Screening diagnostic candidates from Leishmania infantum proteins for human visceral leishmaniasis using an immunoproteomics approach.

There is no suitable vaccine against human visceral leishmaniasis (VL) and available drugs are toxic and/or present high cost. In this context, diagnostic tools should be improved for clinical management and epidemiological evaluation of disease. However, the variable sensitivity and/or specificity of the used antigens are limitations, showing the necessity to identify new molecules to be tested in a more sensitive and specific serology. In the present study, an immunoproteomics approach was performed in Leishmania infantum promastigotes and amastigotes employing sera samples from VL patients. Aiming to avoid undesired cross-reactivity in the serological assays, sera from Chagas disease patients and healthy subjects living in the endemic region of disease were also used in immunoblottings. The most reactive spots for VL samples were selected, and 29 and 21 proteins were identified in the promastigote and amastigote extracts, respectively. Two of them, endonuclease III and GTP-binding protein, were cloned, expressed, purified and tested in ELISA experiments against a large serological panel, and results showed high sensitivity and specificity values for the diagnosis of disease. In conclusion, the identified proteins could be considered in future studies as candidate antigens for the serodiagnosis of human VL.

Impact of a clinical decision support tool on adherence to the Ottawa Ankle Rules.

OBJECTIVE: The objective of the study is to determine impact of a clinical decision support (CDS) tool on documented adherence to the Ottawa Ankle Rules (OAR) and utilization and yield of ankle/foot radiography, for emergency department patients with acute ankle injury. METHODS: This is a before-and-after intervention study conducted at a 793-bed, quaternary care, academic hospital from August 2012 to October 2013. Emergency department visits from adults with acute ankle injury 6 months before and 8 months after the intervention were included. The intervention embedded the OAR into a CDS tool integrated with a computerized physician order entry system, which had data capture capability and provided feedback at the time of ankle/foot radiography order. Primary outcome was rate of documented adherence to OAR. Secondary outcomes were utilization and yield (clinically significant fracture rates among patients with acute ankle injuries) of ankle/foot radiography. RESULTS: The study population included 460 visits; 205 (44.6%) occurred preintervention. After intervention, documented OAR adherence increased from 55.9% (229/410) to 95.7% (488/510; P < .001). Utilization remained stable for ankle (77.5%; P = .800) and foot (48.6%; P = .514) radiography. Yield remained stable for ankle (17.8%; P = .891) and foot (19.8%; P = .889) radiography. DISCUSSION: Lack of documentation of key clinical data may hamper provider communication, delay care coordination, and result in legal liability. By embedding the OAR into a CDS tool, we achieved the same rate of documented adherence as previous onerous educational implementations while automating data collection/retrieval. In summary, implementation of the OAR into a CDS tool was associated with an increase in documented adherence to the OAR.

Impact of a Structured Report Template on the Quality of MRI Reports for Rectal Cancer Staging.

OBJECTIVE: The purpose of this study is to assess the impact of implementing a structured report template on the quality of MRI reports for rectal cancer staging. MATERIALS AND METHODS: After excluding examinations performed after surgery or neoadjuvant therapy, we analyzed all rectal cancer staging MRI reports finalized at an academic medical center 12 months before and after an intervention consisting of implementing a structured report template integrated into the institution's speech recognition system. The primary outcome measure was the quality of rectal cancer staging MRI reports classified as optimal, satisfactory, or unsatisfactory, on the basis of the documentation of 14 quality measures predefined by a consensus of the institution's abdominal radiology subspecialists. Chi-square and t tests were used to assess differences in report quality and documentation of each discrete quality measure before and after the intervention. RESULTS: The study cohort included 106 MRI reports from 104 patients (mean age, 60 years; 58.5% male); 52 (49.1%) of the reports were completed before implementation of the structured report template. After implementation, the proportion of total reports classified as optimal or satisfactory increased from 38.5% (20/52) to 70.4% (38/54) (p = 0.0010). No reports generated before the intervention were classified as optimal, whereas 40.7% (22/54) of reports were classified as optimal after the intervention. CONCLUSION: Implementation and voluntary use of a structured report template improved the quality of MRI reports for rectal cancer staging compared with free-text format.

A biomarker for tegumentary and visceral leishmaniasis based on a recombinant Leishmania hypothetical protein.

The measures for leishmaniasis control include the precise diagnosis of disease. However, although several recombinant antigens have been tested with this biotechnological purpose, no effective product exists, which could detects patients with the active disease, as well as differentiates them from cured and treated patients. In this study, a conserved Leishmania hypothetical protein, which was identified in Leishmania infantum parasites, but evaluated to presents high homology in the amino acid sequences between distinct parasite species, was evaluated for the diagnosis of tegumentary and visceral leishmaniasis. In addition, PBMCs collected from treated and untreated mucosal leishmaniasis (ML) and visceral leishmaniasis (VL) patients, as well as in healthy subjects living in endemic region of disease, were in vitro stimulated, when IFN-γ, IL-4 and IL-10 levels were evaluated in the cell supernatant. Regarding the serological analyses, ELISA experiments using the recombinant protein (rLiHyL) and a human serological panel revealed high sensitivity and specificity values to detect both diseases, while control antigens showed worst results. Regarding the cellular response, results showed that rLiHyL-stimulated cells produced higher IFN-γ and lower IL-4 and IL-10 levels in the supernatants. Also, the anti-protein antibody production was evaluated in these patients, and data showed higher IgG2 and lower IgG1 levels found in the treated patients and healthy controls, demonstrating the stimulation of a Th1-type response induced by the rLiHyL protein. In conclusion, this hypothetical protein can be considered as antigenic in TL and VL, as well as a vaccine candidate to be tested in future studies to protect against disease.

Development and Evaluation of a Continuing Education Program for Nursing Technicians at a Pediatric Cardiac Intensive Care Unit in a Developing Country.

BACKGROUND: The nursing profession faces continuous transformations demonstrating the importance of professional continuing education to extend knowledge following technological development without impairing quality of care. Nursing assistants and technicians account for nearly 80% of nursing professionals in Brazil and are responsible for uninterrupted patient care. Extensive knowledge improvement is needed to achieve excellence in nursing care. The objective was to develop and evaluate a continuing education program for nursing technicians at a pediatric cardiac intensive care unit (PCICU) using a virtual learning environment entitled EDUCATE. METHODS: From July to September 2015, a total of 24 nursing technicians working at the PCICU at a children's hospital located in the northwestern region of São Paulo state (Brazil) fully participated in the continuing education program developed in a virtual learning environment using Wix platform, allowing access to video classes and pre- and post-training theoretical evaluation questionnaires outside the work environment. The evaluation tools recorded participants' knowledge evolution, technological difficulties, educational, and overall rating. RESULTS: Knowledge development was descriptively presented as positive in more than 66.7%. Content and training were considered "excellent" by most participants and 90% showed an interest in the use of technological resources. Technical difficulties were found and quickly resolved by 40% of participants including Internet access, login, and lack of technical expertise. CONCLUSION: The continuing education program using a virtual learning environment positively contributed to the improvement in theoretical knowledge of nursing technicians in PCICU.

External validation of risk stratification strategy in the use of renal ultrasonography in the evaluation of acute kidney injury.

BACKGROUND: Per the American College of Radiology Appropriateness Criteria, renal ultrasound is the most appropriate imaging examination to evaluate patients with acute kidney injury. However, recent studies suggest that renal ultrasound may be more selectively performed, which could lead to reductions in the use of medical imaging. OBJECTIVE: Evaluate a published risk stratification prediction model (the Licurse model) for using renal ultrasound in hospitalized patients with acute kidney injury. DESIGN: Prospective, observational cohort study. SETTING: A 793-bed, quaternary care, academic hospital. PATIENTS: All adult hospitalized patients who underwent renal ultrasound for the indication of acute kidney injury. INTERVENTION/EXPOSURE: None. MEASUREMENTS: Primary outcome was rate of hydronephrosis diagnosed on ultrasound. Secondary outcome was rate of hydronephrosis resulting in urologic intervention. RESULTS: Of 778 patients who underwent renal ultrasonography to evaluate acute kidney injury, hydronephrosis was present in 106 (13.6%); urologic intervention was performed in 23 patients (3.0%). The Licurse model had sensitivity of 91.3% (95% confidence interval [CI]: 73.2%-97.6%) for urologic intervention and 93.4% (95% CI: 87.2%-96.8%) for hydronephrosis, respectively. Specificity was low for urologic intervention (23.0% [95% CI: 20.2-26.2]) and hydronephrosis (25.1% [95% CI: 22.0-28.6]). We estimated that for 22.6% of patients, hydronephrosis could be ruled out based on clinical predictors. CONCLUSIONS: We found that the Licurse renal ultrasonography risk stratification model was sufficiently accurate in classifying patients at risk for ureteral obstruction among hospitalized patients with acute kidney injury. Journal of Hospital Medicine 2016;11:763-767. © 2016 Society of Hospital Medicine.

Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting.

IMPORTANCE: The Wells score to determine the pretest probability of deep vein thrombosis (DVT) was validated in outpatient settings, but it is unclear whether it applies to inpatients. OBJECTIVE: To evaluate the utility of the Wells score for risk stratification of inpatients with suspected DVT. DESIGN, SETTING, AND PARTICIPANTS: A prospective study was conducted in a 793-bed quaternary care, academic hospital using Wells score clinical predictor findings entered by health care professionals in a computerized physician order entry system at the time lower-extremity venous duplex ultrasound studies were ordered. All adult inpatients suspected of having lower-extremity DVT who underwent lower-extremity venous duplex ultrasound studies between November 1, 2012, and December 31, 2013, were included. Patients with DVT diagnosed within the prior 3 months were excluded. For patients undergoing multiple lower-extremity venous duplex ultrasound studies, only the first was included. MAIN OUTCOMES AND MEASURES: Our primary outcome was the Wells score's utility for risk stratification among inpatients with suspected DVT as measured by the difference in incidence of proximal DVT among the 3 Wells score categories (low, moderate, and high pretest probability), the discrimination accuracy of the Wells score categories as the area under the receiver operating characteristics curve, the failure rate of Wells score prediction, and the efficiency of the Wells score to exclude DVT. RESULTS: In a study cohort of 1135 inpatients, 137 (12.1%) had proximal DVT. Proximal DVT incidence in low, moderate, and high pretest probability groups was 5.9% (8 of 135), 9.5% (48 of 506), and 16.4% (81 of 494), respectively (P < .001). The area under the receiver operating characteristics curve for the discriminatory accuracy of the Wells score for risk of proximal DVT identified on lower-extremity venous duplex ultrasound studies was 0.60. The failure rate of the Wells score to classify patients with a low pretest probability was 5.9% (95% CI, 3.0%-11.3%); the efficiency was 11.9% (95% CI, 10.1%-13.9%). CONCLUSIONS AND RELEVANCE: The Wells score performed only slightly better than chance for discrimination of risk for DVT in hospitalized patients. It had a higher failure rate and a lower efficiency in the inpatient setting compared with that reported in the outpatient literature. Therefore, the Wells score risk stratification is not sufficient to rule out DVT or influence management decisions in the inpatient setting.

Impact of an Information Technology-Enabled Initiative on the Quality of Prostate Multiparametric MRI Reports.

RATIONALE AND OBJECTIVES: Assess the impact of implementing a structured report template and a computer-aided diagnosis (CAD) tool on the quality of prostate multiparametric magnetic resonance imaging (mp-MRI) reports. MATERIALS AND METHODS: Institutional Review Board approval was obtained for this Health Insurance Portability and Accountability Act-compliant study performed at an academic medical center. The study cohort included all prostate mp-MRI reports (n = 385) finalized 6 months before and after implementation of a structured report template and a CAD tool (collectively the information technology [IT] tools) integrated into the picture archiving and communication system workstation. Primary outcome measure was quality of prostate mp-MRI reports. An expert panel of our institution's subspecialty-trained abdominal radiologists defined prostate mp-MRI report quality as optimal, satisfactory, or unsatisfactory based on documentation of nine variables. Reports were reviewed to extract the predefined quality variables and determine whether the IT tools were used to create each report. Chi-square and Student's t tests were used to compare report quality before and after implementation of IT tools. RESULTS: The overall proportion of optimal or satisfactory reports increased from 29.8% (47/158) to 53.3% (121/227) (P < .001) after implementing the IT tools. Although the proportion of optimal or satisfactory reports increased among reports generated using at least one of the IT tools (47/158 = [29.8%] vs. 105/161 = [65.2%]; P < .001), there was no change in quality among reports generated without use of the IT tools (47/158 = [29.8%] vs. 16/66 = [24.2%]; P = .404). CONCLUSIONS: The use of a structured template and CAD tool improved the quality of prostate mp-MRI reports compared to free-text report format and subjective measurement of contrast enhancement kinetic curve.