Inhibitory effect of alpha-lipoic acid on mitochondrial dysfunction and interleukin-8 expression in interleukin-1beta-stimulated ataxia teleangiectasia fibroblasts

Ataxia telangiectasia (A-T) is an inherited neurodegenerative disease caused by mutation in the ataxia telangiectasia mutated (ATM) gene, leading to loss of function in the encoded protein ATM. Because ATM functions to reduce oxidative stress by up-regulating antioxidant enzymes, oxidative stress is a prevalent A-T phenotype and a mediator of the inflammation that drives A-T pathology. Reactive oxygen species (ROS) levels and the expression of pro-inflammatory cytokine interleukin-8 (IL-8) were higher in A-T cells than in normal cells. ROS are related to mitochondrial dysfunction and activation of nuclear factor kappa B (NF-κB) to induce IL-8 expression. Alpha-lipoic acid (α-LA), a naturally occurring thiol compound, shows an antioxidant effect in various cells. This study is aimed to determine if α-LA confers protection against NF-κB activation, IL-8 expression, and mitochondrial dysfunction in A-T cells which are exposed to the inflammatory cytokine IL-1β. A-T fibroblasts were treated with or without α-LA. The levels of intracellular and mitochondrial ROS, mRNA and protein levels of IL-8, mitochondrial membrane potential (MMP), ATP levels, and DNA binding activity of NF-κB were determined. As a result, IL-1β increased NF-κB activation, IL-8 expression, intracellular and mitochondrial ROS levels, but decreased MMP and ATP level in A-T cells. Pretreatment of A-T cells with α-LA inhibited IL-1β-induced activation of NF-κB, IL-8 expression, and mitochondrial dysfunction by reducing ROS levels. In conclusion, supplementation with α-LA may be beneficial for reducing the oxidative stress-induced mitochondrial dysfunction and IL-8 production associated with A-T.

Sex Differences in Pediatric Poisonings by Age Group: a Toxicology Investigators' Consortium (ToxIC) Analysis (2010-2016)

OBJECTIVE

To review pediatric poisonings evaluated at the bedside by medical toxicologists and reported in the ToxIC registry, by sex and age group.

METHODS

Pediatric poisoning cases age ≤18 years, reported between January 2010 and December 2016, were reviewed. Descriptive statistics were used to describe study variables by age group and sex.

RESULTS

A total of 12,699 cases were analyzed. There were 7517 females and 5182 males. Those < 2 years old represented 12.5% of the study group (n = 1584), 17.2% were 2-6 years old (n = 2178), 8.6% were 7-12 years old (n = 1097), and 61.7% were 13-18 years old (n = 7840). The most common primary reasons for encounter were intentional pharmaceutical with 4900 females and 1836 males; intentional non-pharmaceutical with 952 females and 1213 males; unintentional pharmaceutical with 539 females and 644 males; and unintentional non-pharmaceutical with 435 females and 593 males. Overall, pharmaceuticals were the most commonly involved agents, including analgesics (20.9% of cases) and antidepressants (11% of cases): 27.8% of females and 10.7% of males were reportedly exposed to an analgesic.13.7% of females and 7.0% of males were reportedly exposed to an antidepressant. Among 1584 cases under 2 years, there were 747 females and 837 males; among 2178 cases aged 2-6 years, there were 954 females and 1224 males; among 1097 cases aged 7-12 years, there were 555 females and 542 males; and among 7840 cases aged 13-18 years, there were 5261 females and 2579 males. Death was reported in 0.7% of the cases: 20 females and 18 males. 6.1% of cases were managed with intubation: 421 females and 351 males.

CONCLUSIONS

Sex-based characteristics of poisonings varied by age group among pediatric poisoning presentations reported to the ToxIC registry and further research is needed to determine implications for education and prevention efforts.

AB1121 IMPLEMENTING HIGH VALUE CARE IN INPATIENT ANTINUCLEAR ANTIBODY TESTING

Background:

Antinuclear Antibody (ANA) testing forms the basis on which many rheumatological diseases are subsequently diagnosed. ANA testing quantifies the dilution of plasma to produce the titer and staining pattern and this can be a part of an ANA order set that reflexively cascades to sub-serology if positive. Studies have shown that a low titer ANA may potentially translate into an erroneous diagnosis: if one estimates a 1 percent prevalence of ANA associated disease in the general population then 30% of those individuals would have a false positive result of ANA detected at 1:40 titer [1]. We theorized that there is no need for several methods to coexist within a single inpatient hospital setting especially since diagnostic value of staining patterns alone is limited.

Objectives:

To compare the utility and yield of “ANA screening reflex to profile” (ARP) and “ANA reflex to titer” (ART) order sets in the inpatient setting of a community tertiary care hospital. We aim to identify the appropriateness of the ANA testing ordered including cost-effectiveness of ordering ARP over ART in order to implement the identified quality measures towards improving utilization of ANA testing.

Methods:

We identified all inpatient ANA reflex testing orders performed at Community Regional Medical Center, Fresno, California completed between 11/2018 till 07/2019. This included ART and ARP orders with 6 sub-serologies: SSA, SSB, dsDNA, Smith, Scl-70 and U1RNP. A Health Information Management report was generated which included patient’s age, gender, length of hospital stay, dates of testing ordered, principal diagnosis and type of ANA testing ordered. Descriptive statistics were computed and analyzed.

Results:

We reviewed a total of 1,012 ANA lab orders performed between 11/01/2018 until 07/30/2019 performed on 700 patients. According to the laboratory standard using Immunofluorescence Assay, an ANA titer starting from 1:40 is reported as positive. Out of the 1,012 tests, 334 tests were positive i.e. 33%. The ART order by itself contributed to 29.9% of the positive testing while ARP formed 70% of the positive testing. 56 of the 910 ARP (6%) performed had one or more sub-serology antibody positive while in 178 ARP orders (20%) only the ANA titer was positive with negative serology. The most common sub-serology antibody noted positive was dsDNA forming 54% of the positive serology results. Multiple testing was noted with 218 orders of ARP and ART being ordered on the same patient within the same week, which shows 21.5% of ANA lab orders were repetitive. Length of stay was noted to be more than 3 days for 89% of the patients who had repetitive testing, majority of those tests (99%) on the same day by the same medical provider. It cost $5.0 for an ART order that resulted negative and $5.0 for an ARP panel that resulted negative. It cost $10.0 for those patients who had both ART and ARP ordered with negative results. A positive ART result added $12.0 additional to the cost of each positive ANA profile ($67.36) when both tests were ordered together.

Conclusion:

Our study findings reflect the need for using higher yield ANA testing that has been standardized. It demonstrated that physicians ordering the testing were not familiar with the ART vs. ARP, and the laboratory orders needed to be re-structured. We removed the ART from the inpatient Electronic Medical Record i.e. Epic system so that only the ARP order remained. This would prevent repetitive testing and reduce healthcare costs through reduction by at least $12.0 per positive ANA result and may also translate into reduced length of hospital stay. We were able to add Centromere Antibody (Ab) to the ANA profile sub serologies to standardize it further as it is an important part of Scleroderma diagnosis.

References:

[1]Range of antinuclear antibodies in “healthy” individuals. AU, Tan EM, et al. Arthritis Rheum. 1997; 40(9):1601

Disclosure of Interests:

None declared

A Narrative Study on the Impact of Information and Communication Technology on the Relationship between Patients and Medical Learners

BACKGROUND

Current medical learners are immersed in an era of tremendous technological advancements. Consequently, the use of information and communication technologies (ICTs) might impact entrustable professional activities (EPAs), such as interpersonal and communication skills between learners and patients.

OBJECTIVE

The aim of this study was to explore medical learners' perspectives on ICTs and its impact on the relationship between them and their patients.

METHODS

Semi-structured interviews were conducted with medical learners to elicit their perspectives regarding ICTs in a clinical setting. Interviews were recorded, transcribed and analyzed to identify key themes.

RESULTS

Participants reported that ICTs implementation improved quality of care by allowing for rapid access to patient information and facilitating clinical decision making. However, technology use created a potential challenge to forging empathy toward patients and developing a rapport with them.

CONCLUSION

It is paramount to devise safeguards or milestone requirements in student evaluations for graduation.

P6419Machine learning in critical care: the role of diabetes and age in acute coronary syndromes

Background

Patients with diabetes and non-ST elevation acute coronary syndrome (NSTE-ACS) have an increased risk of mortality and adverse outcomes following percutaneous coronary intervention (PCI).

Purpose

We aimed to investigate the impact of early, within 24 hours PCI compared with only routine medical treatment on clinical outcomes in a large international cohort of patients with NSTE-ACS and diabetes.

Methods

We identified 1,250 patients with diabetes and NSTE-ACS from a registry-based population between October 2010 and April 2016. The primary endpoint was 30-day all-cause mortality. The secondary endpoint was the composite outcome of 30-day all-cause mortality and left ventricular dysfunction (ejection fraction <40%). We undertook analyses to explore the heterogeneity of treatment effects using meta-classification (MC) algorithms followed by propensity score matching and inverse-probability-of-treatment weighting (IPTW) from a landmark of 24 hours from hospitalization.

Results

Of 1,250 NSTE-ACS first-day survivors with diabetes (median age 67 years; 59%, men), 470 (37.6%) received early PCI and 780 routine medical treatment. The overall 30-day all-cause mortality rates were higher in the routine medical treatment than the early PCI group (6.3% vs. 2.5%). The prediction results of the MC algorithms accounted for only one interaction term that was statistically significant: age ≥65 years. After propensity-matched analysis as well as IPTW, early PCI was associated with reduced 30-day all-cause mortality in the older age (OR: 0.35; 95% CI: 0.14 to 0.92 and 0.43; 95% CI: 0.21 to 0.86, respectively), whereas younger age had no association with the primary endpoint. Similar results were also obtained for the secondary endpoint.

Conclusions

Among patients with diabetes hospitalized for NSTE-ACS, an early, within 24 hours, PCI strategy is associated with reduced odds of 30-day mortality only for patients aged 65 years or over. MC algorithms provide accurate identification of treatment effect modifiers.

Experiences of Nurses Working in a Fully Digital Hospital: A Phenomenological Study

Background

With the increasing development and integration of information and communication technology (ICT) into hospitals, there remains a lack of understanding of the impact of these technologies on the hospital's largest core users: nurses. Humber River Hospital (HRH), one of the first hospitals to completely integrate technology across all hospital systems and workflows, has sought to understand how ICTs have transformed the clinical working environment.

Objective

The aim of the study was to achieve a deeper understanding of the lived experiences of nurses practising in North America's first digital hospital.

Methods

The methodological approach was informed by van Manen's hermeneutic phenomenological methodology. Data were gathered through in-depth semi-structured interviews with eight nurses at HRH. Thematic analysis was conducted using the van Manen and Colaizzi methods of data analysis.

Results

Six thematic categories that formed the nurses' lived experiences of working in a digital environment were identified: safety, time, teamwork, technology failures, patient responses and adapting.

Conclusion

Nurses at HRH identified six themes regarding their lived experiences working in a fully digital hospital that provide an insight into nurses' values and cause us to reflect on how we might use this information to further support nursing practice in the fully digital environment. Nurses at HRH seem to have normalized the nursing process within the fully digital environment. Technology appears to be viewed by nurses at HRH within the premise of nursing as an art, allowing patient responses to be acknowledged and incorporated into nursing workflows, and as a science, permitting safe care delivery. Overall, nurses perceived technology as being essential for patient safety and facilitating nursing practice. These findings offer insight into nurses' perception of ICTs, and as technological advancements continue to emerge, these findings will inform education, practice and policy.

Smartphone Technology: Enabling Prioritization of Patient Needs and Enhancing the Nurse-Patient Relationship

Background

Mobile health (mHealth) is a rapidly growing field with the potential to transform healthcare delivery. Smartphone technologies have been developed and integrated into the patient call bell system for healthcare staff to receive calls; however, there is a lack of high-quality evidence to support the implementation and evaluate the effectiveness of these devices in a healthcare setting.

Aim

The aim of this study is to explore nurses' perceptions of smartphone technology devices in enhancing the nurse-patient relationship and improving nursing workflows.

Methods

A semi-structured focus group and interviews were used to illicit nurses' experiences with smartphone technology. Interviews were audio recorded, transcribed and subjected to a content analysis to identify emerging themes from the data.

Results

Interviews with nurses provided insight into the benefits and challenges of smartphone use in the clinical setting. Multiple benefits were identified by nurse participants, including time management and convenience, prioritization, patient safety and enhancement of the nurse-patient relationship.

Conclusion

There are multiple benefits of smartphone technology for both nurses and patients. Hospitals proposing to introduce smartphone technology need to educate patients and families about the clinical use of smartphones to avoid unfavourable perceptions. Smartphone technology must be interoperable with the electronic medical record to optimize interprofessional communication and exchange of patient information.

Optimizing Nursing Practice through Integration of Best Practice Guidelines into Electronic Medical Records

A commitment to best practice guidelines (BPGs) is crucial for ensuring the safety of patients. Recognizing the power of information technology, Humber River Hospital has integrated BPGs into the electronic medical record (EMR) infrastructure. The large-scale implementation institutes a uniform standard of care and ensures adherence to BPGs through a forcing function designed to require nurses to complete and document the necessary assessments. The initiative strengthens the audit process and provides the opportunity to identify long-term trends. The implications of the quality improvement initiative are discussed. Due to the widespread use of EMRs, the replication of this initiative is economically feasible in other healthcare settings.

Generational Differences in Hospital Technology Adoption: A Cross-Sectional Study

Background

The advancement of technological change within healthcare means that it is essential for nurses to have the necessary technological skills to deliver safe and efficient nursing care. Few studies have examined whether generational differences affect the adoption of technology within the healthcare system.

Aim

The primary purpose of this study was to explore predictors that influence the adoption of technology.

Methods

In this cross-sectional study, nurses were asked to rate their level of competency on 20 key skills related to clinical technological devices (CTDs) in a self-administered questionnaire. Participants' demographic data and level of proficiency related to personal computer skills were also collected. Multiple linear regression analysis was used to examine whether demographic characteristics and personal computer skills predicted higher scores related to CTDs.

Results

Sixty-three nurses completed the questionnaires. Overall mean score for skills related to CTD was high at 3.74 (SD = 0.75) out of 5. Length of employment at the hospital and previous exposure to the technology used at the hospital (β = 0.06, p = 0.021; β = 0.054, p = 0.011, respectively) were the only variables significantly associated with higher CTD skills scores. Generational cohort, gender, years of nursing experience and self-rated proficiency related to personal computer skills were not related to higher CTD skills scores.

Conclusion

The results of this study emphasize that consistent exposure to technology enhances its adoption. Generational cohort did not play a role in the perception of nurses' technology competency at Humber River Hospital.

Patient Empowerment and Nursing Clinical Workflows Enhanced by Integrated Bedside Terminals

Background

Integrated bedside terminals (IBTs) were implemented at Humber River Hospital with the goal of supporting patient independence and autonomy and improving nursing workflows. The IBTs provide access to a range of convenience and entertainment services as well as access to personal health information. Due to the novelty of the technology, there is a paucity of empirical data on patients' use of, satisfaction with and perceptions of bedside terminals.

Aim

The purpose of this study was to evaluate the impact of IBTs on patient empowerment and nursing workflows.

Methods

A mixed methods design was employed using a cross-sectional patient survey and semi-structured interviews with nurses. The patient survey assessed patient empowerment and satisfaction with the range of services offered through the IBT. Patient scores were summarized using descriptive statistics. Additionally, face-to-face interviews with nurses were used to illicit feedback regarding the IBTs' impacts on nursing workflows.

Results

In total, 113 patients and 11 nurses participated in the study. Analysis of patient satisfaction surveys indicated that the IBTs enhanced the patient experience and increased self-care management. Nurses reported that the IBTs helped patients feel comfortable and entertained and helped enhance the nurse-patient relationship. However, nurses also expressed concern that elderly patients were less inclined to use the IBT.

Conclusion

The results from the present study suggest that the IBT system has the potential to empower patients and decrease demands on nurses. Patients' notes incorporated into the IBT may provide the necessary level of involvement to garner a greater sense of patient empowerment. The IBT does not replace the need for nurses to deliver information to patients in a manner that supports their trust.

Violence Prevention: Technology-Enabled Therapeutic Intervention

Background

Nurses are disproportionately prone to experience incidents of violent victimization. Despite the vast literature on violence in healthcare settings, few studies have identified effective violence prevention interventions.

Aim

The aim of the study was to explore the experiences of nurses regarding the implementation of technology-based violence prevention interventions.

Methods

Qualitative data were collected through semi-structured focus groups and interviews with 11 nurses at Humber River Hospital. Interviews were audiotaped, transcribed and subjected to a content analysis to identify core themes from the data.

Results

Three themes were identified: reassurance of safety, an increase in proactive measures and limitations of technology. Nurses held positive perceptions of the impact of technology-based interventions on violent incidents. The interventions were regarded as effective for the detection of potentially violent patients as well as for providing assistance from security staff when a violent incident occurs or appears imminent. However, nurses also acknowledged that patient-related violence was "unavoidable" and that technology cannot fully prevent violence from occurring.

Conclusion

The findings from this study support the replication of these interventions in other healthcare facilities. Engaging staff, patients and families in this unique digital and technology-enriched environment has been critical for the successful implementation of the violence prevention electronic flagging system. Patient and family education and communication were essential for addressing concerns related to "labelling."