Blue Cross Blue Shield of Michigan Foundation

Pancreatic cancer (PC) is among the most lethal cancers. The lack of effective tools for early detection results in late tumor detection and, consequently, high mortality rate. Precision oncology aims to develop targeted individual treatments based on advanced computational approaches of omics data. Biomarkers, such as global alteration of cytosine (CpG) methylation, can be pivotal for these objectives. In this study, we performed DNA methylation profiling of pancreatic cancer patients using circulating cell-free DNA (cfDNA) and artificial intelligence (AI) including Deep Learning (DL) for minimally invasive detection to elucidate the epigenetic pathogenesis of PC. The Illumina Infinium HD Assay was used for genome-wide DNA methylation profiling of cfDNA in treatment-naïve patients. Six AI algorithms were used to determine PC detection accuracy based on cytosine (CpG) methylation markers. Additional strategies for minimizing overfitting were employed. The molecular pathogenesis was interrogated using enrichment analysis. In total, we identified 4556 significantly differentially methylated CpGs (q-value < 0.05; Bonferroni correction) in PC versus controls. Highly accurate PC detection was achieved with all 6 AI platforms (Area under the receiver operator characteristics curve [0.90-1.00]). For example, DL achieved AUC (95% CI): 1.00 (0.95-1.00), with a sensitivity and specificity of 100%. A separate modeling approach based on logistic regression-based yielded an AUC (95% CI) 1.0 (1.0-1.0) with a sensitivity and specificity of 100% for PC detection. The top four biological pathways that were epigenetically altered in PC and are known to be linked with cancer are discussed. Using a minimally invasive approach, AI, and epigenetic analysis of circulating cfDNA, high predictive accuracy for PC was achieved. From a clinical perspective, our findings suggest that that early detection leading to improved overall survival may be achievable in the future.

Summary For the past 25 years in Michigan, the Collaborative Quality Initiatives (CQIs) have taken a cooperative bottom-up approach to health care quality improvement. Made up of physician organizations and hospitals around the state and led by local clinicians who set the quality improvement agenda, the CQIs rely on an approach that uses granular data collection, analysis, and transparency to develop and implement practice improvements to support a learning health system. The quality improvement work of the CQIs is administered directly by clinician leaders who direct statewide consortiums of their peers. Each CQI is financially supported by Blue Cross Blue Shield of Michigan. There are currently 23 active CQIs, each of which focuses on a specific clinical specialty or challenge. In this article, the authors review the processes and results of this collaborative approach to health care quality improvement.

The clinical use of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is explicitly stated as a goal for both the DSM Fourth Edition and DSM Fifth Edition (DSM-5) revisions. Many uses assume a relatively faithful application of the DSM diagnostic definitions. However, studies demonstrate significant discrepancies between clinical psychiatric diagnoses with those made using structured interviews suggesting that clinicians do not systematically apply the diagnostic criteria. The limited information regarding how clinicians actually use the DSM raises important questions: a) How can the clinical use be improved without first having a baseline assessment? b) How can potentially significant shifts in practice patterns based on wording changes be assessed without knowing the extent to which the criteria are used as written? Given the American Psychiatric Association's plans for interim revisions to the DSM-5, the value of a detailed exploration of its actual use in clinical practice remains a significant ongoing concern and deserves further study including a number of survey and in vivo studies.

The School Nutrition Advances Kids project tested the effectiveness of school-initiated and state-recommended school nutrition practice and policy changes on student dietary intake in low-income middle schools. Schools recruited by an application for grant funding were randomly assigned to (1) complete an assessment of nutrition education, policies, and environments using the Healthy School Action Tools (HSAT) and implement an action plan, (2) complete the HSAT, implement an action plan, and convene a student nutrition action team, (3) complete the HSAT and implement an action plan and a Michigan State Board of Education nutrition policy in their cafeteria à la carte, or (4) a control group. All intervention schools were provided with funding and assistance to make self-selected nutrition practice, policy, or education changes. Block Youth Food Frequency Questionnaires were completed by 1176 seventh-grade students from 55 schools at baseline and during eighth-grade follow-up. Nutrient density and food group changes for the intervention groups were compared to the control group, controlling for baseline dietary intake values, gender, race/ethnicity, school kitchen type, urbanization, and percent of students eligible for free or reduced-price meals. Analyses were conducted by randomization and based on changes the schools self-selected. Improvements in students' nutrient density and food group intake were found when schools implemented at least three new nutrition practice changes and established at least three new nutrition policies. Students in schools that introduced mostly healthful foods in competitive venues at lunch demonstrated the most dietary improvements. New USDA nutrition standards for à la carte and vending will likely increase the healthfulness of middle school children's diets.

Teamwork is essential for patient safety and results in less missed nursing care. The aim of this study was to test the impact of a train-the-trainer intervention on the level of satisfaction with nursing teamwork and the amount of missed nursing care. This study used a quasiexperimental design with repeated measures taken at pretest, posttest, and 2 months after completion of the intervention. The sample for this study was the nursing staff on three medical-surgical units in three separate acute care hospitals (one unit in each hospital). Three nurses from each unit underwent a training program and then taught the skills and knowledge they acquired to the staff members on their units in three-hour-long sessions. The training involved staff role-playing scenarios based on teamwork problems that occur regularly on inpatient units in acute care hospitals followed by debriefing, which focused on teamwork behaviors (e.g., leadership, team orientation, backup, performance monitoring) and missed nursing care. Four measures were used to test the efficacy of this intervention: The Nursing Teamwork Survey, the MISSCARE Survey, and questions about the knowledge of and satisfaction with teamwork. Return rates for the surveys ranged from 73% to 84%. Follow-up tests individually comparing pretest, posttest, and delayed posttest were conducted within the mixed model and used the Bonferroni correction for multiple comparisons. Teamwork increased (F = 6.91, df = 259.01, p = .001) and missed care decreased (F = 3.59, df = 251.29, p = .03) over time. Nursing staff also reported a higher level of satisfaction with teamwork and an increase of teamwork knowledge after the intervention. The intervention tested in this study shows promise of being an effective and efficient approach to increase nursing teamwork and decrease missed nursing care.