Student perceptions of a teaching electronic medical record in Health Administration education.

Given the ubiquity of electronic health records (EHR), health administrators should be formally trained on the use and evaluation of EHR data for common operational tasks and managerial decision-making. A teaching electronic medical record (tEMR) is a fully operational electronic medical record that uses de-identified electronic patient data and provides a framework for students to familiarize themselves with the data, features, and functionality of an EHR. Although purported to be of value in health administration programs, specific benefits of using a tEMR in health administration education is unknown. We sought to examine Master of Health Administration (MHA) students' perceptions of the use, challenges, and benefits of a tEMR. We analyzed qualitative data collected from a focus group session with students who were exposed to the tEMR during a semester MHA course. We also administered pre- and post-survey questions on students' self-efficacy and perceptions of the ease of use, usefulness, and intention to use health care data analysis in their future jobs. We found several MHA students valued their exposure to the tEMR, as this provided them a realistic environment to explore de-identified patient data. Scores for students' perceived ease of using healthcare data analysis in their future job significantly increased following use of the tEMR (pre-test score M=3.31, SD=0.21; post-test score M=3.71, SD=0.18; p=0.01). Student exposure and use of a tEMR may positively affect perceptions of using EHR data for strategic and managerial tasks typical of health administrators.

Implementation of Lean in a Health System: Lessons Learned From a Meta-Analysis of Rapid Improvement Events, 2013-2017.

EXECUTIVE SUMMARY: Recent data suggest that a majority of hospitals now engage in some form of Lean process improvement in an attempt to reduce costs and/or improve quality. The literature on Lean healthcare has evolved from describing theoretical benefits, implementation barriers, and best practices to studies describing where implementations have occurred and their outcomes. Nevertheless, previous studies are mostly limited to case studies in which Lean was implemented on a limited basis in a healthcare facility. In this article, we present lessons learned from the largest implementation of Lean in a single healthcare system composed of 16 hospitals, a health plan, and many outpatient clinics. Our analysis of 1,144 rapid improvement events (RIEs) over a 5-year period revealed that 45% were associated with some organizational benefit in several categories, including cost reductions, time savings, a reduction in clinical and nonclinical defects, and a reduction in workflow steps. As the organization became more experienced with RIEs, the benefits realized changed from mostly cost reductions to a more diverse mix of benefits, with time savings becoming the most common. RIEs implemented in certain settings and/or by certain types of employees were associated with the likelihood of realizing a benefit. Based on these analyses, we provide recommendations to hospital and health system leaders interested in optimizing their Lean implementations-especially on a large enterprise-wide scale.

A novel GABRG2 mutation, p.R136*, in a family with GEFS+ and extended phenotypes.

Genetic mutations in voltage-gated and ligand-gated ion channel genes have been identified in a small number of Mendelian families with genetic generalised epilepsies (GGEs). They are commonly associated with febrile seizures (FS), childhood absence epilepsy (CAE) and particularly with generalised or genetic epilepsy with febrile seizures plus (GEFS+). In clinical practice, despite efforts to categorise epilepsy and epilepsy families into syndromic diagnoses, many generalised epilepsies remain unclassified with a presumed genetic basis. During the systematic collection of epilepsy families, we assembled a cohort of families with evidence of GEFS+ and screened for variations in the γ2 subunit of the γ-aminobutyric acid (GABA) type A receptor gene (GABRG2). We detected a novel GABRG2(p.R136*) premature translation termination codon in one index-case from a two-generation nuclear family, presenting with an unclassified GGE, a borderline GEFS+ phenotype with learning difficulties and extended behavioural presentation. The GABRG2(p.R136*) mutation segregates with the febrile seizure component of this family's GGE and is absent in 190 healthy control samples. In vitro expression assays demonstrated that γ2(p.R136*) subunits were produced, but had reduced cell-surface and total expression. When γ2(p.R136*) subunits were co-expressed with α1 and ß2 subunits in HEK 293T cells, GABA-evoked currents were reduced. Furthermore, γ2(p.R136*) subunits were highly-expressed in intracellular aggregations surrounding the nucleus and endoplasmic reticulum (ER), suggesting compromised receptor trafficking. A novel GABRG2(p.R136*) mutation extends the spectrum of GABRG2 mutations identified in GEFS+ and GGE phenotypes, causes GABAA receptor dysfunction, and represents a putative epilepsy mechanism.

Rarities in neurology: blue rubber bleb naevus syndrome.

A 62-year-old woman presented with stabbing pain over her left temple radiating to her left cheek when bending forwards or coughing. Neurological examination was normal. There were many cutaneous venous prominences over her body. CT and MR brain scans showed multiple venous anomalies and venous occlusive disease of the left sylvian fissure and superior sagittal sinus. We excluded arteriovenous malformation and dural fistulae with cerebral angiography. Following a clinical genetics assessment, we diagnosed blue rubber bleb naevus syndrome (BRBNS) and gave amitriptyline for her pain. There are only 200 cases of BRBNS in the literature, and central nervous system involvement is rarer still. The syndrome involves multiple cutaneous and visceral venous malformations. Most appear to be sporadic though a few have autosomal dominant inheritance. Although rare, BRBNS represents an important differential diagnosis for patients presenting with multiple and/or multisystem vascular malformations.

Canadian Guidelines on Alcohol Use Disorder Among Older Adults.

BACKGROUND: Alcohol use disorder (AUD) is an increasingly common, under-recognized, and under-treated health concern in older adults. Its prevalence is expected to reach unprecedented levels as the Canadian population ages. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of AUD in older adults. METHODS: A systematic review of English language literature from 2008-2018 regarding AUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method by drawing on current literature. Recommendations were created and assessed using the GRADE method. RESULTS: Twenty-two recommendations were created. Prevention recommendations: Best advice for older adults who choose to drink is to limit intake to well below the national Low-Risk Alcohol Drinking Guidelines. Screening recommendations: Alcohol consumption should be reviewed and discussed on an annual basis by primary care providers. This type of discussion needs to be normalized and approached in a simple, neutral, straight-forward manner. Assessment recommendations: Positive screens for AUD should be followed by a comprehensive assessment. Once more details are obtained an individualized treatment plan can be recommended, negotiated, and implemented. Treatment recommendations: AUD falls on a spectrum of mild, moderate, and severe. It can also be complicated by concurrent mental health, physical, or social issues, especially in older adults. Naltrexone and Acamprosate pharmacotherapies can be used for the treatment of AUD in older adults, as individually indicated. Psychosocial treatment and support should be offered as part of a comprehensive treatment plan. CONCLUSION: These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of AUD in older adults within the Canadian context.

Screening for depression in chronic hemodialysis patients: comparison of the Beck Depression Inventory, primary nurse, and nephrology team.

Depression in patients with end-state renal disease (ESRD) is both underdiagnosed and treated, which may contribute to an increase in morbidity and mortality. Efforts aimed at screening, diagnosing, and treating depression could potentially modify outcomes in this population. The purpose of this study was to compare the prevalence of depression, as measured by the Beck Depression Inventory (BDI-II), the primary nurse, and nephrology team, among a cohort of patients receiving chronic hemodialysis (HD). A secondary objective was to identify patient variables associated with depression. Patients were screened for depression at the same time point, using the BDI-II, the primary nurse and the nephrology team. Depression was defined as a BDI-II score > or =14. Agreement between the BDI-II score, nurse, and nephrology team assessment of depression was compared using a kappa score and receiver-operating characteristic (ROC) curves were generated. One hundred and twenty-four of an eligible 154 patients completed the study. Depression as measured by a BDI-II> or =14, the nurse and the team was diagnosed in 38.7%, 41.9%, and 24.2% of patients, respectively. With the BDI-II as the gold standard, the nurses' diagnosis of depression had an agreement of 74.6% vs. only 24.2% agreement with the nephrology team. A previous history of malignancy was the only variable associated with the diagnosis of depression. Depression is common among patients on HD, supporting the need for a routine depression-screening program. The primary dialysis nurse is in a key position to identify patients with depression and should be considered as an integral part of the nephrology team.

Epilepsy in the elderly.

Epilepsy is the most common serious neurological disorder in the elderly after stroke and dementia. It may be more important for elderly people because it is intermittent and unpredictable. There is no reliable diagnostic test and so its diagnosis and management requires clinical acumen and experience. The situation is further complicated because the elderly may have many comorbidities and therefore may have many other reasons for losing consciousness. Despite their growing number, there is remarkably little research to underpin the best epilepsy management in the elderly. This article summarizes the scope of epilepsy in elderly people, highlights cerebrovascular and neurodegenerative diseases as the main underlying etiologies, explores the diagnostic challenges in this age group, including the hurdles and processes in their investigation, and examines pertinent clinical management issues.

Cost-effectiveness of pregabalin: a UK perspective.

The management of epilepsy and neuropathic pain poses a substantial burden on individuals and society with significant healthcare resource implications. Pregabalin has been approved for add-on treatment of adults with partial seizures with or without secondary generalization and for central and peripheral neuropathic pain syndromes. New antiepileptic drugs, such as pregabalin, have higher acquisition costs than established 'off-patent' drugs, but boast advantages in terms of efficacy, tolerability and side-effect profiles. There is, however, scant health economic research concerning the use of any current antiepileptic drugs used to treat epilepsy and neuropathic pain. This article reviews the available data on pregabalin. There are currently insufficient data to draw conclusions on cost-effectiveness regarding its use in epilepsy, neuropathic pain or other nonepileptic conditions. Long-term retention studies and prescribing practices may give an indication as to the effectiveness and tolerability of pregabalin and consequent cost-effectiveness analyses may then prove useful.

Sudden unexpected death in epilepsy.

Mortality in people with epilepsy is two- to three-times that of the general population. This can be attributed to epilepsy itself (epilepsy-related death) or to the underlying cause of the epilepsy. Sudden unexpected death in epilepsy (SUDEP) is the commonest cause of epilepsy-related death. It is a syndrome where a person with epilepsy dies suddenly and no other cause of death is found. There are frequent reports of persons dying alone in their sleep. It is assumed that death occurs following a seizure but since the deaths are often unwitnessed this is only an assumption. The most important risk factor appears to be poor seizure control. Lately, SUDEP has received much public interest, has been the subject of international forums, ethical debates and comprises part of national guidelines on epilepsy management. Despite its high profile, the evidence for specific risk factors and pathophysiology is still not established. Poor incident case reporting, inaccurate death certification and fewer post-mortem examinations have limited the value of epidemiological data on SUDEP. Here, we review the characteristics of SUDEP, its likely risk factors, mechanisms and differential diagnosis, and consider possible strategies for prevention. We also explore the discussion of SUDEP with patients and the management of relatives of SUDEP patients.