknowledge David Nyweide and Catherine Hersey.This work was supported by the Centers for Medicare and Medicaid Services (CMS) (contract number, HHSM50020140026I. Task order number, HHSM500T0004). The statements contained herein are those of the authors and do not necessarily reflect the views or policies of CMS..