Impact of Clinical Decision Support Within the Electronic Medical Record on Opioid Prescribing and Dispensing.

INTRODUCTION: Clinical decision support tools support prescribers and pharmacists as they select and verify appropriate opioid regimens in efforts to combat the high variability in opioid prescribing. This study seeks to examine the impact of alerts within the electronic medical record and pharmacy system on day supply of initial opioid prescribing and dispensing. METHODS: This retrospective study compared a 6-month pre- and postimplementation of clinical decision support tool alerts at an integrated health care system. Data were analyzed to assess changes in the day supply of an opioid at the point of initial prescribing and dispensing based on alerts. RESULTS: The best practice alert in the electronic medical record was associated with a 27% change (p = 0.007) in prescribing by the physician, which resulted in a reduction of average day supply from 12.09 to 6.58 days. The alert in the pharmacy system was associated with a 41.3% change (p < 0.001) in dispensing, which resulted in a reduction of average day supply from 13.46 to 6.96 days. DISCUSSION: To promote judicious opioid prescribing, the best practice alert in the electronic medical record led to a statistically significant change in prescribing. To support appropriate dispensing, the alert in the pharmacy system led to a statistically significant change in dispensing. CONCLUSION: Implementation of two clinical decision support tools that mirrored Centers for Disease Control and Prevention recommendations of prescribing less than a 7-day supply when initiating opioids resulted in a decrease in day supply of the opioid prescription for patients identified as opioid-naïve at the point of prescribing and dispensing.

Alumni perspectives on interprofessional experiential learning and interprofessional collaborative practice in health care settings.

INTRODUCTION: Interprofessional collaborative practice (ICP) is essential for optimizing patient outcomes in health care settings. Experiential learning (EL) is a method of modeling ICP to students during their education. No studies have evaluated the lasting impact of EL on self-reported clinical practice after students graduate. The aims of this study are to (a) examine what opportunities for ICP are available for alumni in current health care settings and (b) explore the early career impact of interprofessional EL on self-reported current clinical practice. METHODS: This study utilized a mixed-methods design using descriptive statistics and a phenomenological approach. Participants included Doctor of Physical Therapy (DPT) and Master of Arts in Marriage and Family Therapy (MAMFT) alumni who previously participated as graduate students in Balanced Families (BF), an interprofessional EL program. Sixty-four alumni were contacted through e-mail, of which 17 (27%) agreed to be interviewed. RESULTS: Quantitative data were analyzed utilizing descriptive statistics to describe demographics and summarize Likert scale responses. Qualitative data were analyzed using an interpretative phenomenological analysis approach. Five major themes were reflected in the transcripts: (a) The impact of interprofessional experiential learning on future clinical practice, (b) The value of holistic approaches, (c) The collaboration in holistic care, (d) The interconnected health care system and family system, and (e) The development of empathy for patients and their families. DISCUSSION: Interprofessional EL positively impacted DPT and MAMFT alumni, improving interprofessional communication skills and leading to more holistic approaches to care. Study outcomes support continued implementation of interprofessional EL in health care graduate study programs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Clinical Evaluation of a Novel Wearable Compression Technology in the Treatment of Lymphedema, an Open-Label Controlled Study.

A diagnosis of lymphedema comes with a lifetime requirement for careful self-care and treatment to control skin deterioration and the consequences of excessive fluid and protein buildup leading to abnormal limb volume and an increased risk of infection. The burden of care and psychosocial aspects of physical disfiguration and loss of function are associated with compromised quality of life (QoL). The current standard therapeutic intervention is complex decongestive therapy with manual lymph drainage and frequent wearing of compression garments. With insurance limitations on therapy visits and the time and travel required, additional home treatment options are needed. Pneumatic compression pumps that mimic the manual massage pressure and pattern are sometimes prescribed, but these are bulky, difficult to apply, and require immobility during treatment. An open-label pilot study in 40 subjects was performed to evaluate the QoL and limb volume maintenance efficacy of a novel wearable compression system (Dayspring™) that is low profile, easy to use, and allows for mobility during treatment. After 28 days of use, subjects had a statistically significant 18% (p < 0.001) improvement in overall QoL as measured by the Lymphedema Quality-of-Life Questionnaire compared with baseline. Individual QoL domains, and limb volume improved with therapy. Adherence was 98% over the course of the study. Results of the clinical evaluation suggest the Dayspring wearable compression device is safe and effective and improves QoL and limb volume. The novel, low-profile device is easy to use and allows for mobility during treatment, addressing a potential barrier to adherence with pneumatic compression devices.

Interventions to Reduce Burnout and Improve Resilience: Impact on a Health System's Outcomes.

With the continuously changing health care environment and dramatic shift in patient demographics, institutions have the responsibility of identifying and dedicating resources for maintaining and improving wellness and resilience among front line providers to assure the quality of patient care. Our institution, the Ohio State University Wexner Medical Center (OSUWMC), has addressed the goal to decrease burnout for providers in a multistep, multiprofessional, and multiyear program starting firstly with institutional cultural change then focused provider interventions, and lastly, proactive resilience engagement. We describe herein our approach and outcomes as measured by provider wellness and health system outcomes. In addition, we address the overall feasibility and effectiveness of these programs in promoting provider compassion and mindfulness while reducing burnout and improving resilience. Institutional culture change and readiness were initiated in 2010 with the introduction of Crew Resource Management training for all providers across the OSUWMC. This multiyear program was implemented and has been sustained to the current day. Focused interventions to improve mindfulness were undertaken in the form of both Mindfulness in Motion (MIM) training for intensive care unit personnel and a "flipped classroom" mindfulness training for faculty and residents. Lastly, sustainable changes were introduced in the form of the Gabbe Health and Wellness program which consists of interprofessional MIM training and other wellness offerings for staff, faculty, and residents embedded across the entire medical center. The introduction of Crew Resource Management in 2010 continues to be endorsed and supported throughout OSUWMC for all providers, including residents and students. The improvements seen have not only improved patient satisfaction but also reduced patient safety events and improved national reputation for the institution as a whole. Subsequently, MIM training for intensive care unit providers has resulted in improved resilience as well as decreased patient safety events. In addition, the "flipped classroom" mindfulness training for residents and faculty has resulted in improvements in providing calm and compassionate care, improvements in physician wellbeing, and reductions in emotional exhaustion and depersonalization. Lastly, implementing the Gabbe Health and Wellness program inclusive of interprofessional MIM training for staff, faculty, and residents has resulted in significant reductions in burnout while significantly increasing resilience postintervention. The engagement from staff and enthusiasm to continue this program have escalated and been positively accepted across OSUWMC. To reduce the incidence of burnout, improve resilience, and ultimately improve patient outcomes, a health system must identify and prioritize a commitment and dedication of resources to develop and sustain a multimodal and interprofessional approach to change. These initiatives at OSU originated with cultural transformation allowing the acceptance of change in the form of mindfulness training, resilience building, and the engagement of organizational science, so as to demonstrate the outcomes and impact to the health system and academic peers. Herein we describe the work that has been done thus far, both published and in progress, to understand our journey.

Severe Vitamin B12 Deficiency in Pregnancy Mimicking HELLP Syndrome.

Severe vitamin B12 deficiency may present with hematologic abnormalities that mimic thrombotic microangiopathy disorders such as hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. We report a patient diagnosed with severe vitamin B12 deficiency, following termination of pregnancy for suspected preeclampsia and HELLP syndrome at 21 weeks' gestation. When hemolysis and thrombocytopenia persisted after delivery, testing was performed to rule out other etiologies of thrombotic microangiopathy, including atypical hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, and vitamin B12 deficiency. This work-up revealed undetectable vitamin B12 levels and presence of intrinsic factor antibodies, consistent with pernicious anemia. Parenteral B12 supplementation was initiated, with subsequent improvement in hematologic parameters. Our case emphasizes the importance of screening for B12 deficiency in pregnancy, especially in at-risk women with unexplained anemia or thrombocytopenia. Moreover, providers should consider B12 deficiency and pernicious anemia in the differential diagnosis of pregnancy-associated thrombotic microangiopathy.

Treatment of ovarian cancer cells with nutlin-3 and resveratrol combination leads to apoptosis via caspase activation.

The current study was focused on the induction of apoptotic effects of resveratrol along with the combination treatments of nutlin-3 and transforming growth factor-ß (TGF-ß) against the human ovarian cancer cell line A2780/CP70. To determine the extent of apoptosis following the above-mentioned treatments, we assessed the execution of apoptotic events that proceed via caspase activation and cytochrome c release. We estimated the caspase-3 and -9 activities using a direct enzymatic assay that measures the cleavage of synthetic peptide substrate (N-acetyl-Asp-Glu-Val-Asp-p-nitroanilide). Our experiments showed an increase in caspase-3 and -9 activities in the cells that were treated with the combination of resveratrol (5 µM) with nutlin-3 (5 µM) or TGF-ß (1 µg/mL). Since activation of procaspase-3 by caspase-9 requires the release of cytochrome c into the cytoplasm, we measured the levels of cytochrome c in the cytoplasm by western blot experiments. The data indicated a considerable increase in caspase-3 and cytochrome c levels when cells were treated with drugs for 24 hours. Experiments with 4,6'-diamino-2-phenylindole dihydrochloride (DAPI) staining also confirmed the induction of apoptosis in all the above-mentioned treatments done at 24 and 48 hours. These results support our hypothesis that resveratrol combination can induce programmed cell death at doses that are less than half of what is typically needed for nutlin-3 and TGF-ß to induce apoptosis.