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.

Carbon trading for phosphorus gain: the balance between rhizosphere carboxylates and arbuscular mycorrhizal symbiosis in plant phosphorus acquisition

Two key plant adaptations for phosphorus (P) acquisition are carboxylate exudation into the rhizosphere and mycorrhizal symbioses. These target different soil P resources, presumably with different plant carbon costs. We examined the effect of inoculation with arbuscular mycorrhizal fungi (AMF) on amount of rhizosphere carboxylates and plant P uptake for 10 species of low-P adapted Kennedia grown for 23 weeks in low-P sand. Inoculation decreased carboxylates in some species (up to 50%), decreased plant dry weight (21%) and increased plant P content (23%). There was a positive logarithmic relationship between plant P content and the amount of rhizosphere citric acid for inoculated and uninoculated plants. Causality was indicated by experiments using sand where little citric acid was lost from the soil solution over 2 h and citric acid at low concentrations desorbed P into the soil solution. Senesced leaf P concentration was often low and P-resorption efficiencies reached >90%. In conclusion, we propose that mycorrhizally mediated resource partitioning occurred because inoculation reduced rhizosphere carboxylates, but increased plant P uptake. Hence, presumably, the proportion of plant P acquired from strongly sorbed sources decreased with inoculation, while the proportion from labile inorganic P increased. Implications for plant fitness under field conditions now require investigation.

Functionalized mesoporous silica particles for application in drug delivery system

In these years, ordered mesoporous silica materials have shown promising applications in drug delivery system as drug carriers. These carriers with stable mesoporous structure, large surface area, good biocompatibility and tailored size of mesopores exhibit significant property of higher drug loading. However, silica-based mesoporous materials cannot control the release of the loaded drug without modifications. In this paper, we review the recent research work discussing functionalization of mesoporous materials by various components and methods for application in drug delivery systems. All the examples show that these functionalized mesoporous silica-based systems have great potential for a variety of drug delivery applications, specifically in the fields of the drug targeted and controlled delivery systems.

Vitreous surgery for macular hole-related retinal detachment after phacoemulsification cataract extraction: 10-year retrospective review

PURPOSE

To evaluate the visual and anatomical results of surgery for macular hole-related retinal detachment (MHRD) after phacoemulsification cataract extraction.

METHODS

Data for all patients who underwent surgery for MHRD after phacoemulsification cataract extraction from 1 December 1998 to 30 September 2008 in one hospital were evaluated. Patient characteristics, best-corrected visual acuity (VA) preoperatively and at last examination, surgical technique, anatomical success, and follow-up period were extracted and analysed statistically.

RESULTS

A total of 13 625 eyes of 10 076 patients who had phacoemulsification cataract surgery were included. In the follow-up period, 10 cases of MHRD in nine patients were observed, of which seven eyes had high myopia. The mean axial length was 30.97 ± 1.36 mm (29.19, 32.97) and mean myopia was-19.35 ± 1.93 (-7.5,-3.5) dioptres. Overall anatomical success was achieved in 90% (9 out of 10 eyes). There was no statistically significant difference (P=0.240) between the logarithm of the MAR VA before the phacoemulsification cataract extraction and after MHRD surgical repair. VA increased in three eyes but decreased in the other seven after MHRD surgery.

CONCLUSIONS

As a primary procedure, vitreous surgery combined with other necessary adjunct procedures such as membrane peeling and retinal tamponade seems to be successful in achieving anatomical success. However, VA improvement is dependent on the type of macular lesion and not the surgical procedure.

Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature

Radiation therapy is a common treatment for cancer patients. One of the most common side effects of radiation is acute skin reaction (radiation dermatitis) that ranges from a mild rash to severe ulceration. Approximately 85% of patients treated with radiation therapy will experience a moderate-to-severe skin reaction. Acute radiation-induced skin reactions often lead to itching and pain, delays in treatment, and diminished aesthetic appearance-and subsequently to a decrease in quality of life. Surveys have demonstrated that a wide variety of topical, oral, and intravenous agents are used to prevent or to treat radiation-induced skin reactions. We conducted a literature review to identify trials that investigated products for the prophylaxis and management of acute radiation dermatitis. Thirty-nine studies met the pre-defined criteria, with thirty-three being categorized as prophylactic trials and six as management trials.For objective evaluation of skin reactions, the Radiation Therapy Oncology Group criteria and the U.S. National Cancer Institute Common Toxicity Criteria were the most commonly used tools (65% of the studies). Topical corticosteroid agents were found to significantly reduce the severity of skin reactions; however, the trials of corticosteroids evaluated various agents, and no clear indication about a preferred corticosteroid has emerged. Amifostine and oral enzymes were somewhat effective in preventing radiation-induced skin reactions in phase II and phase III trials respectively; further large randomized controlled trials should be undertaken to better investigate those products. Biafine cream (Ortho-McNeil Pharmaceuticals, Titusville, NJ, U.S.A.) was found not to be superior to standard regimes in the prevention of radiation-induced skin reactions (n = 6).In conclusion, the evidence is insufficient to support the use of a particular agent for the prevention and management of acute radiation-induced skin reactions. Future trials should focus on comparing agents and approaches that, in phase I and II trials, suggest efficacy. These future phase III randomized controlled trials must clearly distinguish between preventive and management strategies for radiation-induced dermatitis. Only then can evidence-based guidelines be developed, with the hope of standardizing the approach across centres and of improving the prevention and management of radiation-induced dermatitis.

Changes of serum omentin levels and relationship between omentin and adiponectin concentrations in type 2 diabetes mellitus

BACKGROUND

Omentin has recently been characterized as a potent insulin-sensitizing adipokine, but its pathophysiologic roles in humans remain largely unknown.

OBJECTIVE

To investigate the change of fasting serum omentin levels and evaluate the relationship of omentin with adiponectin in patients with type 2 diabetes mellitus.

DESIGN

35 patients with newly diagnosed type 2 diabetes (T2DM), 35 patients with impaired glucose regulation (IGT) and 35 patients with normal glucose tolerance (NGT) participated in this study. Fasting serum omentin and adiponectin levels were measured by enzyme-linked immunosorbent assay. The relationship between serum omentin, serum adiponectin levels and metabolic parameters was also analyzed.

RESULTS

Fasting serum omentin levels were significantly lower in T2DM and IGT groups than in NGT group (16.75±1.71 vs. 18.62±1.22 vs. 24.60±1.43 ng/ml, all P<0.01). Obesity subjects had significantly lower serum omentin levels than normal body weight subjects ( P<0.01 or P<0.05). Female subjects had moderately higher fasting serum omentin levels than male subjects. Fasting serum adiponectin levels showed a similar variation trend to omentin in T2DM and NGT groups, obesity and normal body weight subjects, female and male subjects. Fasting serum omentin levels were negatively correlated with HOMA-IR and positively correlated with adiponectin. Moreover, HOMA-IR and adiponectin were the independently predictors of fasting serum omentin levels.

CONCLUSIONS

Serum omentin levels possibly play an important role in the pathogenesis of insulin resistance and diabetes. More importantly, there is such a close connection between serum omentin and adiponectin levels that regulation of omentin may be dependent on adiponectin.

Extramammary Paget disease: review of patients seen in a non-melanoma skin cancer clinic

Extramammary Paget disease (EMPD) is a rare skin disease commonly found in the anogenital region. In this study, we aimed to identify EMPD patients seen in the non-melanoma skin cancer clinic at Odette Cancer Centre and to describe the treatments delivered and outcomes achieved. From 2000 to 2009, 14 patients were seen. Initial treatment recommendations included imiquimod and surgical excision, although half the patients required more than one treatment modality, highlighting the difficulty of achieving complete eradication of this disease.

Expression profiling identifies new function of collapsin response mediator protein 4 as a metastasis-suppressor in prostate cancer

Metastasis is the chief cause of mortality from cancer, but the mechanisms leading to metastasis are poorly understood. We used a proteomics approach to screen for metastasis-associated proteins and found that collapsin response mediator protein-4 (CRMP4) expression was inversely associated with the lymph node metastasis of prostate cancer (PCa). Subsequent in vitro and in vivo studies revealed that overexpression of CRMP4 not only suppressed the invasion ability of PCa cells, but also strongly inhibited tumor metastasis in an animal model. Furthermore, methylation of a CpG island within the promoter region of the CRMP4 gene is responsible for downregulation of CRMP4 expression. Thus, in this study, we show new function of CRMP4 as a metastasis-suppressor in PCa. The findings provide new mechanistic insights into metastasis and therapeutic potential for this most common male cancer.

Self-complementary AAV-mediated gene therapy restores cone function and prevents cone degeneration in two models of Rpe65 deficiency

To test whether fast-acting, self-complimentary (sc), adeno-associated virus-mediated RPE65 expression prevents cone degeneration and/or restores cone function, we studied two mouse lines: the Rpe65-deficient rd12 mouse and the Rpe65-deficient, rhodopsin null ('that is, cone function-only') Rpe65(-/-)::Rho(-/-) mouse. scAAV5 expressing RPE65 was injected subretinally into one eye of rd12 and Rpe65(-/-)::Rho(-/-) mice at postnatal day 14 (P14). Contralateral rd12 eyes were injected later, at P35. Rd12 behavioral testing revealed that rod vision loss was prevented with either P14 or P35 treatment, whereas cone vision was only detected after P14 treatment. Consistent with this observation, P35 treatment only restored rod electroretinogram (ERG) signals, a result likely due to reduced cone densities at this time point. For Rpe65(-/-)::Rho(-/-) mice in which there is no confounding rod contribution to the ERG signal, cone cells and cone-mediated ERGs were also maintained with treatment at P14. This work establishes that a self-complimentary AAV5 vector can restore substantial visual function in two genetically distinct models of Rpe65 deficiency within 4 days of treatment. In addition, this therapy prevents cone degeneration but only if administered before extensive cone degeneration, thus supporting continuation of current Leber's congenital amaurosis-2 clinical trials with an added emphasis on cone subtype analysis and early intervention.

Comparison of the MMSE and RUDAS cognitive screening tools in an elderly inpatient population in everyday clinical use

We compared test score and performance times of Folstein's Mini Mental State Examination (MMSE) and the Rowland Universal Dementia Assessment Scale (RUDAS). Forty-six patients were recruited. The mean score was 20.6 for the MMSE and 20.5 for the RUDAS. Linear regression analysis revealed an r value of 0.83 (P < 0.05). The mean performance time was 9.4 min for both the MMSE and the RUDAS. Patient satisfaction was similar for both tests. Surveyed clinicians preferred the MMSE because of greater familiarity. We concluded that the RUDAS correlates well with the MMSE and is no more time-consuming to perform. It has good clinical utility as a cognitive screening tool.