Discharge documentation improvement project: a pilot study

BACKGROUND

Discharge summaries remain a critical communication tool with primary care physicians. In a previous study of over 200 general medicine discharge summaries, we demonstrated that only 50% contain information regarding the indication and follow up required of any medicine changes on discharge.

AIM

In this follow up pilot study, we assess the role of feedback and token incentives in improving discharge documentation.

METHODS

Over a 14-week period, we randomly audited a selection of discharge summaries on a fortnightly basis. The results of these audits were fed back to the junior medical staff who compiled these summaries. If over 80% of the audited discharge summaries adequately documented the indication, with required follow up for new medication changes, junior doctors were provided with a token, non-monetary incentive for their efforts. At the end of the study period, we then conducted a survey of the junior doctors involved and collected feedback regarding their impressions of the study.

RESULTS

Over the study period, 722 discharge summaries were completed and eligible for analysis. Over this time, mean appropriate documentation regarding medicine indication improved by 32%, and follow-up documentation improved by 10%. Overall, the participants felt the interventions were beneficial and that they should be continued beyond the study period.

CONCLUSIONS

Education coupled with regular feedback and non-monetary incentives can potentially lead to improvements in the quality of discharge summaries.

Intraperitoneal Administration of Low Dose Aluminium in The Rat: How Good is It to Produce a Model for Alzheimer Disease

Since neurotoxicity of aluminium (Al) resembles the progressive neurodegeneration observed in Alzheimer Disease (AD), Al administration in several ways has been used to produce AD model. Intraperitoneal (ip) low dose (4.2 mg/ kg) Al injection in rats for long periods is the preferred method by some researchers. In this paper, the efficiency of this method for producing an AD model was evaluated. In this study, we looked at the neuropathology of Al and the characteristic lesions of AD by histological and immunohistochemical techniques and determined oxidative stress markers in the brains of Al-treated and control rats. We also made electrophysiological recordings at the hippocampus and evaluated possible behavioural changes by Morris water maze test. However, no pathologic changes occurred in the animals except for an impairment in long-term potentiation (LTP) in the hippocampus (e.g. the LTPs of population spike (PS) amplitude at 15 min post-tetanus were measured as 217±27% in Al-treated rats and as 240±42% in sham-treated rats, of baseline PS amplitude). According to the findings of the present study, low dose of ip Al in rats is not sufficient to produce a good AD model. Higher doses (≥10 mg/kg) should be used.

Effects of multiple ascending doses of the glucagon receptor antagonist PF-06291874 in patients with type 2 diabetes mellitus

AIMS

To assess the pharmacokinetics, pharmacodynamics, safety and tolerability of multiple ascending doses of the glucagon receptor antagonist PF-06291874 in patients with type 2 diabetes mellitus (T2DM).

METHODS

Patients were randomized to oral PF-06291874 or placebo on a background of either metformin (Part A, Cohorts 1-5: 5-150 mg once daily), or metformin and sulphonylurea (Part B, Cohorts 1-2: 15 or 30 mg once daily) for 14-28 days. A mixed-meal tolerance test (MMTT) was administered on days -1 (baseline), 14 and 28. Assessments were conducted with regard to pharmacokinetics, various pharmacodynamic variables, safety and tolerability. Circulating amino acid concentrations were also measured.

RESULTS

PF-06291874 exposure was approximately dose-proportional with a half-life of ∼19.7-22.7 h. Day 14 fasting plasma glucose and mean daily glucose values were reduced from baseline in a dose-dependent manner, with placebo-corrected decreases of 34.3 and 42.4 mg/dl, respectively, at the 150 mg dose. After the MMTT, dose-dependent increases in glucagon and total glucagon-like peptide-1 (GLP-1) were observed, although no meaningful changes were noted in insulin, C-peptide or active GLP-1 levels. Small dose-dependent increases in LDL cholesterol were observed, along with reversible increases in serum aminotransferases that were largely within the laboratory reference range. An increase in circulating gluconeogenic amino acids was also observed on days 2 and 14. All dose levels of PF-06291874 were well tolerated.

CONCLUSION

PF-06291874 was well tolerated, has a pharmacokinetic profile suitable for once-daily dosing, and results in reductions in glucose with minimal risk of hypoglycaemia.

Distribution of common pathogens in patients with pyogenic liver abscess in China: a meta-analysis

Pyogenic liver abscess (PLA) is a potentially life-threatening disease in many parts of the world, especially in Asia. The aim of this study was to quantify the proportion of common pathogens in patients with PLA in China, using a meta-analysis method based on systematic review of published studies. Several electronic databases were searched to identify the studies reporting the pathogens of PLA. We performed a meta-analysis to calculate the pooled proportion of pathogens and subgroup analysis among the included studies using R 3.1.1 software. In total, 183 studies were included in our final analysis, Klebsiella spp (54 %), Escherichia spp (29 %), Enterobacter spp (9 %), Proteus spp (6 %) and Pseudomonas spp (5 %) comprised the major gram-negative bacteria. Gram-positive bacteria mainly included Staphylococcus spp (13 %), Streptococcus spp (8 %) and Enterococcus spp (7 %). The distribution of pathogens in PLA patients were different in different economic regions in China. The proportion of Klebsiella spp had an upward tendency in recent years compared to other pathogens. In addition, the proportion of common pathogens in PLA patients with diabetes mellitus (DM) were carried out indicating that the dominant pathogens were Klebsiella spp (66 %), Escherichia spp (21 %) and Enterobacter spp (11 %). This meta-analysis showed that the main pathogens of PLA were Klebsiella spp, Escherichia spp, Staphylococcus spp, and Enterobacter spp in China. To ensure a precise estimate of the epidemiology of the pathogens, further large-scale or even a population-based study is needed.

Heart Failure Clinics in the Netherlands in 2003

PURPOSE

Heart failure (HF) care in the Netherlands is going through a lot of changes. Nurses have increasingly important roles in providing optimal care for these chronically ill patients. In this study, we describe the current number of HF management programs and the role of the nurses in these programs.

METHOD

Data were collected by a national survey as part of a European HF clinic survey of the UNITE study group of the Working Group on Cardiovascular Nursing between February and March 2003 to 142 hospitals in the Netherlands.

RESULTS

In 60% of the hospital locations, there is a HF management program. Most of the programs are organized as HF outpatient clinics. In all HF programs, cardiologists and nurses are involved. Other health care providers involved are, amongst others, general practitioners (29%), dieticians (59%), physical therapists (47%), social workers (30%) and psychologists (17%). All programs offer follow-up after discharge from the hospitals and in most of the programs patients have increased access to a health care provider. Behavioural interventions (68%), psychosocial counselling (64%), patient education (88%) and support of the informal caregivers (59%) are important components. In 90% of the programs (restricted), physical examination is the responsibility of the HF nurse and in 65% of the programs nurses are involved in optimizing medical treatment. Financial support and education of HF nurses is still unstructured and diverse.

CONCLUSION

There is a rise in the number of HF programs in the Netherlands. There is diversity in content and intensity of these programs and the role of the nurse is not clearly defined yet. Research and discussion on the subject of optimal effective HF care and the role of the HF nurse is still needed.

Identification of a novel mutation of the EDA gene in X-linked hypohidrotic ectodermal dysplasia

This study aimed to identify the disease-causing mutation in the ectodysplasin A (EDA) gene in a Chinese family affected by X-linked hypohidrotic ectodermal dysplasia (XLHED). A family clinically diagnosed with XLHED was investigated. For mutation analysis, the coding region of EDA of 2 patients and 7 unaffected members of the family was sequenced. The detected mutation in EDA was investigated in 120 normal controls. A missense mutation (c.878T>G) in EDA was detected in 2 patients and 3 female carriers, but not in 4 unaffected members of the family. The mutation was not found in the 120 healthy controls and has not been reported previously. Our findings indicate that a novel mutation (c.878T>G) of EDA is associated with XLHED and adds to the repertoire of EDA mutations.

Ultrafast laser functionalized rare phased gold-silicon/silicon oxide nanostructured hybrid biomaterials

We introduce a hybrid nanostructured biomaterial that is a combination of rare phases of immiscible gold and silicon oxide, functionalized via ultrafast laser synthesis. For the first time, we show cancer controlling properties of rare phases of gold silicides, which include Au7Si, Au5Si, Au0.7Si2.3 and Au8Si2. Conventionally, pure forms of gold and silicon/silicon oxide are extensively employed in targeted therapy and drug delivery systems due to their unique properties. While silicon and silicon oxide nanoparticles have shown biocompatibility, gold nanoparticles show conflicting results based on their size and material properties. Several studies have shown that gold and silicon combinations produce cell controlling properties, however, these studies were not able to produce a homogenous combination of gold and silicon, owing to its immiscibility. A homogenous combination of gold and silicon may potentially enable properties that have not previously been reported. We describe rare phased gold-silicon oxide nanostructured hybrid biomaterials and its unique cancer controlling properties, owing to material properties, concentration, size and density. The gold-silicon oxide nanostructured hybrid is composed of individual gold-silicon oxide nanoparticles in various concentrations of gold and silicon, some nanoparticles possess a gold-core and silicon-shell like structure. The individual nanoparticles are bonded together forming a three dimensional nanostructured hybrid. The interaction of the nanostructured hybrids with cervical cancer cells showed a 96% reduction in 24h. This engineered nanostructured hybrid biomaterial presents significant potential due to the combination of immiscible gold and silicon oxide in varying phases and can potentially satiate the current vacuum in cancer therapy.

Ultrafast Laser Synthesized Nanostructures for Controlling Cell Proliferation

The state-of-the-art in synthesis of nanostructured cell and contra-cell surfaces relies on techniques that utilize elaborate precursor chemicals, catalysts, or vacuum conditions, and any combination thereof. Two type s of nanostructures, sodium oxide (Na2O) nanotips and silicon oxide (SiO2) nanofibers, have been fabricated on soda-lime glass using ultrafast laser ablation. Control over nanotip width was demonstrated via laser dwell time and a new tip formation mechanism is proposed. The nanofibers generated in this work display a level of nanomorphology unseen in other fiber fabrication methods. The resulting fibers show striking morphological similarity to proteins that comprise the natural extra cellular matrix. The interaction of both nanostructures with NIH 3T3 fibroblasts was explored by incubating nanostructured glass with fibroblasts over periods of 12 hours, 1 day, or 1 week. The Na2O nanotip surfaces dissolved within a day yet appeared to induce apoptosis in cells while the SiO2 nanofibers degraded over time but influenced cells to display unique, healthy characteristics such as preferential adhesion to nanofibers and increased microvilli generation. These growth-positive and growth-negative surfaces for cells could find use in novel biological testing equipment.

Transition from hospital to primary care: an audit of discharge summary - medication changes and follow-up expectations

BACKGROUND

The clinical discharge summary remains a critical, but often poorly implemented tool in communication with primary care. An area of concern is the documentation of medication lists and appropriate follow up of medication changes.

AIMS

To assesses the accuracy of documentation of medication changes and expectations with regard to follow up from an acute assessment unit (AAU) of a tertiary metropolitan hospital.

METHODS

All patients who were admitted and discharged directly from the unit during the month of June 2013 were audited. For all admissions, discharge summaries were audited for medication errors and for the appropriate documentation of indications and follow up for prescribed medications. All medications prescribed on discharge were collated using the World Health Organization Anatomical, Therapeutic and Chemical (ATC) classification.

RESULTS

In total, 219 admissions were analysed. There were 204 out of 219 (93.1%) discharge summaries that had an accurate medication list. Of 219 (74%) patients, 163 had at least one change to their medications during admission. Of 163 discharge summaries, 82 (50%) contained information regarding their indication and outpatient management. The most commonly prescribed classes along with the rates of indication and follow up documentation were anti-infectives (62%), gastrointestinal (51%), cardiovascular (50%) and central nervous system (44%).

CONCLUSION

Although there were fewer documentation errors in discharge summaries than previously described in the literature, concerns regarding the documentation of medication indication and follow up remain.

Engineering functionalized multi-phased silicon/silicon oxide nano-biomaterials to passivate the aggressive proliferation of cancer

Currently, the use of nano silicon in cancer therapy is limited as drug delivery vehicles and markers in imaging, not as manipulative/controlling agents. This is due to limited properties that native states of nano silicon and silicon oxides offers. We introduce nano-functionalized multi-phased silicon/silicon oxide biomaterials synthesized via ultrashort pulsed laser synthesis, with tunable properties that possess inherent cancer controlling properties that can passivate the progression of cancer. This nanostructured biomaterial is composed of individual functionalized nanoparticles made of a homogenous hybrid of multiple phases of silicon and silicon oxide in increasing concentration outwards from the core. The chemical properties of the proposed nanostructure such as number of phases, composition of phases and crystal orientation of each functionalized nanoparticle in the three dimensional nanostructure is defined based on precisely tuned ultrashort pulsed laser-material interaction mechanisms. The amorphous rich phased biomaterial shows a 30 fold (95%) reduction in number of cancer cells compared to bulk silicon in 48 hours. Further, the size of the cancer cells reduces by 76% from 24 to 48 hours. This method exposes untapped properties of combination of multiple phases of silicon oxides and its applications in cancer therapy.

Annexin A2 is implicated in multi-drug-resistance in gastric cancer through p38MAPK and AKT pathway

Studies have shown that Annexin A2 (ANXA2) is related with tumor proliferation, apoptosis, differentiation, invasion, migration, and drug resistance. The purpose of this study was to investigate the role and its mechanisms of ANXA2 in multi-drug-resistance (MDR) in gastric cancer. ANXA2 expression in both gastric cancer tissues and cell lines were detected by quantitative real-time PCR (RT-qPCR) and Western blotting. The cell proliferation was measured by SRB assay. The pool of siRNA against ANXA2 was designed and synthesized and then transfected into resistant gastric cancer SGC7901/DDP cells. ANXA2 expression was detected by RT-qPCR and Western blotting. Drug sensitivities of SGC7901/DDP cells to P-gp-related drug (doxorubicin) and P-gp-non-related drugs (5-FU and cisplatin) were measured by SRB assay. Expression of MDR-related genes and phosphorylation of AKT and MAPKs were also detected by RT-qPCR and Western blotting. Results showed that ANXA2 expression was significantly higher in gastric specimens than that in normal tissues, and negatively correlated with the differentiation level of gastric cancer. In addition, ANXA2 expression level was higher in SGC7901/DDP cells than that in parent SGC7901 cells. After knock-down ANXA2 expression using ANXA2 small interfering RNA, the drug sensitivity of SGC7901/DDP cells to doxorubicin, 5-FU and DDP increased. Delivery of ANXA2 siRNA significantly downregulated the expression of P-gp, MRP1 and Bcl-2, while markedly upregulated Bax in SGC7901/DDP cells. However, several other MDR factors such as GST-π, TOPO-I and TOPO-II had no obvious changes. Additionally, phosphorylation of P38MAPK and AKT, but not ERK1/2 or JNKs was specifically decreased in SGC7901/DDP cells after ANXA2 siRNA delivery. Importantly, P38MAPK and AKT inhibitor increased the drug sensitivity of SGC701/DDP cells in a similar way as ANXA2 siRNAs does. ANXA2 is involved in gastric cancer MDR through regulating p38MAPK and AKT pathways as well as certain MDR factors.

Inhibition of Vav3 could reverse the drug resistance of gastric cancer cells by downregulating JNK signaling pathway

This study aims to investigate the effect and mechanism of Vav3 on the multidrug resistance of gastric cancer. Fluorescence quantitative RT-PCR and western blot assay were used to detect Vav3 and drug resistance genes in gastric cancer tissues as well as gastric cell lines such as SGC7901, SGC7901/adriamycin (ADR) and GES-1. Besides, Vav3-specific small interfering RNA (Vav3-siRNA) was applied to inhibit Vav3 in SGC7901/ADR, and SRB assay was used to determine chemosensitivity. After that, drug resistance genes and proteins in MAPK and PI3K/AKT signaling pathway were detected after Vav3-siRNA transfection. The results showed that overexpressed Vav3 was found in gastric cancer tissues and SGC7901 and SGC7901/ADR cells. Activity of SGC7901/ADR cells transfected with Vav3-siRNA combined with 5-fluorouracil/oxaliplatin was much lower than that of control groups, and MDR1/P-gp, GST-π and Bcl-2, Bax genes were significantly downregulated in Vav3-siRNA transfection group. AKT, ERK and p38 total protein and their phosphorylation levels showed no significant change in Vav3-siRNA-transfected SGC7901/ADR cells, whereas the ratio of C-Jun phosphorylation levels to total C-Jun protein was significantly downregulated. The results suggested that Vav3 may play a role in drug resistance of gastric cancer by inhibiting drug resistance genes MDR1/P-gp, GST-π and Bcl-2 through regulating the JNK signaling pathway.

Renal tumor-derived exosomes inhibit hepaCAM expression of renal carcinoma cells in a p-AKT-dependent manner

HepaCAM mediates cancer cell proliferation, migration and differentiation. Our previous studies showed the effects of hepaCAM on the inhibition of renal carcinoma cell proliferation. To further investigate the reason for the low expression of hepaCAM in renal carcinoma and the corresponding molecular mechanisms, we detected renal carcinoma OS-RC-2 cell lines containing high expression of hepaCAM; and hepaCAM and p-AKT were also detected in these cells. Exosomes were isolated and purified from the supernatant liquid of OS-RC-2 cells. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and flow cytometry analysis were conducted to determine the effect of exosomes on the proliferation and cycle distribution of OS-RC-2 cells. OS-RC-2 cells (high expression of hepaCAM) were treated with exosomes or plus MK-2206 (AKT inhibitor); and hepaCAM, AKT and p-AKT were detected in these cells by western blot analysis. The correlation between hepaCAM and p-AKT was analysed by immunohistochemical method. Results showed that hepaCAM re-expression in OS-RC-2 cell lines resulted in significant weakening of proliferation ability and more prominent G0/G1 population as well as reduction of p-AKT protein. The increase in proliferation caused by exosomes was followed by hepaCAM downregulation and p-AKT upregulation in OS-RC-2 cells (high expression of hepaCAM). By comparison, the promotion of proliferation caused by exosomes was weakened and hepaCAM expression changed after MK-2206 treatment; however, this change was not significant. HepaCAM was negatively correlated with p-AKT protein in renal cell carcinoma tissues. Therefore, renal tumor-derived exosomes may be an important factor resulting in the low expression of hepaCAM by upregulating p-AKT in renal carcinoma.