HealthCare Partners Medical Group

To evaluate the long-term safety and clinical effect of INO-3107 immunotherapy in adults with recurrent respiratory papillomatosis (RRP). RRP-002 was a retrospective, observational extension study that followed patients enrolled in the 52-week RRP-001 study. Patients with moderate to severe juvenile or adult-onset RRP who had undergone ≥ 2 surgical interventions in the year preceding dosing were eligible for enrollment in RRP-001. Participants underwent surgical debulking within 14 days prior to initial dosing and then received INO-3107 on Day 0, Weeks 3, 6, and 9. Efficacy assessments during RRP-002 follow-up were the frequency of surgical interventions and alternative medication use. The safety evaluation included reported serious adverse events (SAEs). Twenty-eight (28) of 32 participants from the 52-week RRP-001 study were enrolled in RRP-002. The median follow-up time for RRP-002 was 1.8 years (range: 1.2-2.4 years) for a total median assessment time of 2.8 years (range: 1.0-3.5 years). There were no SAEs or long-term safety concerns identified. The mean number of surgeries was reduced from 4.1 in the pre-treatment period to 1.7 in the first year post-INO-3107 treatment (Year 1) to 0.9 in the second year (Year 2). The complete response rate (0 surgeries per year) increased from 28% (9/32) in Year 1 to 50% (14/28) in Year 2. INO-3107 is well tolerated and provides a continued clinical effect against HPV-6 and 11 RRP that results in further reduction of the surgical burden observed in Year 1. These data support the role of INO-3107 immunotherapy for adult patients with RRP. III.

Temporal variability and methodological differences in data normalization, among other factors, complicate effective trend analysis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) wastewater surveillance data and its alignment with coronavirus disease 2019 (COVID-19) clinical outcomes. As there is no consensus approach for these analyses yet, this study explored the use of piecewise linear trend analysis (joinpoint regression) to identify significant trends and trend turning points in SARS-CoV-2 RNA wastewater concentrations (normalized and non-normalized) and corresponding COVID-19 case rates in the greater Las Vegas metropolitan area (Nevada, USA) from mid-2020 to April 2023. The analysis period was stratified into three distinct phases based on temporal changes in testing protocols, vaccination availability, SARS-CoV-2 variant prevalence, and public health interventions. While other statistical methodologies may require fewer parameter specifications, joinpoint regression provided an interpretable framework for characterization and comparison of trends and trend turning points, revealing sewershed-specific variations in trend magnitude and timing that also aligned with known variant-driven waves. Week-level trend agreement corroborated previous findings demonstrating a close relationship between SARS-CoV-2 wastewater surveillance data and COVID-19 outcomes. These findings guide future applications of advanced statistical methodologies and support the continued integration of wastewater-based epidemiology as a complementary approach to traditional COVID-19 surveillance systems.

Polypharmacy is commonly encountered by providers caring for patients with medically complex and palliative care needs in many settings. The purpose of this quality improvement project was to measure the impact of an evidence-based educational deprescribing intervention on polypharmacy rate and provider confidence and knowledge in the nursing home. We invited providers working in 52 nursing homes to attend a 1-hour-long educational deprescribing session. Twenty-one nurse practitioners and 1 physician assistant across 11 states participated in the intervention. Provider confidence level related to deprescribing improved in all categories, with statistical significance demonstrated with both paired t test and Wilcoxon signed rank test ( P < .001). The polypharmacy rate 3 months after the intervention decreased more in centers where a provider had attended the training. Additional open-ended data about experiences with and barriers to deprescribing were collected and analyzed. The findings from this quality improvement project demonstrate that an educational intervention focused on providers practicing in the nursing home setting can improve deprescribing confidence and reduce polypharmacy rates. These findings may be used to implement similar deprescribing education programs for palliative care nurses and providers that prioritize goals of care for patients living with serious illness.

Pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) are severe but highly treatable postinfectious inflammatory brain conditions. Despite published diagnostic and treatment guidelines for this condition, there are long delays in obtaining appropriate care. The reasons for these delays are poorly understood. We sought to identify health care system barriers to timely treatment by examining cases of PANDAS/PANS occurring in children of health care professionals. We recruited families via e-mail request through the PANDAS Physicians Network. Participating parents completed a structured questionnaire and provided a written case description. Eleven families completed data collection, representing a broad spectrum of disease (child disease onset age 4-15, 7 males/4 females, mild to severe). Parents included 11 physicians, 2 mental health professionals, 2 nurses, and a PharmD. Nine cases (82%) had "very delayed" diagnosis and treatment (>4 weeks after onset). The most commonly encountered causes for treatment delay were clinician lack of awareness (82%), clinician skepticism (82%), overdependence on diagnostic testing (91%), and out-of-pocket expenses >$100 US (82%). Other common challenges included difficulties finding a provider to spearhead care (64%), psychological misdiagnosis (55%), and children's suppression of behaviors during assessments (55%). We found numerous barriers to treatment of PANDAS/PANS among children of health care providers. Our findings suggest that even among the medically sophisticated, PANDAS/PANS diagnosis and treatment remains challenging. Improvement in PANDAS/PANS education of clinicians who may encounter children with this disorder is 1 key step toward addressing our identified barriers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

BACKGROUND AND AIM: There is a growing body of evidence that pre-pregnancy exposure to ambient air pollution is associated with fecundity and pregnancy, however much existing evidence depends on poorly quantified exposure measures. This study uses highly resolved exposure predictions for ambient air pollution in biologically critical pre-pregnancy windows in a population undergoing in vitro fertilization (IVF) to estimate if air pollutants are associated with adverse IVF outcomes. METHODS: This study includes individuals initiating a first IVF cycle from 2012-2013 at one of four clinics. Participant characteristics and cycle outcomes were extracted from medical records. PM2.5, NO2, and NOx were estimated using a highly resolved city-specific spatiotemporal prediction models. Exposures were estimated for 2 and 8-week periods prior to cycle initiation representing biologically critical time periods. Outcomes evaluated included percent oocytes fertilized, embryo grade, clinical pregnancy, and live birth. Poisson and linear regression were used to evaluate binary and continuous outcomes, respectively. RESULTS:There were 4,756 eligible participants with a mean age of 35. Mean 2-week exposures were 9.5 µg/m3 for PM2.5, 9.6 ppb for NO2, and 14.5 ppb for NOx. We did not detect associations between any exposure and embryo quality, pregnancy, and live birth. Across pollutants, exposure was associated with a small but consistently lower fertilization rate. We found 0.13% (95% CI: -0.24, -0.02), 0.04% (95% CI: -0.07, -0.01), and 0.01% (95% CI: -0.02, -0.01) lower percent oocytes fertilized with a 2 µg/m3 PM2.5, 6ppb NO2, and 11ppb NOX 2-week average exposure, respectively. Results for an 8-week exposure were similar. CONCLUSIONS:These findings support recent studies which indicate a link between air pollution, fertility, and fecundity. The results of this study indicate that recent exposure to ambient air pollution may be related fecundity, though the effects seen here are not clinically relevant. Further work in characterizing this early time period is necessary. KEYWORDS: fecundity, fertility, pregnancy, air pollution

As the new graduate nurse transitions from academia to practice, they commit to lifelong learning to enhance their professional and personal growth. This article provides a comparison between bachelor of science in nursing and associate degree nursing nurses who participated in a multisite national nurse residency program between 2015 and 2019 in areas of professional development, leadership, and academic progression during their initial 3 years of practice. It also provides nursing professional development practitioners with strategies from two national experts to support new graduate nurses during early practice.

NA

Objectives: While the value of glycemic control to minimize adverse health outcomes among patients with diabetes is clear, achieving hemoglobin A1c (A1c) goals remain a challenge. We evaluated the use of financial incentives to increase enrollment and improve glycemic control among patients invited to participate in a monthly diabetes group appointment (DGA) as part of their enrollment in DaVita HealthCare Partners, a large southern California managed care organization. Methods: Adult diabetes patients (≥18 years) with a currently uncontrolled hemoglobin A1c level (>8.0% if 9.0% if ≥ 65 years) were randomized to 1) no DGA, 2) DGA with no financial incentives (non-incentive DGA) or 3) DGA with financial incentives (incentive DGA). Results: Nine sites among four regions of the greater Los Angeles area participated. Each site offered one non-incentive DGA and one incentive DGA. Over 1500 patients were identified for recruitment and at the peak of enrollment, 299 patients were enrolled in 18 DGAs. On average, hemoglobin A1c values dropped more for patients participating in the incentive DGA (9.9% to 8.7%, -1.2%) versus non-incentive DGA (9.7% to 9.0%, -0.7%) versus no DGA group (9.1% to 8.7%, -0.4%). Several unexpected implementation challenges arose which complicated evaluation but provide important learning lessons. Conclusions: Management of chronic diseases like diabetes is challenging for patients and the primary care system alike. Continuing to implement and evaluate programs under “real-world” conditions can provide further insight into how best to support patients with diabetes and their primary care teams in order to achieve glycemic control and avoid preventable complications.

Zusammenfassung Ziel Die postoperative Behandlung und frühzeitige Mobilisierung nach der Implantation eines künstlichen Gelenkersatzes ist für den Heilungsprozess von essenzieller Bedeutung. Die vorliegende Arbeit evaluiert die Kosteneffektivität von zwei therapeutischen Optionen für Patienten nach Knie- Endoprothesenimplantation. Methodik Im Rahmen einer Modellrechnung basierend auf einer in Deutschland durchgeführten klinischen Studie wurden mittels Entscheidungsbaum-Analysen die Effektivität und die Kostenfaktoren der Therapieoptionen „ambulante Rehabilitation“ und „stationäre Rehabilitation“ verglichen. Die Effektparameter wurden der deutschen Studie von Sauer und Egermann entnommen, die Kostenfaktoren basieren auf einer Literaturrecherche. Das gesundheitsökonomische Modell ist eine Kosten-Effektivitäts-Analyse für den Rehabilitationszeitraum von drei Wochen. Die Kosten-Effektivität der Behandlungsalternativen wurde zu drei Beobachtungszeitpunkten (postoperativ nach 6, 12 und 52 Wochen) berechnet. Zur Überprüfung der Robustheit der Ergebnisse wurden Sensitivitätsanalysen durchgeführt. Ergebnis Nach dreiwöchiger Rehabilitationsbehandlung fallen Kosten in Höhe von 2845,50 € für die stationäre und 1565,25 € (bzw. bei maximalem Schienenpreis 1625,25 €) für die ambulante Therapie an. Zum ersten postoperativen Untersuchungszeitpunkt (6 Wochen postoperativ) wurden unter Betrachtung des Knee Society Scores (KSS) effektivitäts-adjustierte Kosten in Höhe von 17,28 € (17,94 €) (Verumgruppe) und 35,66 € (Kontrollgruppe) generiert. Bei Betrachtung des Bewegungsumfanges in Flexion entstehen effektivitäts-adjustierte Kosten von 13,69 € (14,22 €) (Verumgruppe) und 28,26 € (Kontrollgruppe) und unter Berücksichtigung des Oxford Scores wurden effektivitäts-adjustierte Kosten von 41,96 € (43,57 €) (Verumgruppe) und 91,79 € (Kontrollgruppe) generiert. Die Ergebnisse blieben robust zu allen postoperativen Untersuchungszeitpunkten und lagen signifikant über denen der Kontrollgruppe. Diskussion und Schlussfolgerung Die Berechnung von effektivitäts-adjustierten Kosten zeigte einen Vorteil für die ambulante Behandlung mit Physiotherapie und CPM-Motorschiene gegenüber einer stationären Behandlung gemäß Reha Standard der Deutschen Rentenversicherung. Zusammenfassend kann aufgeführt werden, dass eine zielgerichtete Nutzung von CPM-Motorschienen dazu beitragen kann, die Versorgungsqualität, aber auch die Patientenzufriedenheit und -Sicherheit langfristig und nachhaltig zu erhöhen.