An Electronic Dashboard to Improve Dosing of Hydroxychloroquine Within the Veterans Health Care System: Time Series Analysis

BACKGROUND

Hydroxychloroquine (HCQ) is commonly used for patients with autoimmune conditions. Long-term use of HCQ can cause retinal toxicity, but this risk can be reduced if high doses are avoided.

OBJECTIVE

We developed and piloted an electronic health record-based dashboard to improve the safe prescribing of HCQ within the Veterans Health Administration (VHA). We observed pilot facilities over a 1-year period to determine whether they were able to improve the proportion of patients receiving inappropriate doses of HCQ.

METHODS

Patients receiving HCQ were identified from the VHA corporate data warehouse. Using PowerBI (Microsoft Corp), we constructed a dashboard to display patient identifiers and the most recent HCQ dose and weight (flagged if ≥5.2 mg/kg/day). Six VHA pilot facilities were enlisted to test the dashboard and invited to participate in monthly webinars. We performed an interrupted time series analysis using synthetic controls to assess changes in the proportion of patients receiving HCQ ≥5.2 mg/kg/day between October 2020 and November 2021.

RESULTS

At the start of the study period, we identified 18,525 total users of HCQ nationwide at 128 facilities in the VHA, including 1365 patients at the 6 pilot facilities. Nationwide, at baseline, 19.8% (3671/18,525) of patients were receiving high doses of HCQ. We observed significant improvements in the proportion of HCQ prescribed at doses ≥5.2 mg/kg/day among pilot facilities after the dashboard was deployed (-0.06; 95% CI -0.08 to -0.04). The difference in the postintervention linear trend for pilot versus synthetic controls was also significant (-0.06; 95% CI -0.08 to -0.05).

CONCLUSIONS

The use of an electronic health record-based dashboard reduced the proportion of patients receiving higher than recommended doses of HCQ and significantly improved performance at 6 VHA facilities. National roll-out of the dashboard will enable further improvements in the safe prescribing of HCQ.

The Development of the Rheumatology Informatics System for Effectiveness Learning Collaborative for Improving Patient-Reported Outcome Collection and Patient-Centered Communication in Adult Rheumatology

Objective

Patient‐reported outcomes (PROs) are an integral part of treat‐to‐target approaches in managing rheumatoid arthritis (RA). In clinical practice, however, routine collection, documentation, and discussion of PROs with patients are highly variable. The RISE LC (Rheumatology Informatics System for Effectiveness Learning Collaborative) was established to develop and share best practices in PRO collection and use across adult rheumatology practices in the United States

Methods

The goals of the RISE LC were developed through site surveys and in‐person meetings. Participants completed a baseline survey on PRO collection and use in their practices. RISE LC learning sessions focused on improving communication around PROs with patients and enhancing shared decision‐making in treatment plans. During the coronavirus disease 2019 (COVID‐19) pandemic, the RISE LC pivoted to adapt PRO tools for telehealth.

Results

At baseline, all responding sites (n = 15) had established workflows for collecting PROs. Most sites used paper forms alone. PRO documentation in electronic health records was variable, with only half of the sites using structured data fields. To standardize and improve the use of PROs, participants iteratively developed a Clinical Disease Activity Index–based RA Disease Activity Communication Tool to solicit treatment goals and improve shared decision‐making across sites. The COVID‐19 pandemic necessitated developing a tool to gauge PROs via telehealth.

Conclusion

The RISE LC is a continuous, structured method for implementing strategies to improve PRO collection and use in rheumatological care, initially adapting from the Learning Collaborative model and extending to include features of a learning network. Future directions include measuring the impact of standardized PRO collection and discussion on shared decision‐making and RA outcomes.

The amplifying influence of increased ocean stratification on a future year without a summer

In 1816, the coldest summer of the past two centuries was observed over northeastern North America and western Europe. This so-called Year Without a Summer (YWAS) has been widely attributed to the 1815 eruption of Indonesia's Mt. Tambora and was concurrent with agricultural failures and famines worldwide. To understand the potential impacts of a similar future eruption, a thorough physical understanding of the YWAS is crucial. Climate model simulations of both the 1815 Tambora eruption and a hypothetical analogous future eruption are examined, the latter occurring in 2085 assuming a business-as-usual climate scenario. Here, we show that the 1815 eruption drove strong responses in both the ocean and cryosphere that were fundamental to driving the YWAS. Through modulation of ocean stratification and near-surface winds, global warming contributes to an amplified surface climate response. Limitations in using major volcanic eruptions as a constraint on cloud feedbacks are also found.

Validity and Responsiveness of a 10-Item Patient-Reported Measure of Physical Function in a Rheumatoid Arthritis Clinic Population

OBJECTIVE

We assessed implementation of the 10-item Patient-Reported Outcomes Measurement Information System (PROMIS) physical function form (PF-10a) in routine practice in a racially and ethnically diverse population with rheumatoid arthritis (RA). Objectives were to determine feasibility of implementing PF-10a in the electronic health record (EHR) and PF-10a validity and longitudinal responsiveness.

METHODS

Clinical and demographic data were abstracted from EHRs for all RA patients seen at a university-based rheumatology clinic between February 2013 and February 2015. We evaluated floor and ceiling (edge) effects and construct validity of PF-10a in a subgroup of patients with Health Assessment Questionnaire (HAQ) scores (n = 189). We used linear mixed-effects models to assess responsiveness of PF-10a to longitudinal changes in the Clinical Disease Activity Index (CDAI) for patients in the entire clinical cohort, with both scores recorded on at least 2 encounters (n = 326).

RESULTS

Half of the patients were nonwhite, and 15% were non-English speakers. Over a 2-year period, PF10a was successfully implemented; 97% of patients and 89% of encounters had at least 1 measurement performed. PF-10a had fewer ceiling (defined as best) effects than the HAQ (8% versus 22%), and convergent validity was high (r = -0.85). PF-10a was sensitive to expected differences (older versus younger patients, more versus less active disease). Longitudinal changes in PF-10a were highly associated with changes in the CDAI score (P < 0.0001).

CONCLUSION

PF-10a was feasible to implement in a diverse RA population. It strongly correlates with the HAQ but has fewer ceiling effects and is responsive to changes in RA disease activity, suggesting its validity for use in routine clinical practice.

International multi-center evaluation of a novel chemiluminescence assay for the detection of anti-dsDNA antibodies

OBJECTIVE

Anti-double stranded desoxyribonucleic acid (anti-dsDNA) antibodies are considered fairly specific for systemic lupus erythematosus (SLE) and their quantification is useful for the clinical management of SLE patients. We assessed the diagnostic performance of the QUANTA Flash dsDNA chemiluminescent immunoassay (CIA) in comparison to an ELISA, using patients from five participating countries. The main focus was to evaluate the correlation between anti-dsDNA antibody results from the CIA and global SLE disease activity, as measured by the SLE Disease Activity Index 2000 (SLEDAI-2K).

PATIENTS AND METHODS

A total of 1431 samples (SLE, n = 843; disease controls, n = 588) from five countries (Canada, USA, Portugal, Sweden and Spain) were tested with QUANTA Flash dsDNA (Inova Diagnostics, San Diego, CA, USA). Data obtained with the QUANTA Lite dsDNA SC ELISA (Inova Diagnostics) were available for samples from three sites (Canada, USA and Sweden, n = 566). The SLEDAI-2K scores were available for 805 SLE patients and a cut-off of > 4 was used to define active disease.

RESULTS

QUANTA Flash dsDNA had a sensitivity of 54.3% for the diagnosis of SLE, combined with 89.8% specificity. Anti-dsDNA antibody levels were significantly higher (p < 0.0001) in active SLE (SLEDAI-2K > 4; n = 232; median value 83.0 IU/mL) versus the inactive patients (n = 573; median value 22.3 IU/mL), and the SLEDAI-2K scoring correlated with their dsDNA antibody levels (Spearman's rho = 0.44, p < 0.0001). Similar but less pronounced findings were also found for the ELISA, in relation to disease activity.

CONCLUSIONS

The QUANTA Flash dsDNA assay showed good clinical performance in a large international multi-center study. Additionally, the strong correlation between anti-dsDNA antibody results and SLEDAI-2K scores supported the potential utility of QUANTA Flash dsDNA for monitoring disease activity.

Variability of the impact of adverse events on physicians' decision making

Background

Physicians frequently differ in their treatment recommendations. However, few studies have examined the reasons underlying these differences. The objective of this study was to examine whether physicians vary in the importance they attach to specific adverse events for two treatment options found in recent randomized controlled trials to have equivalent efficacy and overall toxicity.

Methods

A Max-Diff survey was administered to physicians attending a national scientific conference to quantify the influence of 23 specific adverse events on decision making related to two treatment options for vasculitis. This approach was chosen because it results in greater item discrimination compared to rating scales. We used Hierarchical Bayes modeling to generate the relative importance score for each adverse event and examined the association between physicians’ characteristics and the five most influential factors.

Results

118 physicians completed the survey. The mean age (SD) was 48 years (10); 68% were male and 81% reported spending the majority of time in clinical practice. There was significant variability in the ratings of the relative importance of all adverse events, except those that were mild and easily reversible. We found a positive correlation between increasing physician age with ratings of sepsis (r = 0.29, p = 0.002) and opportunistic infection (r = 0.23, p = 0.016), and an inverse association between age with progressive multifocal leukoencephalopathy (r = - 0.28, p = 0.003). Physician sex, work setting, location, and number of patients with vasculitis seen per year were not associated with the influence of specific adverse events on decision making.

Conclusion

Our findings demonstrate that physicians differ substantially in how they perceive the importance of specific adverse events which may help explain observed unwarranted variability in physicians’ recommendations in clinical practice. Further efforts are needed to ensure that the reasons underlying variability in physicians’ recommendations are transparent.

Loss of insulin receptor in osteoprogenitor cells impairs structural strength of bone

Type 1 diabetes mellitus (T1D) is associated with decreased bone mineral density, a deficit in bone structure, and subsequently an increased risk of fragility fracture. These clinical observations, paralleled by animal models of T1D, suggest that the insulinopenia of T1D has a deleterious effect on bone. To further examine the action of insulin signaling on bone development, we generated mice with an osteoprogenitor-selective (osterix-Cre) ablation of the insulin receptor (IR), designated OIRKO. OIRKO mice exhibited an 80% decrease in IR in osteoblasts. Prenatal elimination of IR did not affect fetal survival or gross morphology. However, loss of IR in mouse osteoblasts resulted in a postnatal growth-constricted phenotype. By 10-12 weeks of age, femurs of OIRKO mice were more slender, with a thinner diaphyseal cortex and, consequently, a decrease in whole bone strength when subjected to bending. In male mice alone, decreased metaphyseal trabecular bone, with thinner and more rodlike trabeculae, was also observed. OIRKO mice did not, however, exhibit abnormal glucose tolerance. The skeletal phenotype of the OIRKO mouse appeared more severe than that of previously reported bone-specific IR knockdown models, and confirms that insulin receptor expression in osteoblasts is critically important for proper bone development and maintenance of structural integrity.

A Clostridium perfringens outbreak traced to temperature-abused beef stew, Norway, 2012

On 21 January 2012, the Norwegian Food Safety Authority was informed about gastrointestinal illness among 111 swimming club members, who were staying at a hotel in Trondheim. A hotel dinner on 20 January was their only common meal. Kitchen staff were interviewed, and food leftovers and kitchen environment were sampled. A case was defined as a swimming team member staying at the hotel from 20 to 22 January, who fell ill with diarrhoea, abdominal pain or nausea during this period. A total of 43 cases were identified, with median duration of symptoms of 35 hours. cpe-positive Clostridium perfringens (3.8 x 108 CFU), but not Bacillus cereus, was isolated from beef stew eaten by cases. cpe-negative C. perfringens was detected in a sample from the kitchen floor. SDS-PAGE showed indistinguishable protein profiles among C. perfringens cultures isolated from the beef stew, but slightly different profiles from the culture isolated from the kitchen floor. Cohort analysis showed that eating beef stew and rice was significantly associated with illness. No pathogens were detected in the rice. The temperature control of the stew, but not of the rice, was poor. Our results strongly indicate that cases were infected by Clostridium perfringens in beef stew that had inadequate temperature control during preparation.

Urodynamic assessment of children treated with botulinum toxin A injections for urge incontinence: a pilot study

OBJECTIVE

This study aimed to investigate changes in urodynamic findings and symptoms after detrusor injections of botulinum toxin A (BTX-A) in children with idiopathic detrusor overactivity (IDO) and urge incontinence.

MATERIAL AND METHODS

Eight girls and five boys, aged 7-19 years, who had urge incontinence refractory to scheduled voiding and anticholinergics, were included this prospective study. Urodynamic studies showed postoperative IDO in 12 patients. A dose of 50-100 IU (1.3 -- 4.8 IU/kg) BTX-A was primarily administered at 15-20 detrusor sites. A control urodynamic study was performed within 3 months after the injections. Seven patients had a repeated procedure 16 (range 6-24) months on the average after the first one.

RESULTS

Eleven of the 13 patients had daily incontinence and two had incontinence a couple of times a week in association with urge symptoms. Postoperatively, no patient had urinary retention, but one girl had a urinary tract infection 4 months after the therapy. Five patients had a full response, seven partial responses and one no response 1-3 months after the first treatment. After 1 year, three of nine patients still have full response. Maximum cystometric capacity increased after the first treatment from a median of 227 ml to 379 ml (p = 0.005) and the number of patients with uninhibited detrusor contractions more than 30 cmH₂O during the filling phase decreased from eight to two out of 13 (p = 0.041).

CONCLUSIONS

Intradetrusor BTX-A injections effectively reduce day-time wetting, significantly increase bladder volume and decrease detrusor overactivity in children with urge incontinence refractory to scheduled voidings and anticholinergics.

Histological asymmetries of primary motor cortex predict handedness in chimpanzees (Pan troglodytes)

Like humans, chimpanzees display robust and consistent hand preferences during the performance of certain tasks. Although correlations have been demonstrated between gross anatomic measures of primary motor cortex asymmetry and handedness in captive chimpanzees, the relationship between histological architecture and behavioral lateralization has not yet been investigated. Therefore, we examined interhemispheric asymmetry of several different microstructural characteristics of the primary motor cortex in the region of hand representation from 18 chimpanzees tested on a coordinated bimanual task before death. At the population level our data showed leftward bias for higher layer II/III neuron density. Of note, however, there was no population-level asymmetry in the areal fraction of Nissl-stained cell bodies, a finding that differs from previous studies of this cortical region in humans. Nonetheless, we found that asymmetry in the density of layer II/III parvalbumin-immunoreactive interneurons was the best predictor of individual hand preference. These results suggest that histological asymmetries are related to handedness in chimpanzees, while overall patterns of asymmetry at the population level might differ from humans.

Isolation of Shiga toxin-producing Escherichia coli O103 from sheep using automated immunomagnetic separation (AIMS) and AIMS-ELISA: sheep as the source of a clinical E. coli O103 case?

AIMS

To investigate whether a sheep flock was the original reservoir of a Shiga toxin-producing Escherichia coli (STEC) O103 strain causing a clinical human case and to compare the two diagnostic methods automated immunomagnetic separation (AIMS) and AIMS-ELISA.

METHODS AND RESULTS

AIMS detected Escherichia coli O103 in 36.5% of the samples and AIMS-ELISA detected E. coli O103 in 52.1% of the samples. Polymerase chain reaction detected stx1 and eae in three of 109 E. coli O103 isolates. Pulsed field gel electrophoresis showed that the sheep and human STEC O103 were characterized by distinctly different profiles.

CONCLUSIONS

The sheep flock was shown to carry STEC O103, although an association between the sheep flock and the clinical human case could neither be proven nor eliminated. Substantial agreement was found between AIMS and AIMS-ELISA, but AIMS-ELISA was less time consuming and resulted in a higher recovery of E. coli O103.

SIGNIFICANCE AND IMPACT OF THE STUDY

The study shows that sheep may be carriers of STEC that are associated with human disease and that the methods described can be used to increase the sensitivity of STEC detection.

A controlled study for gender selection

OBJECTIVE

To evaluate the success for gender selection of insemination with a sample of semen separated by a serum albumin density separation gradient.

DESIGN

We retrospectively compared the gender outcome of conceptions of couples who conceived spontaneously with those who conceived secondary to an insemination with separated semen.

SETTING

Private practice of one author (M.A.K.).

PATIENTS, PARTICIPANTS

The study group consisted of 48 pregnancies of couples who conceived by the separation technique. The control group consisted of 46 pregnancies of couples who initially presented for consultation for gender selection but conceived spontaneously.

INTERVENTIONS

In the study group, one timed intrauterine insemination with separated semen was performed per cycle, with a mean of 2.3 cycles per couple. Patients desiring a female were also treated with clomiphene citrate and human chorionic gonadotropin.

MAIN OUTCOME MEASURE

The gender outcome of the pregnancies of the two groups was evaluated based on the known desired gender.

RESULTS

The success rate for conceiving a desired male was 56.5% in the study group and 60.9% in the control group (P = 1.000). Of couples seeking females, 78.6% of the procedure group versus 35.3% of the control group were successful (P = 0.019).

CONCLUSIONS

This study debates the albumin gradient as definitively enriching the proportion of Y-bearing sperm after in vitro separation.

Structure of some aliphatic dicarboxylic acids found in the urine of an infant with congenital lactic acidosis

Gas chromatography/mass spectrometry was used to identify a series of acids in urine and serum from a child who died 26 h after birth in severe metabolic acidosis with high lactate excretion. cis-5-Decene-1, 10-dioic acid and cis-5-dodencene-1, 12-dioic acid were synthesized and used as references. The following acids were found: hexane-1,6-dioic acid, octane-1,8-dioic acid, decane-1,10-dioic acid, dodecane-1,12-dioic acid, cis-5-decene-1,10-dioic acid, cis-5-dodecen-1,12-dioic acid, cis-5-tetradecene-1,14-dioic acid, trans-3-decene-1,10-dioic acid, and trans-3-dodecene-1,12-dioic acid. The concentration of C6 to C14 acids in the patient's urine was 3.7 mol/mol of creatinine; it was less than 0.2 mol/mol of creatinine in eight normal newborns and approximately 0.1 mol/mol of creatinine in a case of fructose-1,6-biphosphatase deficiency with lactic acidosis. 5-cis-Dodecenedioic acid was present in highest concentration: 1 mol/mol of creatinine in urine and 61 mumol/liter in serum. We propose that impaired beta-oxidation, probably at the acyl-CoA-dehydrogenase step, resulted in the formation of the observed acids. The parents were consanguineous, and a sibling died with the same clinical picture, which suggests a genetic defect.