Pseudorandomized Testing of a Discharge Medication Alert to Reduce Free-Text Prescribing.

BACKGROUND: Pseudorandomized testing can be applied to perform rigorous yet practical evaluations of clinical decision support tools. We apply this methodology to an interruptive alert aimed at reducing free-text prescriptions. Using free-text instead of structured computerized provider order entry elements can cause medication errors and inequity in care by bypassing medication-based clinical decision support tools and hindering automated translation of prescription instructions. OBJECTIVE: The objective of this study is to evaluate the effectiveness of an interruptive alert at reducing free-text prescriptions via pseudorandomized testing using native electronic health records (EHR) functionality. METHODS: Two versions of an EHR alert triggered when a provider attempted to sign a discharge free-text prescription. The visible version displayed an interruptive alert to the user, and a silent version triggered in the background, serving as a control. Providers were assigned to the visible and silent arms based on even/odd EHR provider IDs. The proportion of encounters with a free-text prescription was calculated across the groups. Alert trigger rates were compared in process control charts. Free-text prescriptions were analyzed to identify prescribing patterns. RESULTS: Over the 28-week study period, 143 providers triggered 695 alerts (345 visible and 350 silent). The proportions of encounters with free-text prescriptions were 83% (266/320) and 90% (273/303) in the intervention and control groups, respectively (p = 0.01). For the active alert, median time to action was 31 seconds. Alert trigger rates between groups were similar over time. Ibuprofen, oxycodone, steroid tapers, and oncology-related prescriptions accounted for most free-text prescriptions. A majority of these prescriptions originated from user preference lists. CONCLUSION: An interruptive alert was associated with a modest reduction in free-text prescriptions. Furthermore, the majority of these prescriptions could have been reproduced using structured order entry fields. Targeting user preference lists shows promise for future intervention.

Diabetes, Hypertension and Kidney Disease Combination "DHKD Syndrome" is common in India.

Objectives: The study was designed to find out frequency of (i) Diabetes mellitus (DM) as a cause Chronic Kidney Disease (CKD), (ii) Association between diabetic-CKD (diabetic patients who subsequently developed CKD as complication), hypertension (HT) and obesity. Further assessment was made to (iii) Identify percentage of diabetics attending medical and nephrology OPD had prior testing for proteinuria and or creatinine. Methods: After ethical consideration this prospective observational study was conducted on consecutive 6175 patients who gave consent to participate in two major referral hospitals one in Delhi and other in Bhubaneswar (BBSR). Primary hypertension was defined as blood pressure of ≥140/90 mmHg detected before onset of DM or detected together in the absence of CKD (elevated serum creatinine S Cr ≥1.7 mg/dL and or proteinuria > 0.3g/24H). Upper limit of serum creatinine was kept at 1.7 mg for this study. Mean value of three estimations on different days was recorded. Detail clinical history of DM and HT was taken. Body Mass Index (BMI), ocular fundi examination, urine analysis, serum creatinine, lipid profile, blood glucose, HbA1C tests were conducted in all patients. They were regularly followed up in renal clinic at about 2 month interval for repeat investigations. Blood pressure in nondiabetic-CKD patients was recorded for comparison. Further, consecutive diabetic patients attending general medicine OPD for first time were examined, their previous investigations were carefully scrutinized and recorded. Urine for albuminuria and serum creatinine were tested every month over a period of one year. Results: In Delhi diabetic-CKD was observed in 68.4% and the same was 56.2% in BBSR giving a combined figure of 62.3 percent. On close analysis of past record primary hypertension was observed in 75.4% who subsequently developed diabetes and CKD. Frequency of association between diabetic-CKD and HT were 88.2% and 69.3% in two cities respectively, combined frequency being 78.7 percent. Association of diabetic-CKD and obesity was 55.1 % and 55.9% in two cities respectively with combined frequency of 55.5 percent. In contrast obesity in non-diabetic-CKD patients in Delhi and BBSR was found in 43.1% and 18.5% respectively, combined frequency being 30.8%. Fifty four percent of diabetic patients who attended medical OPD for the first time were found to have proteinuria and elevated serum creatinine. However, they were not earlier tested for those parameters. Hence, they were unaware of CKD. Conclusion: Diabetes was found to be a bigger cause (62.3%) of CKD than what has been reported thus far in India. At presentation association of diabetic-CKD with HT was recorded higher (78.7%) in India. Hence use of the syndrome "DHKD", (complex of diabetes, hypertension and kidney disease) is justifiable. Our study shows 54.4% of diabetic patients attending medicine OPD were uninvestigated by either physician or GP for CKD because urine albumin and serum creatinine tests were lacking. Thus, progression to CKD in many patients went unnoticed. Syndromic diagnosis of "DHKD" therefore in our view is important to create general awareness for early detection and effective treatment of diabetic nephropathy.

Transpedicular surgical approach for the management of thoracic osteophyte-induced intracranial hypotension refractory to non-operative modalities: case report and review of literature.

PURPOSE: In this article, we aim to describe the presentation and management of a case of spontaneous intracranial hypotension caused by a dural tear from a ventral thoracic osteophyte at the T12 level that was refractory to non-surgical treatment modalities. A review of the literature has been performed. Also a proposal of diagnostic and treatment algorithm is presented. Intracranial hypotension and CSF leak as a result of dural tear is a common phenomenon. However, the detection of the source of CSF leak from a thoracic spinal osteophyte has rarely been reported. METHODS: Diagnostic workup including MRI and CT Myelogram as well as application of epidural blood patches and surgical technique of hemilaminectomy and osteophytectomy by transpedicular approach have been described. Literature review was conducted using relevant search terms in PubMed. RESULTS: The patient's spontaneous intracranial hypotension symptoms resolved and this persisted on follow up visits. Review our experience as well as similar cases in the literature pointed us towards a diagnostic and treatment algorithm. CONCLUSIONS: Spontaneous resolution is the norm for intracranial hypotension of most etiologies and management of all such cases begins with fluid resuscitation coupled with bed rest. On failure of conservative therapy, autologous epidural blood patches into the spinal epidural space should be tried, which often produce an immediate relief of symptoms. Osteophyte-induced dural tear and consequent intracranial hypotension may require surgical intervention if the symptoms are refractory to conservative treatment. Under all circumstances a careful step-wise approach for diagnosis and treatment of spontaneous intracranial hypotension needs to be followed, as we have proposed in our article.

Effect of Sudarshan Kriya on male prisoners with non psychotic psychiatric disorders: a randomized control trial.

OBJECTIVES: To investigate whether Sudarshan Kriya and related practices (SK&P) can lead to increased global assessment of functioning (GAF) and increased feeling of wellness in male prisoners with a non psychotic psychiatric disorder. METHODOLOGY: This is a six month parallel randomized controlled study with sample size of 230 male prisoners. Participants meeting inclusion and exclusion criteria were assigned to a study or control group by simple random allocation in which random allocation sequence was generated using a random number table. Each individual study participant was involved in a daily program of SK&P for six weeks. Each individual control participant was instructed to sit in an armchair with his eyes closed and gentle attention to their breath for duration of six weeks. To be included in this study, a participant must be a male prisoner diagnosed to be suffering from a psychiatric disorder (except psychosis and bipolar affective disorder [BPAD]) by ICD-10 (DCR) criteria with age between 18 and 65 years. RESULTS: Majority of subjects were unemployed married individuals, educated until undermatric level and not having occupational skills of more than an unskilled labor level. Practicing SK&P for six weeks led to improvement in mean±SD score of study participants in GAF, anxiety (ANX), depressed mood (DEP), positive well being (PWB), general health (GH), self control (SC), vitality (VT) and total positive general well being (PGWB). Change in mean±SD score of study participants when compared with control participants was statistically significant in terms of GAF, ANX, DEP, PWB, GH and PGWB. Increase in SC and VT scores was statistically insignificant when compared with control participants. CONCLUSION: Practicing SK&P helps in improving GAF, PWB, GH and total PGWB of an individual. SK&P also causes significant reduction in anxiety and depression levels. Effect of SK&P on SC and VT is insignificant.

Coevolution between attine ants and actinomycete bacteria: a reevaluation.

We reassess the coevolution between actinomycete bacteria and fungus-gardening (attine) ants. Actinomycete bacteria are of special interest because they are metabolic mutualists of diverse organisms (e.g., in nitrogen-fixation or antibiotic production) and because Pseudonocardia actinomycetes are thought to serve disease-suppressing functions in attine gardens. Phylogenetic information from culture-dependent and culture-independent microbial surveys reveals (1) close affinities between free-living and ant-associated Pseudonocardia, and (2) essentially no topological correspondence between ant and Pseudonocardia phylogenies, indicating frequent bacterial acquisition from environmental sources. Identity of ant-associated Pseudonocardia and isolates from soil and plants implicates these environments as sources from which attine ants acquire Pseudonocardia. Close relatives of Atta leafcutter ants have abundant Pseudonocardia, but Pseudonocardia in Atta is rare and appears at the level of environmental contamination. In contrast, actinomycete bacteria in the genera Mycobacterium and Microbacterium can be readily isolated from gardens and starter-cultures of Atta. The accumulated phylogenetic evidence is inconsistent with prevailing views of specific coevolution between Pseudonocardia, attine ants, and garden diseases. Because of frequent acquisition, current models of Pseudonocardia-disease coevolution now need to be revised. The effectiveness of Pseudonocardia antibiotics may not derive from advantages in the coevolutionary arms race with specialized garden diseases, as currently believed, but from frequent recruitment of effective microbes from environmental sources. Indeed, the exposed integumental structures that support actinomycete growth on attine ants argue for a morphological design facilitating bacterial recruitment. We review the accumulated evidence that attine ants have undergone modifications in association with actinomycete bacteria, but we find insufficient support for the reverse, modifications of the bacteria resulting from the interaction with attine ants. The defining feature of coevolution--reciprocal modification--therefore remains to be established for the attine ant-actinomycete mutualism.