Importance Patients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care ...and, ultimately, an inpatient hospital death that may be misaligned with their goals of care. Objective To assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life. Design, Setting, and Participants This pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022. Main Outcome and Measures The primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality. Results This study included 270 patients (median age, 74.0 years IQR, 62.0-85.0 years; 133 of 270 women 49.3%) in the control period, and 388 patients (median age, 73.0 years IQR, 60.0-84.0 years; 208 of 388 women 53.6%) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period ( P < .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days IQR, 1.1-3.0 days vs 1.9 days IQR, 1.1-3.0 days; P = .84), but in-hospital mortality was lower in the intervention period (48.5% 188 of 388 vs 64.4% 174 of 270; P < .001). Conclusions and Relevance In this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.
Vacuum gravitational fields invariant for a non-Abelian Lie algebra generated by two Killing fields whose commutator is light-like are analyzed. It is shown that they represent non-linear ...gravitational waves obeying to two non-linear superposition laws. The energy and the polarization of this family of waves are explicitly evaluated.
Cushing's syndrome is commonly complicated with an impairment of glucose metabolism, which is often clinically manifested as diabetes mellitus. The development of diabetes mellitus in Cushing's ...syndrome is both a direct and indirect consequence of glucocorticoid excess. Indeed, glucocorticoid excess induces a stimulation of gluconeogenesis in the liver as well as an inhibition of insulin sensitivity both in the liver and in the skeletal muscles, which represent the most important sites responsible for glucose metabolism. In particular, glucocorticoid excess stimulates the expression of several key enzymes involved in the process of gluconeogenesis, with a consequent increase of glucose production, and induces an impairment of insulin sensitivity either directly by interfering with the insulin receptor signaling pathway or indirectly, through the stimulation of lipolysis and proteolysis and the consequent increase of fatty acids and amino acids, which contribute to the development of insulin resistance. Moreover, the peculiar distribution of adipose tissue throughout the body, with the predominance of visceral adipose tissue, significantly contributes to the worsening of insulin resistance and the development of a metabolic syndrome, which participates in the occurrence and maintenance of the impairment of glucose tolerance. Finally, glucocorticoid excess is able to impair insulin secretion as well as act at the level of the pancreatic beta cells, where it inhibits different steps of the insulin secretion process. This phenomenon is probably responsible for the passage from an impairment of glucose tolerance to an overt diabetes mellitus in susceptible patients with Cushing's syndrome.
The so-called q-z-Rényi Relative Entropies provide a huge two parameter family of relative entropies which include almost all well-known examples of quantum relative entropies for suitable values of ...the parameters. In this paper we consider a log-regularized version of this family and use it as a family of potential functions to generate covariant (0,2) symmetric tensors on the space of invertible quantum states in finite dimensions. The geometric formalism developed here allows us to obtain the explicit expressions of such tensor fields in terms of a basis of globally defined differential forms on a suitable unfolding space without the need to introduce a specific set of coordinates. To make the reader acquainted with the intrinsic formalism introduced, we first perform the computation for the qubit case, and then, we extend the computation of the metric-like tensors to a generic n-level system. By suitably varying the parameters q and z, we are able to recover well-known examples of quantum metric tensors that, in our treatment, appear written in terms of globally defined geometrical objects that do not depend on the coordinates system used. In particular, we obtain a coordinate-free expression for the von Neumann–Umegaki metric, for the Bures metric and for the Wigner–Yanase metric in the arbitrary n-level case.
The aim of the work is to interpret recent topics of discussion related to the theory of exchange rates, taking into account the conclusions of the theoretical research on financial and currency ...markets. The author suggests that the setup of the analysis of financial markets should be reconsidered to focus on the elements of inertia and uncertainty in the behaviour of economic agents, factors that are capable of distancing currency markets from efficient conditions. Highlighting the existing empirical and theoretical principals, the author first considers the various reasons for the compatibility of rationality with the distortion of expectations and then the characteristics of the models of the formation of expectations regarding the nature of speculation. A fundamental component of short-term dynamics is identified in "chartism", for which the theoretical reasons are discussed. JEL Codes: D51
Bisphosphonates such as zoledronic, alendronic and risedronic acids are a class of drugs clinically used to prevent bone density loss and osteoporosis. Novel P-C-P bisphosphonates were synthesized ...for targeting human farnesyl pyrophosphate synthase (hFPPS) and human geranylgeranyl pyrophosphate synthase (hGGPPS), key enzymes of the mevalonate pathway, and capable of anti-proliferative action on a number of cell lines (PC3, MG63, MC3T3, RAW 264.7, J774A.1, bone marrow cells and their co-colture with PC3) involved in bone homeostasis, bone formation and death. Among sixteen compounds, 1-hydroxy-2-(pyrimidin-2-ylamino)ethane-1,1-diylbis(phosphonic acid) (10) was effective in reducing PC3 and RAW 264.7 cell number in crystal-violet and cell-dehydrogenase activity assays at 100 μM concentration. 10 reduced differentiated osteoclasts number similarly with zoledronic acid in osteoclastogenesis assay. At nanomolar concentrations, 10 was more effective than zoledronic acid in inducing mineralization in MC3T3 and murine bone marrow cells. Further, 10 significantly inhibited the activity of hFPPS showing an IC50 of 0.31 μM and a remarkable hydroxyapatite binding of 90%. Docking calculations were performed identifying putative interactions between some representative novel bisphosphonates and both hFPPS and hGGPPS. Then, 10 was found to behave similarly or even better than zoledronic acid as a anti-resorptive agent.
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•Bisphosphonic acids (N-BPs) were synthesized with fair to good yields.•hFPPS and hGGPPS were produced and purified.•Pyrimidine- and quinazoline-N-BPs were tested as hFPPS and hGGPPS inhibitors.Zoledronate and pyrimidine-N-BP (py-N-BP) show a similar anti-proliferative profile.•py-N-BP induces osteoblast mineralization and restorative osteoblastogenesis effect.
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