Increasing patient engagement: patients' responses to viewing problem lists online

OBJECTIVE

To characterize the opinions, emotions, and actions taken by patients who viewed their electronic problem list via an online personal health record (PHR).

MATERIALS AND METHODS

An online survey of patients who viewed their problem lists, as maintained by their healthcare provider, in a web-based PHR linked to an electronic health record for the first time.

RESULTS

A total 3,649 patients completed the survey, yielding a response rate of 42.1%. Patient attitudes towards the problem list function were positive overall, with 90.4% rating it at least somewhat useful and 86.7% reporting they would probably or definitely use it again. Nearly half (45.6%) of patients identified at least one major or minor problem missing from their list. After viewing the list, 56.1% of patients reported taking at least one action in response, with 32.4% of patients reporting that they researched a condition on the Internet, 18.3% reported that they contacted their healthcare provider and 16.7% reported changing or planning to change a health behavior (patients could report multiple actions). 64.7% of patients reported feeling at least somewhat happy while viewing their problem list, though others reported feeling sad (30.4%), worried (35.7%) or scared (23.8%) (patients could report multiple emotions). A smaller number of patients reported feeling angry (16.6%) or ashamed (14.3%). Patients who experienced an emotional response were more likely to take action.

CONCLUSION

Overall, patients found the ability to view their problem lists very useful and took action in response to the information. However, some had negative emotions. More research is needed into optimal strategies for supporting patients receiving this information.

Reducing risk with clinical decision support: a study of closed malpractice claims

OBJECTIVE

Identify clinical opportunities to intervene to prevent a malpractice event and determine the proportion of malpractice claims potentially preventable by clinical decision support (CDS).

MATERIALS AND METHODS

Cross-sectional review of closed malpractice claims over seven years from one malpractice insurance company and seven hospitals in the Boston area. For each event, clinical opportunities to intervene to avert the malpractice event and the presence or absence of CDS that might have a role in preventing the event, were assigned by a panel of expert raters. Compensation paid out to resolve a claim (indemnity), was associated with each CDS type.

RESULTS

Of the 477 closed malpractice cases, 359 (75.3%) were categorized as substantiated and 195 (54%) had at least one opportunity to intervene. Common opportunities to intervene related to performance of procedure, diagnosis, and fall prevention. We identified at least one CDS type for 63% of substantiated claims. The 41 CDS types identified included clinically significant test result alerting, diagnostic decision support and electronic tracking of instruments. Cases with at least one associated intervention accounted for $40.3 million (58.9%) of indemnity.

DISCUSSION

CDS systems and other forms of health information technology (HIT) are expected to improve quality of care, but their potential to mitigate risk had not previously been quantified. Our results suggest that, in addition to their known benefits for quality and safety, CDS systems within HIT have a potential role in decreasing malpractice payments.

CONCLUSION

More than half of malpractice events and over $40 million of indemnity were potentially preventable with CDS.

Genome-wide association studies: applications and insights gained in Ophthalmology

Genome-wide association studies (GWAS) use high-throughput genotyping technologies to genotype thousands of single-nucleotide polymorphisms (SNPs) and relate them to the development of clinical and quantitative traits. Their use has been highly successful in the field of ophthalmology, and since the advent of GWAS in 2005, many genes not previously suspected of having a role in disease have been identified and the findings replicated. We conducted an extensive literature review and describe the concept, design, advantages, and limitations of GWAS and provide a detailed description of the applications and discoveries of GWAS in the field of eye disease to date. There have been many novel findings revealing previously unknown biological insights in a diverse range of common ocular conditions. GWAS have been a highly successful modality for investigating the pathogenesis of a wide variety of ophthalmic conditions. The insights gained into the pathogenesis of disease provide not only a better understanding of underlying disease mechanism but also offer a rationale for targeted treatment and preventative strategies. Expansive international collaboration and standardised phenotyping will permit the continued success of this investigative technique.

Evidence-Based Clinical Decision Support

Background: Clinical decision support (CDS) is a key tool for enabling evidence-based medicine and improving the quality of healthcare. However, effective CDS faces a variety of challenges, including those relating to knowledge synthesis, capture, transformation, localization and maintenance. If not properly addressed, these challenges can limit the effectiveness of CDS, and potentially risk inaccurate or inappropriate interventions to clinicians.

Objectives: (1) To describe an approach to CDS development using evidence as a basis for clinical decision support systems that promote effective care; (2) To review recent evidence regarding the effectiveness of selected clinical decision support systems.

Method: Review and analysis of recent literature with identification of trends and best practices.

Results: The state-of-the-art in CDS has advanced significantly, and many recent trials have shown CDS to be effective, although the results are mixed overall. Issues related to knowledge capture and synthesis, problems in knowledge transformation at the interface between knowledge authors and CDS developers, and problems specific to local CDS design and implementation can interfere with CDS development. Best practices, tools and techniques to manage them are described.

Conclusions: CDS, when used well, can be effective, but further research is needed for it to reach its full potential.

Control Strategies for Cyclic Polymer Processes

This paper presents the simulation of a typical cyclic polymer processing operation with respect to the performance of different control strategies for part quality when subjected to disturbances with realistic load-profiles. Disturbances enter the simulation in a complex, probabilistic manner creating a unique flexibility in load representation which helps the simulation more accurately capture the performance of real processing operations. Realistic simulations can provide necessary information and be less costly than benchmark studies on actual processes. The objective of the research is to examine the effect of different control strategies on the overall control of part-to-part quality, not the control of the continuous processes that occur in part fabrication. The performance of six different control strategies is compared; two strategies are conventional feedback, and four strategies are statistically based. The statistically based algorithms effect closed loop control, but only when a true load exists. Results are analyzed using statistical analysis of variance (ANOVA) via a completely randomized block experimental design, and Duncan's multiple range test is used to rank the control strategies. The results indicate that as more disturbances enter the system, the conventional controllers perform better than the other strategies. When fewer disturbances are present, however, the statistically based controllers perform better. The most notable result is that one statistically based controller, the Western Electric runs rules controller, performs well over the entire range of disturbances.

Bipolar disorder in a national survey using the World Mental Health Version of the Composite International Diagnostic Interview: the impact of differing diagnostic algorithms

OBJECTIVE

The World Mental Health Version of the Composite International Diagnostic Interview (WMH-CIDI) DSM-IV bipolar disorder diagnostic algorithms were recalibrated in about 2006 following evidence of over-diagnosis of bipolar I disorder. There have been no reports of the impact of this recalibration on epidemiological findings.

METHOD

Data were taken from the 2007 Australian National Survey of Mental Health and Wellbeing. Findings for cases identified by the recalibrated bipolar disorder definition were contrasted against those identified by the un-recalibrated definition.

RESULTS

The 12-month prevalence of recalibrated bipolar disorder and un-recalibrated bipolar disorder were 0.9% and 1.7% respectively. The un-recalibrated bipolar disorder group was younger and more likely to have never married than the recalibrated bipolar disorder group. They were also more likely to have a comorbid alcohol use disorder, substance use disorder and asthma or arthritis. While they were more likely to have at least severe interference in at least one of the Sheehan Scale domains of functioning, they were less likely to have made a suicide attempt. Similarly, they were less likely to have consulted a psychiatrist.

CONCLUSION

It is not possible to be certain about the nature of these differences. Some may be artifactual (reflecting greater statistical power to detect differences with the larger un-recalibrated bipolar disorder defined sample), while others may be indicative of the inclusion of a clinically distinct subpopulation with the un-recalibrated bipolar disorder definition, thereby producing a more heterogeneous sample. These findings indicate the need for clarity in the diagnostic algorithm used in epidemiological reports on bipolar disorder using the World Mental Health Version of the Composite International Diagnostic Interview.

Screening for diabetic retinopathy in pregnancy using photographic review clinics

AIMS

To assess the efficacy and value of the National Institute for Health and Clinical Excellence guidelines for digital photographic screening for diabetic retinopathy in pregnancy using photographic review clinics.

METHODS

Pregnant patients (n = 186) with known diabetes were screened at first antenatal visit and at 28 weeks' gestation, if no retinopathy was noted at first visit, or at other intervals if retinopathy was present. Two 45° images (disc-centred and macula-centred views) were taken in both eyes and graded by trained graders and by an ophthalmologist.

RESULTS

Ninety-three patients (50%) remained free of diabetic retinopathy throughout pregnancy. Eighteen (10%) presented with sight-threatening retinopathy at their first antenatal screen and were referred to the hospital eye service. Fifty patients (27%) were shown to have relatively stable retinopathy throughout pregnancy, with only two patients deteriorating and requiring referral to hospital eye service. Twenty-three (12%) failed to complete the screening protocol after their first screen.

CONCLUSIONS

The study showed that pregnant patients screened for retinopathy in an ophthalmic photographic diabetic review clinic achieved National Institute for Health and Clinical Excellence guidelines in the majority and were clinically safe. Only 1% of patients required referral to ophthalmology after their initial screen, thus avoiding unnecessary hospital eye service appointments.

Provider use of and attitudes towards an active clinical alert: a case study in decision support

BACKGROUND

In a previous study, we reported on a successful clinical decision support (CDS) intervention designed to improve electronic problem list accuracy, but did not study variability of provider response to the intervention or provider attitudes towards it. The alert system accurately predicted missing problem list items based on health data captured in a patient's electronic medical record.

OBJECTIVE

To assess provider attitudes towards a rule-based CDS alert system as well as heterogeneity of acceptance rates across providers.

METHODS

We conducted a by-provider analysis of alert logs from the previous study. In addition, we assessed provider opinions of the intervention via an email survey of providers who received the alerts (n = 140).

RESULTS

Although the alert acceptance rate was 38.1%, individual provider acceptance rates varied widely, with an interquartile range (IQR) of 14.8%-54.4%, and many outliers accepting none or nearly all of the alerts they received. No demographic variables, including degree, gender, age, assigned clinic, medical school or graduation year predicted acceptance rates. Providers' self-reported acceptance rate and perceived alert frequency were only moderately correlated with actual acceptance rates and alert frequency.

CONCLUSIONS

Acceptance of this CDS intervention among providers was highly variable but this heterogeneity is not explained by measured demographic factors, suggesting that alert acceptance is a complex and individual phenomenon. Furthermore, providers' self-reports of their use of the CDS alerting system correlated only modestly with logged usage.

Validation of an association rule mining-based method to infer associations between medications and problems

BACKGROUND

In a prior study, we developed methods for automatically identifying associations between medications and problems using association rule mining on a large clinical data warehouse and validated these methods at a single site which used a self-developed electronic health record.

OBJECTIVE

To demonstrate the generalizability of these methods by validating them at an external site.

METHODS

We received data on medications and problems for 263,597 patients from the University of Texas Health Science Center at Houston Faculty Practice, an ambulatory practice that uses the Allscripts Enterprise commercial electronic health record product. We then conducted association rule mining to identify associated pairs of medications and problems and characterized these associations with five measures of interestingness: support, confidence, chi-square, interest and conviction and compared the top-ranked pairs to a gold standard.

RESULTS

25,088 medication-problem pairs were identified that exceeded our confidence and support thresholds. An analysis of the top 500 pairs according to each measure of interestingness showed a high degree of accuracy for highly-ranked pairs.

CONCLUSION

The same technique was successfully employed at the University of Texas and accuracy was comparable to our previous results. Top associations included many medications that are highly specific for a particular problem as well as a large number of common, accurate medication-problem pairs that reflect practice patterns.

Evidence-based clinical decision support

BACKGROUND

Clinical decision support (CDS) is a key tool for enabling evidence-based medicine and improving the quality of healthcare. However, effective CDS faces a variety of challenges, including those relating to knowledge synthesis, capture, transformation, localization and maintenance. If not properly addressed, these challenges can limit the effectiveness of CDS, and potentially risk inaccurate or inappropriate interventions to clinicians.

OBJECTIVES

(1) To describe an approach to CDS development using evidence as a basis for clinical decision support systems that promote effective care; (2) To review recent evidence regarding the effectiveness of selected clinical decision support systems.

METHOD

Review and analysis of recent literature with identification of trends and best practices.

RESULTS

The state-of-the-art in CDS has advanced significantly, and many recent trials have shown CDS to be effective, although the results are mixed overall. Issues related to knowledge capture and synthesis, problems in knowledge transformation at the interface between knowledge authors and CDS developers, and problems specific to local CDS design and implementation can interfere with CDS development. Best practices, tools and techniques to manage them are described.

CONCLUSIONS

CDS, when used well, can be effective, but further research is needed for it to reach its full potential.

Rifampicin-resistant Mycobacterium tuberculosis: susceptibility to isoniazid and other anti-tuberculosis drugs

Based on data from 14 Supranational Tuberculosis (TB) Reference Laboratories worldwide, the proportion of rifampicin (RMP) resistant isolates that were isoniazid (INH) susceptible by phenotypic drug susceptibility testing varied widely (0.5-11.6%). RMP-resistant isolates that were INH-susceptible had significantly lower rates of resistance to other first- and second-line anti-tuberculosis drugs (except rifabutin) compared to multidrug-resistant isolates. RMP resistance is not always a good proxy for a presumptive diagnosis of multidrug-resistant TB, which has implications for use of molecular assays that identify only RMP resistance-associated DNA mutations.

Methods of weaning preterm babies <30 weeks gestation off CPAP: a multicentre randomised controlled trial

BACKGROUND

Controversy exists whether different continuous positive airway pressure (CPAP) weaning methods influence time to wean off CPAP, CPAP duration, oxygen duration, Bronchopulmonary Dysplasia (BPD) or length of admission.

AIMS

In a multicentre randomised controlled trial, the authors have primarily compared CPAP weaning methods impact on time to wean off CPAP and CPAP duration and secondarily their effect on oxygen duration, BPD and time of admission.

METHODS

Between April 2006 and October 2009, 177 infants <30 weeks gestational age (GA) who fulfilled stability criteria on CPAP were randomised to one of the three CPAP weaning methods (M). M1: Taken 'OFF' CPAP with the view to stay 'OFF'. M2: Cycled on and off CPAP with incremental time 'OFF'. M3: As with m(2), cycled on and off CPAP but during 'OFF' periods were supported by 2 mm nasal cannula at a flow of 0.5 l/min.

RESULTS

Based on intention to treat analysis, there was no significant difference in mean GA or birthweight between the groups (27.1 ± 1.4, 26.9 ± 1.6 and 27.3 ± 1.5 (weeks ± 1SD) and 988 ± 247, 987 ± 249 and 1015 ± 257 (grams ± 1SD), respectively). Primary outcomes showed M1 produced a significantly shorter time to wean from CPAP (11.3 ± 0.8, 16.8 ± 1.0, 19.4 ± 1.3 (days ± 1SE) p<0.0001, respectively) and CPAP duration (24.4 ± 0.1, 38.6 ± 0.1, 30.5 ± 0.1 (days ± 1SE) p<0.0001, respectively). All the secondary outcomes were significantly shorter with M1, (oxygen duration: 24.1 ± 1.5, 45.8 ± 2.2, 34.1 ± 2.0 (days ± 1SE) p<0.0001, BPD: 7/56 (12.5%), 29/69 (42%), 10/52 (19%) p=0.011 and length of admission: 58.5 ± 0.1, 73.8 ± 0.1 69.5 ± 0.1 (days ± 1SE) p<0.0001, respectively).

CONCLUSION

Method 1 significantly shortens CPAP weaning time, CPAP duration, oxygen duration, BPD and admission time.

Clinical Summarization Capabilities of Commercially-available and Internally-developed Electronic Health Records

OBJECTIVE: Clinical summarization, the process by which relevant patient information is electronically summarized and presented at the point of care, is of increasing importance given the increasing volume of clinical data in electronic health record systems (EHRs). There is a paucity of research on electronic clinical summarization, including the capabilities of currently available EHR systems. METHODS: We compared different aspects of general clinical summary screens used in twelve different EHR systems using a previously described conceptual model: AORTIS (Aggregation, Organization, Reduction, Interpretation and Synthesis). RESULTS: We found a wide variation in the EHRs' summarization capabilities: all systems were capable of simple aggregation and organization of limited clinical content, but only one demonstrated an ability to synthesize information from the data. CONCLUSION: Improvement of the clinical summary screen functionality for currently available EHRs is necessary. Further research should identify strategies and methods for creating easy to use, well-designed clinical summary screens that aggregate, organize and reduce all pertinent patient information as well as provide clinical interpretations and synthesis as required.

First evidence of pep solar neutrinos by direct detection in Borexino

We observed, for the first time, solar neutrinos in the 1.0-1.5 MeV energy range. We determined the rate of pep solar neutrino interactions in Borexino to be 3.1±0.6{stat}±0.3{syst}  counts/(day·100  ton). Assuming the pep neutrino flux predicted by the standard solar model, we obtained a constraint on the CNO solar neutrino interaction rate of <7.9  counts/(day·100  ton) (95% C.L.). The absence of the solar neutrino signal is disfavored at 99.97% C.L., while the absence of the pep signal is disfavored at 98% C.L. The necessary sensitivity was achieved by adopting data analysis techniques for the rejection of cosmogenic {11}C, the dominant background in the 1-2 MeV region. Assuming the Mikheyev-Smirnov-Wolfenstein large mixing angle solution to solar neutrino oscillations, these values correspond to solar neutrino fluxes of (1.6±0.3)×10{8}  cm{-2} s^{-1} and <7.7×10{8}  cm{-2} s{-1} (95% C.L.), respectively, in agreement with both the high and low metallicity standard solar models. These results represent the first direct evidence of the pep neutrino signal and the strongest constraint of the CNO solar neutrino flux to date.

Precision measurement of the (7)Be solar neutrino interaction rate in Borexino

The rate of neutrino-electron elastic scattering interactions from 862 keV (7)Be solar neutrinos in Borexino is determined to be 46.0±1.5(stat)(-1.6)(+1.5)(syst) counts/(day·100  ton). This corresponds to a ν(e)-equivalent (7)Be solar neutrino flux of (3.10±0.15)×10(9)  cm(-2) s(-1) and, under the assumption of ν(e) transition to other active neutrino flavours, yields an electron neutrino survival probability of 0.51±0.07 at 862 keV. The no flavor change hypothesis is ruled out at 5.0 σ. A global solar neutrino analysis with free fluxes determines Φ(pp)=6.06(-0.06)(+0.02)×10(10)  cm(-2) s(-1) and Φ(CNO)<1.3×10(9)  cm(-2) s(-1) (95% C.L.). These results significantly improve the precision with which the Mikheyev-Smirnov-Wolfenstein large mixing angle neutrino oscillation model is experimentally tested at low energy.

Comparison of Computer-based Clinical Decision Support Systems and Content for Diabetes Mellitus

BACKGROUND

Computer-based clinical decision support (CDS) systems have been shown to improve quality of care and workflow efficiency, and health care reform legislation relies on electronic health records and CDS systems to improve the cost and quality of health care in the United States; however, the heterogeneity of CDS content and infrastructure of CDS systems across sites is not well known.

OBJECTIVE

We aimed to determine the scope of CDS content in diabetes care at six sites, assess the capabilities of CDS in use at these sites, characterize the scope of CDS infrastructure at these sites, and determine how the sites use CDS beyond individual patient care in order to identify characteristics of CDS systems and content that have been successfully implemented in diabetes care.

METHODS

We compared CDS systems in six collaborating sites of the Clinical Decision Support Consortium. We gathered CDS content on care for patients with diabetes mellitus and surveyed institutions on characteristics of their site, the infrastructure of CDS at these sites, and the capabilities of CDS at these sites.

RESULTS

The approach to CDS and the characteristics of CDS content varied among sites. Some commonalities included providing customizability by role or user, applying sophisticated exclusion criteria, and using CDS automatically at the time of decision-making. Many messages were actionable recommendations. Most sites had monitoring rules (e.g. assessing hemoglobin A1c), but few had rules to diagnose diabetes or suggest specific treatments. All sites had numerous prevention rules including reminders for providing eye examinations, influenza vaccines, lipid screenings, nephropathy screenings, and pneumococcal vaccines.

CONCLUSION

Computer-based CDS systems vary widely across sites in content and scope, but both institution-created and purchased systems had many similar features and functionality, such as integration of alerts and reminders into the decision-making workflow of the provider and providing messages that are actionable recommendations.

Mapping the stem cell state: eight novel human embryonic stem and embryonal carcinoma cell antibodies

The antigenic profile of human embryonic stem (ES) and embryonal carcinoma (EC) cells has served as a key element of their characterization, with a common panel of surface and intracellular markers now widely used. Such markers have been used to identify cells within the 'undifferentiated state', yet it appears that this categorization may be an oversimplification, because a number of sub-states appear to exist within this state. To increase the resolution of the undifferentiated state, we have generated eight novel monoclonal antibodies, all capable of recognizing undifferentiated human ES and EC cells, and herein describe their characterization. The reactivity of these antibodies against a range of cell lines is reported, as well as their developmental regulation, basic biochemistry and reactivity in immunohistochemistry of testicular germ cell tumours. Our data reveal a range of reactivity for all antibodies against both ES and EC cells, suggesting that these markers will afford recognition of unique sub-states within the undifferentiated stem cell compartment.

PIM kinase activity is required for B cell function in vitro and in vivo (109.5)

The PIM family of serine/threonine kinases has roles in proliferation, differentiation, and cell survival. In lymphocytes, their activity is regulated by inducible expression following cytokine or antigen receptor signaling. Using small molecule inhibitors, we have examined the role of PIM1/3 kinases in B cells in vitro and in vivo and in the MRL/LPR model of lupus. PIM kinases were expressed 1-3 hours after B cell activation with anti-IgM or anti-CD40 but not BAFF. Inhibition of PIM-1/3 kinase activity decreased anti-IgM- and anti-CD40-induced B cell proliferation without inducing apoptosis. AR-254 also prevented IL-4-, and IFNy-induced B cell survival, but had no affect on BAFF-induced B cell survival consistent with the inability of BAFF to upregulate PIM expression. AR-770 administration in the HEL immunization model resulted in a 90% reduction of HEL-specific IgG2a and IgG3, but had no effect on IgG1 suggesting a role for PIM kinases in IFNy-mediated class switching. In the MRL/MpJ-Fas&lt;lpr&gt; lupus model, mice treated with AR-770 had &gt;90% reduction in proteinuria AUC, normalized anti-dsDNA antibody titers and ~80% decrease in kidney glomerulo- and interstitial nephritis as well as vessel and protein cast formation. Under specific conditions, Taken together, the data suggests that inhibition of PIM kinases may be a useful strategy for patients with B cell-mediated diseases such as lupus.

Growth and Structure of Alumino-Silicate Polymers

Gels have been prepared in the H2O, HOiPr, (BuO)2Al-O-Si(OEt)3 ternary phase diagram in a large range of oxide concentrations. The gelation time is governed by the initial water concentration, showing that the hydrolysis of Si-OR groups is the rate-determining process for the gelation.

The structure of clusters and the kinetics of aggregation have been studied by SANS. We observe mass-fractal particles characterized by a fractal dimension of 1.9, in agreement with the existence of a cluster-cluster aggregation mechanism during the gelation. The scattering curves exhibit a maximum intensity corresponding to interparticle correlations due to purely excluded-volume effects.

Paradoxical reactions in non-HIV tuberculosis presenting as endobronchial obstruction

Paradoxical reaction (PR) in tuberculosis (TB) is common and may affect up to 25% of patients. PR has the potential to cause significant morbidity and, on occasion, death. Although PR has been recognised for some time, the pathophysiology, especially in HIV-negative patients, is not well understood. We present two cases of PR in HIV-negative patients with TB presenting as significant airway obstruction secondary to a florid endobronchial component. These cases demonstrate that PR should be considered in all patients presenting with airway symptoms who have started TB treatment. The outcomes of the cases illustrate the need for wider recognition of this condition and more research to characterise patients who may be at risk, in order to gain a greater understanding of the mechanisms involved and to make or predict this diagnosis earlier.

Towards meaningful medication-related clinical decision support: recommendations for an initial implementation

SUMMARY

Clinical decision support (CDS) can improve safety, quality, and cost-effectiveness of patient care, especially when implemented in computerized provider order entry (CPOE) applications. Medication-related decision support logic forms a large component of the CDS logic in any CPOE system. However, organizations wishing to implement CDS must either purchase the computable clinical content or develop it themselves. Content provided by vendors does not always meet local expectations. Most organizations lack the resources to customize the clinical content and the expertise to implement it effectively. In this paper, we describe the recommendations of a national expert panel on two basic medication-related CDS areas, specifically, drug-drug interaction (DDI) checking and duplicate therapy checking. The goals of this study were to define a starter set of medication-related alerts that healthcare organizations can implement in their clinical information systems. We also draw on the experiences of diverse institutions to highlight the realities of implementing medication decision support. These findings represent the experiences of institutions with a long history in the domain of medication decision support, and the hope is that this guidance may improve the feasibility and efficiency CDS adoption across healthcare settings.

Drug susceptibility testing proficiency in the network of supranational tuberculosis reference laboratories

SETTING

The network of supranational tuberculosis reference laboratories (SRLs).

OBJECTIVE

To evaluate the annual SRL Rounds 6-14 of proficiency testing for first-line drug susceptibility testing (DST).

DESIGN

Panels consisted of 20-30 cultures (including 10 pairs of duplicate strains), aiming at 50% resistance prevalence with a variety of profiles. The 27 SRLs participating in at least one of these rounds were free to use their preferred DST method. A judicial gold standard of at least 80% concordant 'susceptible' or 'resistant' was used to determine sensitivity, specificity and efficiency; otherwise the strain was excluded.

RESULTS

Of 600 strains, 10% were excluded from evaluation. The average SRL sensitivity and specificity varied between rounds, without attaining significance or trends. Both sensitivity and specificity remained at >95% for isoniazid (INH), rifampicin (RMP) and streptomycin and at >80% for ethambutol. The 16 SRLs participating in all rounds performed consistently better.

CONCLUSION

The rounds succeeded in comparing the proficiency of laboratories, and should be further promoted for DST quality assessment. However, to function with greater precision and to ultimately improve the clinical relevance of DST, the INH and RMP judicial result gold standard also needs to take into account genotypic and treatment outcome information.

Rapid assessment of clinical information systems in the healthcare setting: an efficient method for time-pressed evaluation

OBJECTIVE

Recent legislation in the United States provides strong incentives for implementation of electronic health records (EHRs). The ensuing transformation in U.S. health care will increase demand for new methods to evaluate clinical informatics interventions. Timeline constraints and a rapidly changing environment will make traditional evaluation techniques burdensome. This paper describes an anthropological approach that provides a fast and flexible way to evaluate clinical information systems.

METHODS

Adapting mixed-method evaluation approaches from anthropology, we describe a rapid assessment process (RAP) for assessing clinical informatics interventions in health care that we developed and used during seven site visits to diverse community hospitals and primary care settings in the U.S.

SETTING

Our multidisciplinary team used RAP to evaluate factors that either encouraged people to use clinical decision support (CDS) systems or interfered with use of these systems in settings ranging from large urban hospitals to single-practitioner, private family practices in small towns.

RESULTS

Critical elements of the method include: 1) developing a fieldwork guide; 2) carefully selecting observation sites and participants; 3) thoroughly preparing for site visits; 4) partnering with local collaborators; 5) collecting robust data by using multiple researchers and methods; and 6) analyzing and reporting data in a structured manner helpful to the organizations being evaluated.

CONCLUSIONS

RAP, iteratively developed over the course of visits to seven clinical sites across the U.S., has succeeded in allowing a multidisciplinary team of informatics researchers to plan, gather and analyze data, and report results in a maximally efficient manner.

Polysaccharide biosynthesis

Polysaccharide synthesis is discussed from the point of view of the sources of biological information that determine the structures and control the rates of synthesis of complex polysaccharides. It is concluded that three types of information contribute in important and different ways, namely enzyme specificity, primer substances, and the structure of the cytoplasmic membrane. Each of these factors is discussed in a general way with examples of its contribution to the structure and organization of specific polysaccharides.

II. BILE CHOLESTEROL : FLUCTUATIONS DUE TO DIET FACTORS, BILE SALT, LIVER INJURY AND HEMOLYSIS

Under uniform diet conditions the normal bile fistula dog will eliminate pretty constant amounts of cholesterol—about 0.5 to 1.0 mg. cholesterol per kilo per 24 hours. Diets rich in cholesterol (egg yolk) will raise the cholesterol output in the bile but compared to the diet intake (1.5 gm. cholesterol) the output increase in the bile is trivial (5–15 mg.). Calves' brains in the diet are inert. Bile salt alone will raise the cholesterol output in the bile as much and often more than a cholesterol rich diet. Bile salt plus egg yolk plus whole bile give maximal output figures for bile cholesterol—60 mg. per 24 hours. Liver injury (chloroform) decreases both bile salt and cholesterol elimination in the bile. Blood destruction (hydrazine) fails to increase the bile cholesterol output and this eliminates the red cell stroma as an important contributing factor. Certain cholagogues (isatin and decholin) will increase the bile flow but cause no change in cholesterol elimination. The ratio of cholesterol to bile salt in the bile normally is about 1 to 100 but the bile salts are more labile in their fluctuations. The ratio is about reversed in the circulating blood plasma where the cholesterol is high (150–300 mg. per cent) and the bile salt concentration very low. Cholesterol runs so closely parallel to bile salt in the bile that one may feel confident of a physical relationship. In addition there is a suspicion that the bile cholesterol is in some obscure fashion linked with the physiological activity of hepatic epithelium.

III. BLOOD PLASMA CHOLESTEROL : FLUCTUATIONS DUE TO LIVER INJURY AND BILE DUCT OBSTRUCTION

Hypocholesteremia with dissociation of the normal ratio of esterified to total cholesterol is related to chronic liver injury caused by chloroform. Hypercholesteremia may develop after prolonged biliary obstruction. The hypercholesteremia of chronic biliary obstruction may be promptly reduced below normal by chloroform poisoning or bile duct infection. Acute injury of liver due to chloroform anesthesia may cause no change in blood plasma cholesterol. Absence of bile in the intestine with faulty fat absorption does not cause the development of hypocholesteremia with dissociation of the ester ratio. Poor food consumption or short periods of fasting may cause no change in blood plasma cholesterol. Liver cells injured by chloroform may subsequently become resistant to chloroform. After prolonged biliary obstruction, the liver is apparently more sensitive to small doses of chloroform by mouth. Analysis of blood plasma cholesterol may have a clinical application in differentiation between simple obstructive and parenchymatous lesions of the liver.

I. CHOLESTEROL AND CHOLESTEROL ESTERS IN DOG BILE : QUANTITATIVE METHODS

The colorimetric method for the determination of total cholesterol in dog bile is consistently accurate as checked by the oxidative digitonin method. This method has the further advantages of being simple, rapid and economical. A method for the determination of esterified cholesterol in bile is described and it is shown that there are no esters of cholesterol in normal dog bile.

Faecal lactoferrin--a novel test to differentiate between the irritable and inflamed bowel?

BACKGROUND

Distinguishing between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) can be challenging.

AIMS

To investigate the utility of faecal lactoferrin as a marker of inflammation in patients with IBD, IBS and controls.

METHODS

Disease activity in IBD patients was assessed using the modified Harvey-Bradshaw Activity Index. Stool samples were analysed using an ELISA assay.

RESULTS

We recruited 137 patients with IBS, 126 with ulcerative colitis (UC) and 104 with Crohn's disease (CD), and 98 healthy volunteers. The median +/- IQ lactoferrin concentration (microg/g faecal weight) was 0 +/- 1.4 for IBS patients, 6.6 +/- 42 for UC patients, 4 +/- 12.7 for CD patients and 0.5 +/- 2 for healthy controls. Lactoferrin levels were significantly higher in IBD patients compared with IBS/healthy controls (P < 0.001). The median lactoferrin concentrations were significantly higher in active UC & CD patients compared with inactive patients (P < 0.001 and P = 0.002 respectively). The sensitivity, specificity, positive and negative predictive values of lactoferrin in distinguishing active IBD from IBS/healthy controls were 67% and 96%, 87% and 86.8% respectively.

CONCLUSIONS

Lactoferrin is useful to differentiate between IBD and IBS, and can be used as an adjunct to blood parameters to determine IBD patients who have ongoing inflammation.

Faecal lactoferrin--a novel test to differentiate between the irritable and inflamed bowel?

BACKGROUND

Distinguishing between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) can be challenging.

AIMS

To investigate the utility of faecal lactoferrin as a marker of inflammation in patients with IBD, IBS and controls.

METHODS

Disease activity in IBD patients was assessed using the modified Harvey-Bradshaw Activity Index. Stool samples were analysed using an ELISA assay.

RESULTS

We recruited 137 patients with IBS, 126 with ulcerative colitis (UC) and 104 with Crohn's disease (CD), and 98 healthy volunteers. The median +/- IQ lactoferrin concentration (microg/g faecal weight) was 0 +/- 1.4 for IBS patients, 6.6 +/- 42 for UC patients, 4 +/- 12.7 for CD patients and 0.5 +/- 2 for healthy controls. Lactoferrin levels were significantly higher in IBD patients compared with IBS/healthy controls (P < 0.001). The median lactoferrin concentrations were significantly higher in active UC & CD patients compared with inactive patients (P < 0.001 and P = 0.002 respectively). The sensitivity, specificity, positive and negative predictive values of lactoferrin in distinguishing active IBD from IBS/healthy controls were 67% and 96%, 87% and 86.8% respectively.

CONCLUSIONS

Lactoferrin is useful to differentiate between IBD and IBS, and can be used as an adjunct to blood parameters to determine IBD patients who have ongoing inflammation.

Dysautonomia in a six-year-old mule in the United States

Equine dysautonomia, also known as equine grass sickness (EGS), is a well documented disease in several countries. To the authors' knowledge, EGS has not been reported previously in North America. This report describes EGS in a 6-year-old female mule in the USA. Failure initially to consider EGS resulted in a delayed diagnosis. EGS should be considered as a differential diagnosis and appropriate diagnostic tests performed in similar cases in North America.