Dropwise Condensation in Ambient on a Depleted Lubricant-Infused Surface

Durability of a lubricant-infused surface (LIS) is critical for heat transfer, especially in condensation-based applications. Although LIS promotes dropwise condensation, each departing droplet condensate acts as a lubricant-depleting agent due to the formation of wetting ridge and cloaking layer around the condensate, thus gradually leading to drop pinning on the underlying rough topography. Condensation heat transfer further deteriorates in the presence of non-condensable gases (NCGs) requiring special experimental arrangements to eliminate NCGs due to a decrease in the availability of nucleation sites. To address these issues while simultaneously improving heat-transfer performance of LIS in condensation-based systems, we report fabrication of both fresh LIS and a lubricant-depleted LIS using silicon porous nanochannel wicks as an underlying substrate. Strong capillarity in the nanochannels helps retain silicone oil (polydimethylsiloxane) on the surface even after it is severely depleted under tap water. The effect of oil viscosity was investigated for drop mobility and condensation heat transfer under ambient conditions, i.e., in the presence of NCGs. While fresh LIS prepared using 5 cSt silicone oil exhibited a low roll-off angle (∼1°) and excellent water drop (5 μL) sliding velocity ∼66 mm s^-1, it underwent rapid depletion as compared to higher viscosity oils. Condensation performed on depleted nanochannel LIS with higher viscosity oil (50 cSt) resulted in a heat-transfer coefficient (HTC) of ∼2.33 kW m^-2 K^-1, which is a ∼162% improvement over flat Si-LIS (50 cSt). Such LIS promote fast drop shedding as is evident from the little change in the fraction of drops with diameter <500 μm from ∼98% to only ∼93% after 4 h of condensation. Improvement in HTC was also seen in condensation experiments conducted for 3 days where a steady HTC of ∼1.46 kW m^-2 K^-1 was achieved over the last 2 days. The ability of reported LIS to maintain long-term hydrophobicity and dropwise condensation will aid in designing condensation-based systems with improved heat-transfer performance.

Left atrial appendage exclusion with less invasive left ventricular assist device implantation

OBJECTIVES

The objective of this single-center, pilot, prospective, and historical control study is to evaluate safety and feasibility outcomes associated with left atrial appendage exclusion (LAAE) concomitant with left ventricular assist device (LVAD) implantation via less invasive surgery (LIS) as a stroke prevention strategy.

METHODS

A predefined number of 30 eligible subjects scheduled for LIS LVAD with LAAE were enrolled in the prospective arm between January 2020 and February 2021. Eligible retrospective LIS LVAD patients without LAAE were propensity-matched in a 1:1 ratio with the prospective arm subjects. The primary study objectives were to evaluate the safety, feasibility, and efficacy of the LAAE concomitant with LIS LVAD.

RESULTS

Preoperative characteristics of patients in the Non-LAAE and LAAE groups were similar. LAAE was successfully excluded in all prospective patients (100%). Primary safety endpoints of chest tube output within the first 24 postoperative hours, Reoperation for bleeding within 48 h, and index hospitalization mortality demonstrated comparable safety of LAAE versus Non-LAAE with LIS LVAD. Cox proportional hazard regression demonstrated that LAAE with LIS LVAD was associated with 37% and 49% reduction in the risk of stroke and disabling stroke, respectively (p > .05).

CONCLUSION

Results from our pilot study demonstrated the safety and feasibility of LAAE concomitant with LIS LVAD as a stroke prevention strategy. This is the first prospective study describing LAAE performed concomitantly to less invasive LVAD implantation. The efficacy of LAAE in long-term stroke prevention needs to be confirmed in future prospective randomized clinical trials.

Impact of surgical approach for left ventricular assist device implantation on postoperative invasive hemodynamics and right ventricular failure

BACKGROUND

Right ventricular failure (RVF) remains one of the major causes of morbidity and mortality after left ventricular assist device (LVAD) implantation. We sought to compare immediate postoperative invasive hemodynamics and the risk of RVF following two different surgical approaches: less invasive surgery (LIS) versus full sternotomy (FS).

METHODS

The study population comprised all 231 patients who underwent implantation of a HeartMate 3 (Abbott) LVAD at our institution from 2015 to 2020, utilizing an LIS (n = 161; 70%) versus FS (n = 70; 30%) surgical approach. Outcomes included postoperative invasive hemodynamic parameters, vasoactive-inotropic score (VIS), RVF during index hospitalization, and 6-month mortality.

RESULTS

Baseline clinical characteristics of the two groups were similar. Multivariate analysis showed that LIS, compared with FS, was associated with the improved cardiac index (CI) at the sixth postoperative hour (p = .036) and similar CI at 24 h, maintained by lower VIS at both timepoints (p = .002). The LIS versus FS approach was also associated with a three-fold lower incidence of in-hospital severe RVF (8.7% vs. 28.6%, p < .001) and need for RVAD support (5.0% vs. 17.1%, p = .003), and with 68% reduction in the risk of 6-month mortality after LVAD implantation (Hazard ratio, 0.32; CI, 0.13-0.78; p = .012).

CONCLUSION

Our findings suggest that LIS, compared with FS, is associated with a more favorable hemodynamic profile, as indicated by similar hemodynamic parameters maintained by lower vasoactive-inotropic support during the acute postoperative period. These findings were followed by a reduction in the risk of severe RVF and 6-month mortality in the LIS group.

Digital Pathology Implementation in Private Practice: Specific Challenges and Opportunities

Digital pathology (DP) is being deployed in many pathology laboratories, but most reported experiences refer to public health facilities. In this paper, we report our experience in DP transition at a high-volume private laboratory, addressing the main challenges in DP implementation in a private practice setting and how to overcome these issues. We started our implementation in 2020 and we are currently scanning 100% of our histology cases. Pre-existing sample tracking infrastructure facilitated this process. We are currently using two high-capacity scanners (Aperio GT450DX) to digitize all histology slides at 40×. Aperio eSlide Manager WebViewer viewing software is bidirectionally linked with the laboratory information system. Scanning error rate, during the test phase, was 2.1% (errors detected by the scanners) and 3.5% (manual quality control). Pre-scanning phase optimizations and vendor feedback and collaboration were crucial to improve WSI quality and are ongoing processes. Regarding pathologists' validation, we followed the Royal College of Pathologists recommendations for DP implementation (adapted to our practice). Although private sector implementation of DP is not without its challenges, it will ultimately benefit from DP safety and quality-associated features. Furthermore, DP deployment lays the foundation for artificial intelligence tools integration, which will ultimately contribute to improving patient care.

Life Span of Slippery Lubricant Infused Surfaces

Since their discovery a decade ago, slippery liquid infused porous surfaces (SLIPSs) or lubricant infused surfaces (LISs) have been demonstrated time and again to have immense potential for a plethora of applications. Of these, one of the most promising is enhancing the energy efficiency of both thermoelectric and organic Rankine cycle power generation via enhanced vapor condensation. However, utilization of SLIPSs in the energy sector remains limited due to the poor understanding of their life span. Here, we use controlled conditions to conduct multimonth steam and ethanol condensation tests on ultrascalable nanostructured copper oxide structured surfaces impregnated with mineral and fluorinated lubricants having differing viscosities (9.7 mPa·s < μ < 5216 mPa·s) and chemical structures. Our study demonstrates that SLIPSs lose their hydrophobicity during steam condensation after 1 month due to condensate cloaking. However, these same SLIPSs maintain nonwetting after 5 months of ethanol condensation due to the absence of cloaking. Surfaces impregnated with higher viscosity oil (5216 mPa·s) increase the life span to more than 8 months of continuous ethanol condensation. Vapor shear tests revealed that SLIPSs do not undergo oil depletion during exposure to 10 m/s gas flows, critical to condenser implementation where single-phase superheated vapor impingement is prevalent. Furthermore, higher viscosity SLIPSs are shown to maintain good stability after exposure to 200 °C air. A subset of the durable SLIPSs did not show change in slipperiness after submerging in stagnant water and ethanol for up to 2 weeks, critical to condenser implementation where single-phase condensate immersion is prevalent. Our work not only demonstrates design methods and longevity statistics for slippery nanoengineered surfaces undergoing long-term dropwise condensation of steam and ethanol but also develops the fundamental design guidelines for creating durable slippery liquid infused surfaces.

A Survival Guide for the Rapid Transition to a Fully Digital Workflow: The "Caltagirone Example"

Digital pathology for the routine assessment of cases for primary diagnosis has been implemented by few laboratories worldwide. The Gravina Hospital in Caltagirone (Sicily, Italy), which collects cases from 7 different hospitals distributed in the Catania area, converted the entire workflow to digital starting from 2019. Before the transition, the Caltagirone pathology laboratory was characterized by a non-tracked workflow, based on paper requests, hand-written blocks and slides, as well as manual assembling and delivering of the cases and glass slides to the pathologists. Moreover, the arrangement of the spaces and offices in the department was illogical and under-productive for the linearity of the workflow. For these reasons, an adequate 2D barcode system for tracking purposes, the redistribution of the spaces inside the laboratory and the implementation of the whole-slide imaging (WSI) technology based on a laboratory information system (LIS)-centric approach were adopted as a needed prerequisite to switch to a digital workflow. The adoption of a dedicated connection for transfer of clinical and administrative data between different software and interfaces using an internationally recognised standard (Health Level 7, HL7) in the pathology department further facilitated the transition, helping in the integration of the LIS with WSI scanners. As per previous reports, the components and devices chosen for the pathologists' workstations did not significantly impact on the WSI-based reporting phase in primary histological diagnosis. An analysis of all the steps of this transition has been made retrospectively to provide a useful "handy" guide to lead the digital transition of "analog", non-tracked pathology laboratories following the experience of the Caltagirone pathology department. Following the step-by-step instructions, the implementation of a paperless routine with more standardized and safe processes, the possibility to manage the priority of the cases and to implement artificial intelligence (AI) tools are no more an utopia for every "analog" pathology department.

Study results suggest less invasive HeartMate 3 implantation is a safe and effective approach for obese patients

BACKGROUND

Historically, obesity was considered a relative contraindication to left ventricular assist device (LVAD) implantation with less invasive surgery (LIS). The present study aimed to compare the outcomes of obese patients who underwent LVAD implantation through LIS with those who received full sternotomy (FS) implantation.

METHODS

We retrospectively reviewed all patients implanted with HeartMate 3 LVAD in our institution between September 2015 and June 2020. Obese patients (BMI ≥ 30 kg/m²) were included and dichotomized based on surgical approach into the FS or LIS cohort.

RESULTS

Of 231 implanted patients, 107 (46%) were obese and included in the study. FS was performed in 26 (24%) patients and LIS approach in 81 (76%) patients. Preoperative patient characteristics were similar between the cohorts. Postoperatively, patients in LIS cohort had less bleeding (p = 0.029), fewer transfusions (p = 0.042), shorter duration of inotropic support (p = 0.049), and decreased incidence of severe RV failure (11.1% vs 30.8%, p = 0.028). Survival to discharge for the obese population was 87.5% overall and did not differ based on an approach (91.4% LIS vs 76.9% FS, p = 0.079). More LIS patients were discharged home (60.0% vs 82.4%, p = 0.041) rather than to rehabilitation center.

CONCLUSION

Our results showed that the LIS approach in obese patients is associated with fewer postoperative complications and a trend towards better short-term survival. These results suggest that less invasive LVAD implantation is a safe and effective approach for obese patients. Future prospective randomized trials are required to substantiate these results.

Enhanced Recovery After Surgery in Patients Implanted with Left Ventricular Assist Device

INTRODUCTION

We sought to develop and implement a comprehensive enhanced recovery after surgery (ERAS) protocol for patients implanted with a left ventricular assist device (LVAD).

METHODS AND RESULTS

In this article, we describe our approach to the development and phased implementation of the protocol. Additionally, we reviewed prospectively collected data for patients who underwent LVAD implantation at our institution from February 2019 to August 2020. To compare early outcomes in our patients before and after protocol implementation, we dichotomized patients into two 6-month cohorts (the pre-ERAS and ERAS cohorts) separated from each other by 6 months to allow for staff adoption of the protocol. Of the 115 LVAD implants, 38 patients were implanted in the pre-ERAS period and 46 patients in the ERAS period. Preoperatively, the patients` characteristics were similar between the cohorts. Postoperatively, we observed a decrease in bleeding (chest tube output of 1006 vs 647.5 mL, P < .001) and blood transfusions (fresh frozen plasma 31.6% vs 6.7%, P = .04; platelets 42.1% vs 8.7%, P = .001). Opioid prescription at discharge were 5-fold lower with the ERAS approach (P < .01). Furthermore, the number of patients discharged to a rehabilitation facility decreased significantly (20.0% vs 2.4%, P = .02). The index hospitalization length of stay and survival were similar between the groups.

CONCLUSIONS

ERAS for patients undergoing LVAD implantation is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. In this article, we describe the details of the protocol and early positive changes in clinical outcomes. Further studies are needed to evaluate benefits of an ERAS protocol in an LVAD population.Lay Summary: Enhanced recovery after surgery (ERAS) is the implementation of standardized clinical pathways that ensures the use of best practices and decreased variation in perioperative care. Multidisciplinary teams work together on ERAS, thereby enhancing communication among health care silos. ERAS has been used for more than 30 years by other surgical services and has been shown to lead to a decreased length of stay, fewer complications, lower mortality, fewer readmissions, greater job satisfaction, and lower costs. Our goal was to translate these benefits to the perioperative care of complex patients with a left ventricular assist device. Early results suggest that this goal is possible; we have observed a decrease in transfusions, discharge on opioids, and discharge to a rehabilitation facility.

Lubricant-Infused Surfaces for Low-Surface-Tension Fluids: The Extent of Lubricant Miscibility

Lubricant-infused surfaces (LISs) and slippery liquid-infused porous surfaces (SLIPSs) have shown remarkable success in repelling low-surface-tension fluids. The atomically smooth, defect-free slippery surface leads to reduced droplet pinning and omniphobicity. However, the presence of a lubricant introduces liquid-liquid interactions with the working fluid. The commonly utilized lubricants for LISs and SLIPSs, although immiscible with water, show various degrees of miscibility with organic polar and nonpolar working fluids. Here, we rigorously investigate the extent of miscibility by considering a wide range of liquid-vapor surface tensions (12-73 mN/m) and different categories of lubricants having a range of viscosities (5-2700 cSt). Using high-fidelity analytical chemistry techniques including X-ray photoelectron spectroscopy, nuclear magnetic resonance, thermogravimetric analysis, and two-dimensional gas chromatography, we quantify lubricant miscibility to parts per billion accuracy. Furthermore, we quantify lubricant concentrations in the collected condensate obtained from prolonged condensation experiments with ethanol and hexane to delineate mixing and shear-based lubricant drainage mechanisms and to predict the lifetime of LISs and SLIPSs. Our work not only elucidates the effect of lubricant properties on miscibility with various fluids but also develops guidelines for developing stable and robust LISs and SLIPSs.

Data Downlink System in the Vast IOT Node Condition Assisted by UAV, Large Intelligent Surface, and Power and Data Beacon

The future development of communication systems will create a great demand for the internet of things (IOT), where the overall control of all IOT nodes will become an important problem. Considering the essential issues of miniaturization and energy conservation, in this study, a new data downlink system is designed in which all IOT nodes harvest energy first and then receive data. To avoid the unsolvable problem of pre-locating all positions of vast IOT nodes, a device called the power and data beacon (PDB) is proposed. This acts as a relay station for energy and data. In addition, we model future scenes in which a communication system is assisted by unmanned aerial vehicles (UAVs), large intelligent surfaces (LISs), and PDBs. In this paper, we propose and solve the problem of determining the optimal flight trajectory to reach the minimum energy consumption or minimum time consumption. Four future feasible scenes are analyzed and then the optimization problems are solved based on numerical algorithms. Simulation results show that there are significant performance improvements in energy/time with the deployment of LISs and reasonable UAV trajectory planning.

Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure

Background

Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life.

Aims

In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy.

Method

This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received.

Results

In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group.

Conclusion

LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Extreme Antiscaling Performance of Slippery Omniphobic Covalently Attached Liquids

Scale formation presents an enormous cost to the global economy. Classical nucleation theory dictates that to reduce the heterogeneous nucleation of scale, the surface should have low surface energy and be as smooth as possible. Past approaches have focused on lowering surface energy via the use of hydrophobic coatings and have created atomically smooth interfaces to eliminate nucleation sites, or both, via the infusion of low-surface-energy lubricants into rough superhydrophobic substrates. Although lubricant-based surfaces are promising candidates for antiscaling, lubricant drainage inhibits their utilization. Here, we develop methodologies to deposit slippery omniphobic covalently attached liquids (SOCAL) on arbitrary substrates. Similar to lubricant-based surfaces, SOCAL has ultralow roughness and surface energy, enabling low nucleation rates and eliminating the need to replenish the lubricant. To enable SOCAL coating on metals, we investigated the surface chemistry required to ensure high-quality functionalization as measured by ultralow contact angle hysteresis (<3°). Using a multilayer deposition approach, we first electrophoretically deposit (EPD) silicon dioxide (SiO₂) as an intermediate layer between the metallic substrate and SOCAL. The necessity of EPD SiO₂ is to smooth (<10 nm roughness) as well as to enable the proper surface chemistry for SOCAL bonding. To characterize antiscaling performance, we utilized calcium sulfate (CaSO₄) scale tests, showing a 20× reduction in scale deposition rate than untreated metallic substrates. Descaling tests revealed that SOCAL dramatically decreases scale adhesion, resulting in rapid removal of scale buildup. Our work not only demonstrates a robust methodology for depositing antiscaling SOCAL coatings on metals but also develops design guidelines for the creation of antifouling coatings for alternate applications such as biofouling and high-temperature coking.

Stable Dropwise Condensation of Ethanol and Hexane on Rationally Designed Ultrascalable Nanostructured Lubricant-Infused Surfaces

Vapor condensation is a widely used industrial process for transferring heat and separating fluids. Despite progress in developing low surface energy hydrophobic and micro/nanostructured superhydrophobic coatings to enhance water vapor condensation, demonstration of stable dropwise condensation of low-surface-tension fluids has not been achieved. Here, we develop rationally designed nanoengineered lubricant-infused surfaces (LISs) having ultralow contact angle hysteresis (<3°) for stable dropwise condensation of ethanol (γ ≈ 23 mN/m) and hexane (γ ≈ 19 mN/m). Using a combination of optical imaging and rigorous heat transfer measurements in a controlled environmental chamber free from noncondensable gases (<4 Pa), we characterize the condensation behavior of ethanol and hexane on ultrascalable nanostructured CuO surfaces impregnated with fluorinated lubricants having varying viscosities (0.496 < μ < 5.216 Pa·s) and chemical structures (branched versus linear, Krytox and Fomblin). We demonstrate stable dropwise condensation of ethanol and hexane on LISs impregnated with Krytox 1525, attaining about 200% enhancement in condensation heat transfer coefficient for both fluids compared to filmwise condensation on hydrophobic surfaces. In contrast to previous studies, we use 7 h of steady dropwise condensation experiments to demonstrate the importance of rational lubricant selection to minimize lubricant drainage and maximize LIS durability. This work not only demonstrates an avenue to achieving stable dropwise condensation of ethanol and hexane, it develops the fundamental design principles for creating durable LISs for enhanced condensation heat transfer of low-surface-tension fluids.

Building a Newborn Screening Information Management System from Theory to Practice

Information Management Systems are the central process management and communication hub for many newborn screening programs. In late 2014, Newborn Screening Ontario (NSO) undertook an end to end assessment of its information management needs which resulted in a project to develop a flexible IS Information Systems (IS) ecosystem and related process changes. This enabled NSO to better manage its current and future work-flows and communication needs. An idealized vision of a Screening Information Management System (SIMS) was developed that was refined into enterprise and functional architectures. This was followed by the development of technical specifications, user requirements and procurement. In undertaking a holistic full product lifecycle redesign approach, a number of change management challenges were faced by NSO across the entire program. Strong leadership support and full program engagement are key for overall project success. It is anticipated that improvements in program flexibility and the ability to innovate will outweigh the efforts and costs.

Lubricant-Infused Surfaces for Low-Surface-Tension Fluids: Promise versus Reality

The past few decades have seen substantial effort for the design and manufacturing of hydrophobic structured surfaces for enhanced steam condensation in water-based applications. Such surfaces promote dropwise condensation and easy droplet removal. However, less priority has been given to applications utilizing low-surface-tension fluids as the condensate. Lubricant-infused surfaces (LISs) or slippery liquid-infused porous surfaces (SLIPSs) have recently been developed, where the atomically smooth, defect-free slippery surface leads to reduced pinning of water droplets and omniphobic characteristics. The remarkable results of LISs and SLIPSs with a range of working fluid droplets give hope of their viability with low-surface-tension condensates. However, the presence of the additional liquid in the form of lubricant brings other issues to consider. Here, in an effort to study the dropwise condensation potential of LISs and SLIPSs, we investigate the miscibility of a range of low-surface-tension fluids with widely used lubricants in LIS and SLIPS design. We consider a wide range of condensate surface tensions (12-73 mN/m) and different categories of lubricants with varied viscosities (5-2700 cSt), namely, fluorinated Krytox oils, hydrocarbon silicone oils, mineral oil, and ionic liquids. In addition, we use both theory and pendant drop experiments to predict the cloaking behavior of the lubricants and immiscible condensate working fluid pairs. Our work not only shows that careful attention must be paid to lubricant-condensate selection to create long-lasting LISs or SLIPSs but also develops lubricant selection design guidelines for stable LISs and SLIPSs for enhanced condensation in applications utilizing low-surface-tension working fluids.

Open-source LIMS in Vietnam: The path toward sustainability and host country ownership

OBJECTIVE

The objectives of this case report are as follows: to describe the process of establishing a national laboratory information management system (LIMS) program for clinical and public health laboratories in Vietnam; to evaluate the outcomes and lessons learned; and to present a model for sustainability based on the program outcomes that could be applied to diverse laboratory programs.

METHODS

This case report comprises a review of program documentation and records, including planning and budgetary records of the donor, monthly reports from the implementer, direct observation, and ad-hoc field reports from technical advisors and governmental agencies. Additional data on program efficacy and user acceptance were collected from routine monitoring of laboratory policies and operational practices.

RESULTS

LIMS software was implemented at 38 hospital, public health and HIV testing laboratories in Vietnam. This LIMS was accepted by users and program managers as a useful tool to support laboratory processes. Implementation cost per laboratory and average duration of deployment decreased over time, and project stakeholders initiated transition of financing (from the donor to local institutions) and of system maintenance functions (from the implementer to governmental and site-level staff). Collaboration between the implementer in Vietnam and the global LIMS user community was strongly established, and knowledge was successfully transferred to staff within Vietnam.

CONCLUSION

Implementing open-sourced LIMS with local development and support was a feasible approach towards establishing a sustainable laboratory informatics program that met the needs of health laboratories in Vietnam. Further effort to institutionalize IT support capacity within key government agencies is ongoing.

How Low-Income Subsidy Recipients Respond to Medicare Part D Cost Sharing

OBJECTIVES

To determine the magnitude and mechanisms of response to Medicare Part D cost sharing by low-income subsidy (LIS) recipients using oral hypoglycemic agents (OHAs) and statins.

DATA SOURCES

Medicare data for a 5 percent random sample of beneficiaries with diabetes enrolled in fee-for-service Part D drug plans in 2008.

STUDY DESIGN

We evaluated the impact of differences between generic and brand cost sharing rates among cohorts of LIS and non-LIS recipients to determine if wider price spreads increased the generic dispensing rate (GDR) and reduced total drug use and cost.

PRINCIPAL FINDINGS

We found little association between cost sharing and aggregate OHA and statin use. In adjusted analyses, non-LIS beneficiaries who paid 46 percent of total OHA costs had 2.5 percent fewer OHA days supply than full benefit dual eligibles who paid just 5 percent of their therapy costs. For statins, the difference in days supply between those facing the lowest and highest cost sharing was 4.6 percent. Higher cost sharing was associated with filling fewer but larger prescriptions for both generics and brands.

CONCLUSIONS

Higher generic and brand copays had little association with OHA and statin use among LIS recipients. This implies that modest changes in required cost sharing for these medicines would have very little substantive impact on generic dispensing or utilization patterns among LIS recipients and thus would have little effect on total program spending. At the same time, any increases in out-of-pocket costs would be expected to shift costs and place greater financial burden on low-income beneficiaries, particularly those in poor health.

Information Technology Support for Clinical Genetic Testing within an Academic Medical Center

Academic medical centers require many interconnected systems to fully support genetic testing processes. We provide an overview of the end-to-end support that has been established surrounding a genetic testing laboratory within our environment, including both laboratory and clinician facing infrastructure. We explain key functions that we have found useful in the supporting systems. We also consider ways that this infrastructure could be enhanced to enable deeper assessment of genetic test results in both the laboratory and clinic.

A theoretical and LIS/NMR investigation of the conformations of substituted benzamides

A refined Lanthanide-Induced-Shift Analysis (LISA) is used with molecular mechanics and ab initio calculations to investigate the conformations of benzamide (1), N-methylbenzamide (2), N,N-dimethylbenzamide (3) and the conformational equilibria of 2-fluoro (4), 2-chloro (5) and N-methyl-2-methoxy benzamide (6). The amino group in 1 is planar in the crystal but is calculated to be pyramidal with the CO/phenyl torsional angle (ω) of 20-25°. The LISA analysis gave acceptable agreement factors (Rcryst ≤ 1%) for the ab initio geometries when ω was decreased to 0°, the other geometries were not as good. In 2, the N-methyl is coplanar with the carbonyl group in all the geometries. Good agreement was obtained for the RHF geometries, with ω 25°, the other geometries were only acceptable with increased values of ω. In 3, good agreement for the RHF and PCModel geometries was found when ω was changed from the calculated values of 40° (RHF) and 90° (PCModel) to ca. 60°, the X-ray and B3LYP geometries were not as good. The two substituted compounds 4, 5 and 6 are interconverting between the cis (O,X) and trans (O,X) conformers. The more stable trans conformer is planar in 4 and 6 but the cis form non-planar. Both the cis and trans conformers of 5 are non-planar. There is an additional degree of freedom in 6 due to the 2-methoxy group, which can be either planar or orthogonal to the phenyl ring in both conformers. The conformer ratios were obtained from the LISA analysis to give Ecis-Etrans in 4 > 2.3 kcal/mol (CDCl3 ) and 1.7 kcal/mol (CD3 CN), in 5 0.0 kcal/mol (CD3 CN) and in 6 > 2.5 kcal/mol (CDCl3 ) and 2.0 kcal/mol (CD3 CN). These values were used with the observed versus calculated (1) H shifts to determine the conformer ratios and energies in DMSO solvent to give Ecis-Etrans 1.1, -0.1 and 1.8 kcal/mol for (4), (5) and (6). Comparison of the observed versus calculated conformer energies show that both the MM and ab initio calculations overestimate the NH..F hydrogen bond in (4) by ca. 2 kcal/mol.

Comparison of skin incisions used for open lateral internal sphincterotomies--radial versus circumferential incisions: a retrospective cohort study

INTRODUCTION

Lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment, commonly used in patients with chronic anal fissures (CAFs). Although LIS is a simple surgical technique, it may cause several complications. Open LIS is usually performed through an incision made in the intersphincteric groove; radial or circumferential incisions, used according to the surgeon's preference. However, differences in clinical outcomes and wound healing, based on type of skin incision, are unclear. We investigated incision site wound healing and other clinical outcomes, after open LIS, according to the type of skin incision employed.

METHODS

We retrospectively reviewed the data of the electronic medical records of 602 patients who underwent open LIS for CAFs between March 2005 and February 2010 at Yang Hospital, Seoul, Korea.

RESULTS

Of the 602 patients, 298 patients received radial incisions and 304 received circumferential incisions. Circumferential incisions of the anus reduced the wound healing time compared to radial incisions (19.1 vs. 24.0 days, p < 0.001). There were no significant differences between the groups in wound complications such as perianal abscess, fistula, or cellulitis. Clinical outcomes including recurrence, persistence of fissures, and continence problems were also similar between the groups.

CONCLUSIONS

Our study shows that circumferential skin incisions, during LIS, are associated with shorter healing times than radial incisions.

Studies on the expression of linalool synthase using a promoter-β-glucuronidase fusion in transgenic Artemisia annua

Artemisinin, an antimalarial endoperoxide sesquiterpene, is synthesized in glandular trichomes of Artemisia annua L. A number of other enzymes of terpene metabolism utilize intermediates of artemisinin biosynthesis, such as isopentenyl and farnesyl diphosphate, and may thereby influence the yield of artemisinin. In order to study the expression of such enzymes, we have cloned the promoter regions of some enzymes and fused them to β-glucuronidase (GUS). In this study, we have investigated the expression of the monoterpene synthase linalool synthase (LIS) using transgenic A. annua carrying the GUS gene under the control of the LIS promoter. The 652bp promoter region was cloned by the genome walker method. A number of putative cis-acting elements were predicted indicating that the LIS is driven by a complex regulation mechanism. Transgenic plants carrying the promoter-GUS fusion showed specific expression of GUS in T-shaped trichomes (TSTs) but not in glandular secretory trichomes, which is the site for artemisinin biosynthesis. GUS expression was observed at late stage of flower development in styles of florets and in TSTs and guard cells of basal bracts. GUS expression after wounding showed that LIS is involved in plant responsiveness to wounding. Furthermore, the LIS promoter responded to methyl jasmonate (MeJA). These results indicate that the promoter carries a number of cis-acting regulatory elements involved in the tissue-specific expression of LIS and in the response of the plant to wounding and MeJA treatment. Southern blot analysis indicated that the GUS gene was integrated in the A. annua genome as single or multi copies in different transgenic lines. Promoter activity analysis by qPCR showed that both the wild-type and the recombinant promoter are active in the aerial parts of the plant while only the recombinant promoter was active in roots. Due to the expression in TSTs but not in glandular trichomes, it may be concluded that LIS expression will most likely have little or no effect on artemisinin production.

Study of variables affecting critical value notification in a laboratory catering to tertiary care hospital

During post-analytical phase, critical value notification to responsible caregiver in a timely manner has potential to improve patient safety which requires cooperative efforts between laboratory personnel and caregivers. It is widely accepted by hospital accreditors that ineffective notification can lead to diagnostic errors that potentially harm patients and are preventable. The objective of the study was to assess the variables affecting critical value notification, their role in affecting it's quality and approaches to improve it. In the present study 1,187 critical values were analysed in the Clinical Chemistry Laboratory catering to tertiary care hospital for neuropsychiatric diseases. During 25 months of study period, we evaluated critical value notification with respect to clinical care area, caregiver to whom it was notified and timeliness of notification. During the study period (25 months), the laboratory obtained 1,279 critical values in clinical chemistry. The analytes most commonly notified were sodium and potassium (20.97 & 20.8 % of total critical results). Analysis of critical value notification versus area of care showed that critical value notification was high in ICU and emergency area followed by inpatients and 64.61 % critical values were notified between 30 and 120 min after receiving the samples. It was found that failure to notify the responsible caregiver in timely manner represent an important patient safety issue and may lead to diagnostic errors. The major area of concern are notification of critical value for outpatient samples, incompleteness of test requisition forms regarding illegible writing, lack of information of treating physician and location of test ordering and difficulty in contacting the responsible caregiver.

Serum calcium (S-Ca), the forgotten test: preliminary results of an appropriateness strategy to detect primary hyperparathyroidism (pHPT)

BACKGROUND

With the introduction of automated calcium measurements with multichannel continuous-flow analyzers in the 1970s, primary hyperparathyroidism (pHPT), the silent disease, began to be detected. Years later, with the first appearance of random access analyzers, laboratory tests were requested if the patient had clinical symptoms and pHPT was again overlooked. In this current scenario, serum calcium (s-Ca) is at risk of becoming a forgotten test. In consensus with endocrinologists and general practitioners (GPs), we implemented a strategy to detect asymptomatic pHPT patients.

METHODS

During a 9 month period, the Laboratory Information System automatically added s-Ca to every sample of blood from primary care patients older than 45 years, without a s-Ca request in the previous three years. If hypercalcemia was detected (albumin-corrected s-Ca > 2.6 mmol/L), phosphate, 25-hydroxy vitamin D and parathyroid hormone (PTH) were automatically processed in the same sample. We reviewed the medical record of every patient with hypercalcemia.

RESULTS

S-Ca was automatically added to 14,461 samples, with 79 hypercalcemia results. 14 hypercalcemia results with PTH levels in the reference range were clinically justified by causes other than pHPT. Of the remaining 65 patients, 41 were referred for evaluation by endocrinology. 34 resulted in a diagnosis of pHPT and 7 are currently in study. 24 patients were not followed by GPs to find out the primary cause of hypercalcemia. After a phone call from the laboratory, they are also currently being studied for hypercalcemia. Each case represented a cost of 110.4 US dollars.

CONCLUSION

Our proposed opportunistic screening to discover pHPT seems cost-effective.

Patient identification errors: the detective in the laboratory

BACKGROUND

The eradication of errors regarding patients' identification is one of the main goals for safety improvement. As clinical laboratory intervenes in 70% of clinical decisions, laboratory safety is crucial in patient safety. We studied the number of Laboratory Information System (LIS) demographic data errors registered in our laboratory during one year.

METHODS

The laboratory attends a variety of inpatients and outpatients. The demographic data of outpatients is registered in the LIS, when they present to the laboratory front desk. The requests from the primary care centers (PCC) are made electronically by the general practitioner. A manual step is always done at the PCC to conciliate the patient identification number in the electronic request with the one in the LIS. Manual registration is done through hospital information system demographic data capture when patient's medical record number is registered in LIS. Laboratory report is always sent out electronically to the patient's electronic medical record. Daily, every demographic data in LIS is manually compared to the request form to detect potential errors.

RESULTS

Fewer errors were committed when electronic order was used. There was great error variability between PCC when using the electronic order.

CONCLUSIONS

LIS demographic data manual registration errors depended on patient origin and test requesting method. Even when using the electronic approach, errors were detected. There was a great variability between PCC even when using this electronic modality; this suggests that the number of errors is still dependent on the personnel in charge of the technology.

Integration of digital gross pathology images for enterprise-wide access

Background:

Sharing digital pathology images for enterprise- wide use into a picture archiving and communication system (PACS) is not yet widely adopted. We share our solution and 3-year experience of transmitting such images to an enterprise image server (EIS).

Methods:

Gross pathology images acquired by prosectors were integrated with clinical cases into the laboratory information system's image management module, and stored in JPEG2000 format on a networked image server. Automated daily searches for cases with gross images were used to compile an ASCII text file that was forwarded to a separate institutional Enterprise Digital Imaging and Communications in Medicine (DICOM) Wrapper (EDW) server. Concurrently, an HL7-based image order for these cases was generated, containing the locations of images and patient data, and forwarded to the EDW, which combined data in these locations to generate images with patient data, as required by DICOM standards. The image and data were then “wrapped” according to DICOM standards, transferred to the PACS servers, and made accessible on an institution-wide basis.

Results:

In total, 26,966 gross images from 9,733 cases were transmitted over the 3-year period from the laboratory information system to the EIS. The average process time for cases with successful automatic uploads (n=9,688) to the EIS was 98 seconds. Only 45 cases (0.5%) failed requiring manual intervention. Uploaded images were immediately available to institution- wide PACS users. Since inception, user feedback has been positive.

Conclusions:

Enterprise- wide PACS- based sharing of pathology images is feasible, provides useful services to clinical staff, and utilizes existing information system and telecommunications infrastructure. PACS-shared pathology images, however, require a “DICOM wrapper” for multisystem compatibility.

Stepwise approach to establishing multiple outreach laboratory information system-electronic medical record interfaces

Clinical laboratory outreach business is changing as more physician practices adopt an electronic medical record (EMR). Physician connectivity with the laboratory information system (LIS) is consequently becoming more important. However, there are no reports available to assist the informatician with establishing and maintaining outreach LIS–EMR connectivity. A four-stage scheme is presented that was successfully employed to establish unidirectional and bidirectional interfaces with multiple physician EMRs. This approach involves planning (step 1), followed by interface building (step 2) with subsequent testing (step 3), and finally ongoing maintenance (step 4). The role of organized project management, software as a service (SAAS), and alternate solutions for outreach connectivity are discussed.