Methylated Thioarsenates and Monothioarsenate Differ in Uptake, Transformation, and Contribution to Total Arsenic Translocation in Rice Plants.

Methylated and inorganic thioarsenates have recently been reported from paddy fields besides the better-known oxyarsenates. Methylated thioarsenates are highly toxic for humans, yet their uptake, transformation, and translocation in rice plants is unknown. Here, hydroponic experiments with 20 day old rice plants showed that monomethylmonothioarsenate (MMMTA), dimethylmonothioarsenate (DMMTA), and monothioarsenate (MTA) were taken up by rice roots and could be detected in the xylem. Total arsenic (As) translocation from roots to shoots was higher for plants exposed to DMMTA, MTA, and dimethylarsenate (DMAV) compared to MMMTA and monomethylarsenate (MMAV). All thioarsenates were partially transformed in the presence of rice roots, but processes and extents differed. MMMTA was subject to abiotic oxidation and largely dethiolated to MMAV already outside the plant, probably due to root oxygen loss. DMMTA and MTA were not oxidized abiotically. Crude protein extracts showed rapid enzymatic reduction for MTA but not for DMMTA. Our study implies that DMMTA has the highest potential to contribute to total As accumulation in grains either as DMAV or partially as DMMTA. DMMTA has once been detected in rice grains using enzymatic extraction. By routine acid extraction, DMMTA is determined as DMAV and thus escapes regulation despite its toxicity.

Monothioarsenate Uptake, Transformation, and Translocation in Rice Plants.

Thioarsenates form under sulfur-reducing conditions in paddy soil pore waters. Sulfur fertilization, recently promoted for decreasing total arsenic (As) grain concentrations, could enhance their formation. Yet, to date, thioarsenate toxicity, uptake, transformation, and translocation in rice are unknown. Our growth inhibition experiments showed that the toxicity of monothioarsenate (MTA) was similar to that of arsenate but lower than that of arsenite. Higher toxicity of MTA with lower phosphate availability might imply uptake through phosphate transporters similar to arsenate. To demonstrate direct uptake of MTA by rice plants, a species-preserving extraction method for plant samples was developed. When plants were exposed to 10 µM MTA for 72 h, up to 19% and 4% of total As accumulated in roots and shoots, respectively, was MTA. Monothioarsenate was detected in xylem sap and root exudates, and its reduction to arsenite in rice roots and shoots was shown. Total As uptake was lower upon exposure to MTA compared to arsenate, but root to shoot translocation was higher, resulting in comparable As shoot concentrations. Thus, before promoting sulfur fertilization, uptake and detoxifying mechanisms of thioarsenates as well as potential contribution to grain As accumulation need to be better understood.

Thioarsenate Toxicity and Tolerance in the Model System Arabidopsis thaliana.

Thioarsenates form from arsenite under sulfate-reducing conditions, e.g., in rice paddy soils, and are structural analogues of arsenate. Even though rice is one of the most important sources of human arsenic intake, nothing is published about uptake, toxicity, or tolerance of thioarsenates in plants. Experiments using the model system Arabidopsis thaliana showed that monothioarsenate is less toxic than arsenite, but more toxic than arsenate at concentrations ≥25 µM As, reflected in stronger seedling growth inhibition on agar plates. Despite higher toxicity, total As accumulation in roots was lower upon exposure to monothioarsenate compared to arsenate, and a higher root efflux was confirmed. Root-shoot translocation was higher for monothioarsenate than for arsenate. Compared to the wild type (Col-0), both arsenate and monothioarsenate induced higher toxicity in phytochelatin (PC)-deficient mutants (cad1-3) as well as in glutathione biosynthesis (cad2) and PC transport (abcc12) mutants, demonstrating the important role of the PC pathway, not only for arsenate, but also for monothioarsenate detoxification. In Col-0, monothioarsenate induced relatively higher accumulation of PCs than arsenate. The observed differences in plant uptake, toxicity, and tolerance of thioarsenate vs oxyarsenate show that studying the effects of As on plants should include experiments with thiolated As species.

Patient flow in the emergency department: a classification and analysis of admission process policies.

STUDY OBJECTIVE: We investigate the effect of admission process policies on patient flow in the emergency department (ED). METHODS: We surveyed an advisory panel group to determine approaches to admission process policies and classified them as admission decision is made by the team of providers (attending physicians, residents, physician extenders) (type 1) or attending physicians (type 2) on the admitting service, team of providers (type 3), or attending physicians (type 4) in the ED. We developed discrete-event simulation models of patient flow to evaluate the potential effect of the 4 basic policy types and 2 hybrid types, referred to as triage attending physician consultation and remote collaborative consultation on key performance measures. RESULTS: Compared with the current admission process policy (type 1), the alternatives were all effective in reducing the length of stay of admitted patients by 14% to 26%. In other words, patients may spend 1.4 to 2.5 hours fewer on average in the ED before being admitted to internal medicine under a new admission process policy. The improved flow of admitted patients decreased both the ED length of stay of discharged patients and the overall length of stay by up to 5% and 6.4%, respectively. These results are framed in context of teaching mission and physician experience. CONCLUSION: An efficient admission process can reduce waiting times for both admitted and discharged ED patients. This study contributed to demonstrating the potential value of leveraging admission process policies and developing a framework for pursuing these policies.

Content and timing of feedback and reflection: a multi-center qualitative study of experienced bedside teachers.

BACKGROUND: Competency-based medical education increasingly recognizes the importance of observation, feedback, and reflection for trainee development. Although bedside rounds provide opportunities for authentic workplace-based implementation of feedback and team-based reflection strategies, this relationship has not been well described. The authors sought to understand the content and timing of feedback and team-based reflection provided by bedside teachers in the context of patient-centered bedside rounds. METHODS: The authors conducted a thematic analysis qualitative study using transcripts from audio-recorded, semi-structured telephone interviews with internal medicine attending physicians (n= 34) identified as respected bedside teachers from 10 academic US institutions (2010-2011). RESULTS: Half of the respondents (50%) were associate/full professors, with an average of 14 years of academic experience. In the context of bedside encounters, bedside teachers reported providing feedback on history-taking, physical-examination, and case-presentation skills, patient-centered communication, clinical decision-making, leadership, teaching skills, and professionalism. Positive feedback about physical-exam skills or clinical decision-making occurred during encounters, positive or constructive team-based feedback occurred immediately following encounters, and individualized constructive feedback occurred in one-on-one settings following rounding sessions. Compared to less frequent, emotionally-charged events, bedside teachers initiated team-based reflection on commonplace "teachable moments" related to patient characteristics or emotions, trainee actions and emotions, and attending physician role modeling. CONCLUSIONS: Bedside teachers use bedside rounds as a workplace-based method to provide assessment, feedback, and reflection, which are aligned with the goals of competency-based medical education. Embedded in patient-centered activities, clinical teachers should be encouraged to incorporate these content- and timing-related feedback and reflection strategies into their bedside teaching.

The art of bedside rounds: a multi-center qualitative study of strategies used by experienced bedside teachers.

BACKGROUND: Medical educators believe bedside rounds are effective for the delivery of patient-centered care, and are necessary in helping trainees acquire competence in clinical care. Although recommendations for bedside rounds have been reported, a recent, systematic assessment of strategies used by current-day bedside teachers was needed to advance knowledge of this teaching method. OBJECTIVE: To identify and understand bedside teachers' 1) preparatory steps, 2) patient selection, and 3) role allocation during the process of bedside rounds. DESIGN: A qualitative inductive thematic analysis using transcripts from audio-recorded, semi-structured telephone interviews. PARTICIPANTS: Internal medicine physicians (n = 34) who perform bedside rounds from ten academic US institutions (2010-2011). APPROACH: A purposive sampling strategy was utilized to identify physicians who were active inpatient attending physicians and met specific inclusion criteria for "bedside rounds." A total of 34 interviews were completed, and each was recorded and transcribed verbatim. A thematic analysis extracted key themes pertaining to the three objectives. KEY RESULTS: Most respondents (51 %) were associate or full professors, with an average of 14 years of academic experience. Attending physicians prepared using trainee-specific, patient-specific and disease-specific information, while also mentally preparing for bedside rounds. They sought trainee buy-in and learning objectives, reviewed expectations and methods to ensure patient comfort, and provided early guidance with bedside encounters. Patients were selected if they required immediate care, were new to the service, or had a high educational value, while patients were deferred if unavailable, unwilling, or unable to communicate. The team members' roles during bedside rounds varied, with trainees being given graduated autonomy with increased experience. CONCLUSIONS: Bedside teachers' methods for preparation, patient selection, and role allocation during bedside rounds enhance trainees' education within the workplace. Strategies used by experienced bedside teachers can be used for faculty development efforts aimed at promoting this activity.

The value of bedside rounds: a multicenter qualitative study.

BACKGROUND: Bedside rounds have decreased on teaching services, raising concern about trainees' clinical skills and patient-physician relationships. PURPOSE: We sought to identify recognized bedside teachers' perceived value of bedside rounds to assist in the promotion of bedside rounds on teaching services. METHODS: Authors used a grounded theory, qualitative study design of telephone semistructured interviews with bedside teachers (n = 34) from 10 U.S. institutions (2010-2011). Main outcomes were characteristics of participants, themes pertaining to the perceived value of bedside rounds, and quotations highlighting each respective theme. RESULTS: The mean years in academic medicine was 13.7, and 51% were associate or full professors. Six main themes emerged: (a) skill development for learners (e.g., physical examination, communication, and clinical decision-making skills); (b) observation and feedback; (c) role-modeling; (d) team building among trainees, attending, and patient; (e) improved patient care delivery through combined clinical decision-making and team consensus; and (f) the culture of medicine as patient-centered care, which was embodied in all themes. CONCLUSIONS: Bedside teachers identify potential benefits of bedside rounds, many of which align with national calls to change our approach to medical education. The practice of bedside rounds enables activities essential to high-quality patient care and education.

Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay.

OBJECTIVE: Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS: Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS: Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS: Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.

Effect of standardized electronic discharge instructions on post-discharge hospital utilization.

BACKGROUND: Several physician organizations and the Centers for Medicare and Medicaid Services (CMS) support compliance measures for written discharge instructions. CMS has identified clear discharge instructions with specific attention to medication management as a necessary intervention. OBJECTIVE: We tested the hypothesis that implementing a standardized electronic discharge instructions document with embedded computerized medication reconciliation would decrease post-discharge hospital utilization. DESIGN: Retrospective pre- and post-implementation comparison cohort study. PATIENTS: Subjects were hospitalized patients age 18 and older discharged between November 1, 2005 and October 31, 2006 (n = 16,572) and between March 1, 2007 and February 28, 2008 (n = 17,516). INTERVENTION: Implementation of a standardized, templated electronic discharge instructions document with embedded computerized medication reconciliation on December 18, 2006. MAIN MEASURES: The primary outcome was a composite variable of readmission or Emergency Department (ED) visit within 30 days of discharge. Secondary outcomes were the individual variables of readmissions and ED visits within 30 days. KEY RESULTS: The implementation of standardized electronic discharge instructions with embedded computerized medication reconciliation was not associated with a change in the primary composite outcome (adjusted OR 1.04, 95% CI 0.98-1.10) or the secondary outcome of 30-day ED visits (adjusted OR 0.98, 95% CI 0.98-1.10). There was an unexpected small but statistically significant increase in 30-day readmissions (adjusted OR 1.08, 95% CI 1.01-1.16). CONCLUSIONS: Implementation of standardized electronic discharge instructions was not associated with reduction in post-discharge hospital utilization. More studies are needed to determine the reasons for post-discharge hospital utilization and to examine outcomes associated with proposed process-related recommendations.

Attributable costs of central line-associated bloodstream infections in a pediatric hematology/oncology population.

BACKGROUND: Although several studies have estimated the attributable cost and length of stay (LOS) of central line-associated bloodstream infections (CLABSIs) in the pediatric intensive care unit setting, little is known about the attributable costs and LOS of CLABSIs in the vulnerable pediatric hematology/oncology population. METHODS: We studied a total of 1562 inpatient admissions for 291 pediatric hematology/oncology patients at a single tertiary care children's hospital in the mid-Atlantic region between January 2008 and May 2011. Costs were normalized to year 2011 dollars. Propensity score matching was used to estimate the effect of CLABSIs on total cost and LOS while controlling for other covariates. RESULTS: Sixty CLABSIs occurred during the 1562 admissions. Compared with the patients without a CLABSI, those who developed a CLABSI tended to be older (9.0 years vs 7.5 years; P = .026) and to have a tunneled catheter (46.7% vs 27.0%) and a peripherally inserted central catheter (20.0% vs 11.2%) as opposed to other types of catheters (P < .0001). Propensity score matching yielded matched groups without significant differences in patient characteristics. In the propensity score analysis, the attributable LOS of a CLABSI was 21.2 days (P < .0001), and the attributable cost of a CLABSI was $69,332 (P < .0001). CONCLUSIONS: Among pediatric hematology/oncology patients, CLABSI was associated with an additional LOS of 21 days and increased costs of nearly $70,000. These findings may inform decisions regarding the value of investing in efforts to prevent CLABSIs in this vulnerable population.

Reduction of central line-associated bloodstream infections in a pediatric hematology/oncology population.

This study reports the results of an initiative to reduce central line-associated bloodstream infections (CLABSIs) among pediatric hematology/oncology patients, a population at increased risk for CLABSI. The study design was a pre-post comparison of a series of specific interventions over 40 months. Logistic regression was used to determine if the risk of developing CLABSI decreased in the postintervention period, after controlling for covariates. The overall CLABSI rate fell from 9 infections per 1000 line days at the beginning of the study to zero in a cohort of 291 patients encompassing 2107 admissions. Admissions during the intervention period had an 86% reduction in odds of developing a CLABSI, controlling for other factors. At the study team's institution, an initiative that standardized blood culturing techniques, lab draw times, line care techniques, and provided physician and nurse education was able to eliminate CLABSI among pediatric hematology/oncology patients.

Identifying and overcoming the barriers to bedside rounds: a multicenter qualitative study.

PURPOSE: The use of bedside rounds in teaching hospitals has declined, despite recommendations from educational leaders to promote this effective teaching strategy. The authors sought to identify reasons for the decrease in bedside rounds, actual barriers to bedside rounds, methods to overcome trainee apprehensions, and proposed strategies to educate faculty. METHOD: A qualitative inductive thematic analysis using transcripts from audio-recorded, semistructured telephone interviews with a purposive sampling of 34 inpatient attending physicians from 10 academic U.S. institutions who met specific inclusion criteria for "bedside rounds" was performed in 2010. Main outcomes were themes pertaining to barriers, methods to overcome trainee apprehensions, and strategies to educate faculty. Quotations highlighting themes are reported. RESULTS: Half of respondents (50%) were associate or full professors, averaging 14 years in academic medicine. Primary reasons for the perceived decline in bedside rounds were physician- and systems related, although actual barriers encountered related to systems, time, and physician-specific issues. To address resident apprehensions, six themes were identified: build partnerships, create safe learning environments, overcome with experience, make bedside rounds educationally worthwhile, respect trainee time, and highlight positive impact on patient care. Potential strategies for educating faculty were identified, most commonly faculty development initiatives, divisional/departmental culture change, and one-on-one shadowing opportunities. CONCLUSIONS: Bedside teachers encountered primarily systems- and time-related barriers and overcame resident apprehensions by creating a learner-oriented environment. Strategies used by experienced bedside teachers can be used for faculty development aimed at promoting bedside rounds.

Reduction of central venous catheter associated blood stream infections following implementation of a resident oversight and credentialing policy.

BACKGROUND: This study assesses the impact that a resident oversight and credentialing policy for central venous catheter (CVC) placement had on institution-wide central line associated bloodstream infections (CLABSI). We therefore investigated the rate of CLABSI per 1,000 line days during the 12 months before and after implementation of the policy. METHODS: This is a retrospective analysis of prospectively collected data at an academic medical center with four adult ICUs and a pediatric ICU. All patients undergoing non-tunneled CVC placement were included in the study. Data was collected on CLABSI, line days, and serious adverse events in the year prior to and following policy implementation on 9/01/08. RESULTS: A total of 813 supervised central lines were self-reported by residents in four departments. Statistical analysis was performed using paired Wilcoxon signed rank tests. There were reductions in median CLABSI rate (3.52 vs. 2.26; p = 0.015), number of CLBSI per month (16.0 to 10.0; p = 0.012), and line days (4495 vs. 4193; p = 0.019). No serious adverse events reported to the Pennsylvania Patient Safety Authority. CONCLUSIONS: Implementation of a new CVC resident oversight and credentialing policy has been significantly associated with an institution-wide reduction in the rate of CLABSI per 1,000 central line days and total central line days. No serious adverse events were reported. Similar resident oversight policies may benefit other teaching institutions, and support concurrent organizational efforts to reduce hospital acquired infections.