Liver regeneration is a complex process that restores functional tissue following resection or injury, and is accompanied by transient ATP depletion and metabolic stress in hepatic parenchymal cells. Heat shock protein-70 (Hsp70) functions as a chaperone during periods of cellular stress, and induces expression of several inflammatory cytokines identified as key players during early liver regeneration. We therefore hypothesized that Hsp70 would be required in the initiation of regeneration. Investigations were carried out in a 70% partial-hepatectomy (PHx) mouse model with mice lacking inducible Hsp70 (Hsp70−/−). Liver regeneration was assessed post-operatively using the ratio of liver weight to body weight (LW/BW), and sera and tissues were collected for analysis. In addition, gene expression of Hsp related genes were assessed in a cohort of 23 human living-donor liver transplantation donors. In mice, the absence of Hsp70 was associated with reduced postoperative LW/BW, Ki-67 staining, and TNF-α expression compared to wild-type mice. TNF-α expression was also reduced in livers from Hsp70−/− mice following induction with LPS (1 mg/kg). Clinically, the transcription of multiple Hsp genes was upregulated following donor hepatectomy, especially Hsp70 family members. Together, these results suggest that the early phase of successful liver regeneration requires the presence of Hsp70 to induce TNF-α. Further studies are required to determine whether Hsp70 contributes to liver regeneration as a chaperone, by stabilizing specific interactions required for growth signalling, or as a paracrine inflammatory signal, as can occur in models of shock.
The Patient-Centered Medical Home (PCMH) is a model of care that has been promoted as a way to transform a broken primary care system in the US. However, in order to convince more practices to make the transformation and to properly reimburse practices who are PCMHs, valid and reliable data are needed. Data that capture patient experiences in a PCMH is valuable, but which instrument should be used remains unclear. Our study aims to compare the validity and reliability of two national PCMH instruments. Telephone surveys were conducted with children who receive care from 20 pediatric practices across Florida (n = 990). All of the children are eligible for Medicaid or the Children's Health Insurance Program. Analyses were conducted to compare the Consumer Assessment of Health Plan Survey-Patient-Centered Medical Home (CAHPS-PCMH) and the National Survey of Children with Special Health Care Needs (NS-CSHCN) medical home domain. Respondents were mainly White non-Hispanic, female, under 35 years old, and from a two-parent household. The NS-CSHCN outperformed the CAHPS-PCMH in regard to scale reliability (Cronbach's alpha coefficients all ≥0.81 vs. 0.56-0.85, respectively). In regard to item-domain convergence and discriminant validity the CAHPS-PCMH fared better than the NS-CSHCN (range of convergence 0.66-0.93 vs. 0.32-1.00). The CAHPS-PCMH did not correspond to the scale structure in construct validity testing. Neither instrument performed well in the known-groups validity tests. No clear best instrument was determined. Further revision and calibration may be needed to accurately assess patient experiences in the PCMH.
BackgroundThe patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature.MethodsEligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware’s seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice’s medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%.ResultsStaff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b = 0.75) and community outreach is negatively associated (b = -0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR = 1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR = 0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout.ConclusionsStaff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale.Electronic supplementary materialThe online version of this article (doi:10.1186/2049-3258-72-36) contains supplementary material, which is available to authorized users.
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