Design and Integration of a Texting Tool to Keep Patients' Family Members Updated During Hospitalization: Family Members' Perspectives.

While there is an evolving literature on the benefits of texting and patient-centered technologies, texting initiatives have not focused on family members. We sought to identify patients' family members' perspectives on facilitators and barriers to using 1 digital texting innovation to promote family-centered care during patients' hospitalizations. This qualitative study was conducted at a tertiary care center in Houston, consisting of 7 hospitals (1 academic hospital and 6 community hospitals), involving analyzation of 3137 comments from family members who used the digital texting technology. Thematic analysis methods were used. The data analysis for loved ones' feedback resulted in 4 themes as facilitators: (1) inpatient text messaging keeps loved ones updated and connected (n = 611); (2) inpatient text messaging allows for stronger continuity of communication (n = 69); (3) messaging promotes a sense of staff compassion and service (n = 245); and (4) messaging reduces phone calls (n = 65). The data analysis resulted in 4 themes as barriers to text messaging helpfulness: (1) messages could feel generic (n = 31); (2) inpatient texting was not needed if all loved ones were regularly at bedside (n = 6); (3) messages could have a perceived delay (n = 37); and (4) security features could impact convenience (n = 29). Our findings indicate that family members and loved ones value inpatient text messages, not only for the information the messages provide, but also because the act of writing text messages and preparing loved ones shows inclusiveness, compassion, and family-centered care.

Design and Integration of a Texting Tool to Keep Patients' Family Members Updated During Hospitalization: Clinicians' Perspectives.

An important gap in the literature is how clinicians feel about patient-centered technologies and how clinicians experience patient-centered technologies in their workflows. Our goal was to identify clinician users' perspectives on facilitators (pros) and barriers (cons) to using 1 digital texting innovation to promote family centered care during patients' hospitalizations. This qualitative study was conducted at a tertiary care center in Houston, consisting of 7 hospitals (1 academic hospital and 6 community hospitals), involving analyzation of 3 focus groups of 18 physicians, 5 advanced practice providers, and 10 nurse directors and managers, as well as a content analysis of 156 real-time alerts signaling family dissatisfaction on the nursing unit/floor. Thematic analysis methods were used. We selected these participants by attending their regularly scheduled service-line meetings. Clinician feedback from focus groups resulted in 3 themes as facilitators: (a) texting platforms must be integrated within the electronic medical record; (b) texting reduces outgoing phone calls; (c) texting reduces incoming family phone calls. Clinician feedback resulted in 3 themes as barriers: (a) best practice alerts can be disruptive; (b) real-time alerts can create hopelessness; and (c) scale-up is challenging. The analyzation of facilitators (pros) and barriers (cons) pertains only to the clinician's feedback. We also analyzed real-time alerts signaling family dissatisfaction (defined as "service recovery escalation" throughout this manuscript). The most common selection for the source of family dissatisfaction, as reflected through the real-time alerts was, "I haven't heard from physicians enough," appearing in 52 out of 156 alerts (33%). The second most common selection for the source of dissatisfaction was "perceived inconsistent or incomplete information provided by team members," which was selected in 48 cases (31%). Our findings indicate that clinicians value inpatient texting, not only for its ability to quickly relay updates to multiple family members with 1 click, but also because, when used intentionally and meaningfully, texting decreases family phone calls.

Parenting Acceptance and Commitment Therapy: An RCT of an online course with families of children with CP.

AIM: To test an online course Parenting Acceptance and Commitment Therapy (PACT) in an RCT with families of children with cerebral palsy (CP), predicting improvements in emotional availability and parent and child adjustment. METHOD: 67 families of children (2-10 years) with CP participated. Families were randomly assigned to waitlist control or PACT. Assessments at baseline, post-intervention and at six-month follow up (durability of intervention effects) focussed on emotional availability, adjustment and quality of life. Analysis consisted of repeated measure linear regression models. RESULTS: At postintervention (T2), an intervention effect was demonstrated for two aspects of observed emotional availability: parental non-intrusiveness MD = 0.68 (-0.56 to 1.92), p = 0.050 and child involvement, MD = 0.91 (-0.36 to 2.18), p = 0.011. An intervention effect was also found for the parent-reported emotional availability in terms of child involvement. Further intervention effects were found in parent-report measures of child quality of life (social wellbeing and acceptance, participation and physical health), parental mindfulness, parental acceptance, support, social connection, and meaning. No effects were found on parent or child adjustment. Analyses focussed on durability of intervention effect, collapsed across groups, indicated that effects persisted at 6 month follow up (T4). INTERPRETATION: PACT demonstrated an intervention effect for two aspects of emotional availability-parental non-intrusiveness and child involvement-as well as parental mindfulness and child quality of life. Parents reported increased comfort with the CP diagnosis, higher likelihood to seek support, higher likelihood to stay connected to others and greater meaningful living. PACT is an effective online/telehealth parenting support intervention for parents of children with CP.

Physical Examination in the Evaluation of Dementia.

Dementia is a common disease worldwide and is largely underdiagnosed. A timely diagnosis of dementia is beneficial for both the patient and family for many reasons, and exclusion and treatment of other mimics of dementia are crucial to avoid long-term consequences. Making a diagnosis of dementia requires attention to subtle cues from both patients and other informants, as often patients and family members will not notice early signs and symptoms. Although universal screening is not recommended by the USPSTF, screening in high-risk populations is recommended by many organizations. Screening with the Mini-Cog and AD8 combined is a highly sensitive way to identify patients with dementia, and confirmation testing can be performed with the MoCA or MMSE. Specific subtypes of dementia, including Alzheimer's disease, vascular dementia, Lewy body dementia, frontotemporal dementia, and others, sometimes can be differentiated by unique physical examination findings. Timely referral to dementia specialists is useful in the management of this group of diseases. However, as the aging population grows and access to specialists is often limited, it is important for all physicians to understand how to make a diagnosis of dementia.

Design and Early Implementation Successes and Challenges of a Pharmacogenetics Consult Clinic.

Pharmacogenetic testing (PGT) is increasingly being used as a tool to guide clinical decisions. This article describes the development of an outpatient, pharmacist-led, pharmacogenetics consult clinic within internal medicine, its workflow, and early results, along with successes and challenges. A pharmacogenetics-trained pharmacist encouraged primary care physicians (PCPs) to refer patients who were experiencing side effects/ineffectiveness from certain antidepressants, opioids, and/or proton pump inhibitors. In clinic, the pharmacist confirmed the need for and ordered CYP2C19 and/or CYP2D6 testing, provided evidence-based pharmacogenetic recommendations to PCPs, and educated PCPs and patients on the results. Operational and clinical metrics were analyzed. In two years, 91 referred patients were seen in clinic (mean age 57, 67% women, 91% European-American). Of patients who received PGT, 77% had at least one CYP2C19 and/or CYP2D6 phenotype that would make conventional prescribing unfavorable. Recommendations suggested that physicians change a medication/dose for 59% of patients; excluding two patients lost to follow-up, 87% of recommendations were accepted. Challenges included PGT reimbursement and referral maintenance. High frequency of actionable results suggests physician education on who to refer was successful and illustrates the potential to reduce trial-and-error prescribing. High recommendation acceptance rate demonstrates the pharmacist's effectiveness in providing genotype-guided recommendations, emphasizing a successful pharmacist-physician collaboration.

Peer assisted feedback: a successful approach for providing feedback on United States Medical Licensing Exam-style clinical skills exam notes in the United States.

PURPOSE: Peer assisted learning (PAL) promotes the development of communication, facilitates improvement of clinical skills, and provides feedback to learners. We utilized PAL as a conceptual framework to explore the feasibility of peer-assisted feedback (PAF) to improve note writing skills without requiring faculty time. The aim was to assess if peer assisted learning was a successful method to provide feedback on USMLE-style clinical skills exam notes by using student feedback on a survey in the United States. METHODS: The University of Florida College of Medicine administers clinical skills examinations (CSEs) includes USMLE-like note-writing. PAL, where students support the learning of peers, was utilized as an alternative to faculty feedback. Second (MS2) and third (MS3) year medical students taking CSEs participated in faculty-run note-grading sessions immediately after testing, which included explanations of grading rubrics and the feedback process. Students graded an anonymized peer's notes. The graded material was then forwarded anonymously to its student author to review. Students were surveyed on perceived ability to provide feedback and benefits derived from PAF using a Likert scale (1-6) and open-ended comments during the 2017-2018 academic year. RESULTS: Students felt generally positively about the activity with mean score for items related to educational value of 4.49 for MS2 and 5.11 for MS3 out of 6. MS3s perceived peer feedback as constructive, felt benefit from evaluating other's notes, and felt the exercise would improve their future notes. While still positive, MS2 students gave comparatively lower scores than the MS2 students. CONCLUSION: PAF was a successful method to provide feedback on student CSE notes, especially for MS3s. MS2s commented that although they learned during the process, they might be more invested in improving their note writing as they approach their own USMLE exam.

Challenges and lessons learned from clinical pharmacogenetic implementation of multiple gene-drug pairs across ambulatory care settings.

PURPOSE: Incorporating a patient's genotype into the clinical decision-making process is one approach to precision medicine. The University of Florida (UF) Health Precision Medicine Program is a pharmacist-led multidisciplinary effort that has led the clinical implementation of six gene-drug(s) pairs to date. This study focuses on the challenges encountered and lessons learned with implementing pharmacogenetic testing for three of these: CYP2D6-opioids, CYP2D6/CYP2C19-selective serotonin reuptake inhibitors, and CYP2C19-proton pump inhibitors within six pragmatic clinical trials at UF Health and partners. METHODS: We compared common measures collected within each of the pharmacogenetic implementations as well as solicited feedback from stakeholders to identify challenges, successes, and lessons learned. RESULTS: We identified several challenges related to trial design and implementation, and learned valuable lessons. Most notably, case discussions are effective for prescriber education, prescribers need clear concise guidance on genotype-based actions, having genotype results available at the time of the patient-prescriber encounter helps optimize the ability to act on them, children prefer noninvasive sample collection, and study participants are willing to answer patient-reported outcomes questionnaires if they are not overly burdensome, among others. CONCLUSION: The lessons learned from implementing three gene-drug pairs in ambulatory care settings will help shape future pharmacogenetic clinical trials and clinical implementations.

CYP2D6-guided opioid therapy improves pain control in CYP2D6 intermediate and poor metabolizers: a pragmatic clinical trial.

PURPOSE: CYP2D6 bioactivates codeine and tramadol, with intermediate and poor metabolizers (IMs and PMs) expected to have impaired analgesia. This pragmatic proof-of-concept trial tested the effects of CYP2D6-guided opioid prescribing on pain control. METHODS: Participants with chronic pain (94% on an opioid) from seven clinics were enrolled into CYP2D6-guided (n = 235) or usual care (n = 135) arms using a cluster design. CYP2D6 phenotypes were assigned based on genotype and CYP2D6 inhibitor use, with recommendations for opioid prescribing made in the CYP2D6-guided arm. Pain was assessed at baseline and 3 months using PROMIS® measures. RESULTS: On stepwise multiple linear regression, the primary outcome of composite pain intensity (composite of current pain and worst and average pain in the past week) among IM/PMs initially prescribed tramadol/codeine (n = 45) had greater improvement in the CYP2D6-guided versus usual care arm (-1.01 ± 1.59 vs. -0.40 ± 1.20; adj P = 0.016); 24% of CYP2D6-guided versus 0% of usual care participants reported ≥30% (clinically meaningful) reduction in the composite outcome. In contrast, among normal metabolizers prescribed tramadol or codeine at baseline, there was no difference in the change in composite pain intensity at 3 months between CYP2D6-guided (-0.61 ± 1.39) and usual care (-0.54 ± 1.69) groups (adj P = 0.540). CONCLUSION: These data support the potential benefits of CYP2D6-guided pain management.

Case of Serotonin Syndrome Initially Presenting as Diffuse Body Pain.

BACKGROUND Serotonin syndrome is a common yet potentially life-threatening condition caused by increased serotonergic activity, usually from serotonergic pharmaceutical agents. Primary features of serotonin syndrome include mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. However, the presentation of serotonin syndrome is often quite variable, leading to its under-diagnosis. CASE REPORT A 50-year-old female with chronic kidney disease on peritoneal dialysis presented to the Emergency Department with severe, diffuse body pain. Over the course of her hospital stay, she developed severe nausea, vomiting, and diarrhea followed by hyperreflexia and inducible clonus. Laboratory studies were remarkable for elevated liver transaminases. Review of her medications revealed several serotonergic agents, including duloxetine, tramadol, and ondansetron. Given her symptoms and the multiple serotonergic agents she was taking, she was diagnosed with serotonin syndrome. Discontinuation of the serotonergic agents led to resolution of her symptoms over the course of 4 days. CONCLUSIONS Our patient's initial presentation of diffuse body pain highlights the variable presentation of serotonin syndrome. Our case also demonstrates the importance of recognizing serotonin syndrome, as the supportive ondansetron we gave to alleviate her nausea and vomiting likely exacerbated her serotonin syndrome.

A difficult situation - balancing critical anticoagulation versus the risk of permanent neurologic deficit: a case report.

BACKGROUND: Anticoagulation is the mainstay of treatment for pulmonary embolism. However, if bleeding unfortunately occurs, the risks and benefits of anticoagulation present a challenge. Management of one hemorrhagic complication, retroperitoneal hematoma, is rare, difficult, and controversial. CASE PRESENTATION: A 73-year-old white man presented with left lower extremity swelling and dyspnea. He was tachycardic, hypertensive, and demonstrated poor oxygen saturation of 81% on ambient air. A computed tomography angiogram revealed a saddle pulmonary embolus. Tissue plasminogen activator was administered and he was started on a heparin infusion. He was eventually transitioned to enoxaparin. On the day of discharge, however, he had sudden onset of right leg numbness and weakness below his hip. A computed tomography of his head was not concerning for stroke, and neurology was consulted. Neurology was concerned for spinal cord infarction versus hematoma and recommended magnetic resonance imaging of his thoracic and lumbar spine. The magnetic resonance imaging revealed a left psoas hematoma. A computed tomography scan of his pelvis also showed a right psoas and iliacus hematoma. He was transitioned to a low intensity heparin infusion. The following day his left leg exhibited similar symptoms. There was concern of progressive and irreversible nerve damage due to compression if the hematomas were not drained. Interventional radiology was consulted for drainage. The heparin infusion was paused, drainage was performed, and the heparin infusion was reinitiated 6 hours following the procedure by interventional radiology. His blood counts and neurologic examination stabilized and eventually improved. He was discharged home on a novel anticoagulant. CONCLUSIONS: Management of a retroperitoneal hematoma can commence with recognition of the warning signs of bleeding and neurological impairment, and consulting the appropriate services in case the need for intervention arises. A conservative approach of volume resuscitation and blood transfusion can be used initially, with the need for pausing or reversing anticoagulation being assessed on an individual basis with expert consultation. If intervention becomes necessary, other interventional radiology-based modalities can be used to identify and stop the bleeding source, and interventional radiology-guided drainage can be performed to decrease the hematoma burden and relieve neurological symptoms.

Recurrent blistering distal dactylitis due to Staphylococcus aureus in an immunocompetent elderly woman.

An 86-year-old woman presented with marked blistering of her left index fingertip and ulceration of the left middle fingertip, with a 2-year history of recurrent blistering and ulceration of her fingers bilaterally. She denied any preceding finger trauma, although she reported frequent gardening. She denied systemic symptoms. Her medical history was significant for a 2-year history of atrial fibrillation on carvedilol, amiodarone and apixaban, and she was a lifetime non-smoker. On admission, she had elevated inflammatory markers but unremarkable autoantibodies. Radiograph of the hand revealed diffuse soft tissue fullness and subtle irregularities at the tuft of the index finger, but all other investigations were unremarkable. The lesion was incised and drained, revealing blood-tinged purulent fluid. Wound biopsy revealed spongiosis with neutrophils, consistent with a diagnosis of blistering distal dactylitis.

Status of portfolios in undergraduate medical education in the LCME accredited US medical school.

AIM: We sought to investigate the number of US medical schools utilizing portfolios, the format of portfolios, information technology (IT) innovations, purpose of portfolios and their ability to engage faculty and students. METHODS: A 21-question survey regarding portfolios was sent to the 141 LCME-accredited, US medical schools. The response rate was 50% (71/141); 47% of respondents (33/71) reported that their medical school used portfolios in some form. Of those, 7% reported the use of paper-based portfolios and 76% use electronic portfolios. Forty-five percent reported portfolio use for formative evaluation only; 48% for both formative and summative evaluation, and 3% for summative evaluation alone. RESULTS: Seventy-two percent developed a longitudinal, competency-based portfolio. The most common feature of portfolios was reflective writing (79%). Seventy-three percent allow access to the portfolio off-campus, 58% allow usage of tablets and mobile devices, and 9% involve social media within the portfolio. Eighty percent and 69% agreed that the portfolio engaged students and faculty, respectively. Ninety-seven percent reported that the portfolios used at their institution have room for improvement. CONCLUSION: While there is significant variation in the purpose and structure of portfolios in the medical schools surveyed, most schools using portfolios reported a high level of engagement with students and faculty.

Online Faculty Development for Implementation and Use of Student Portfolios.

INTRODUCTION: Over the past decade, portfolios have gained popularity in medical education as tools to evaluate and provide feedback about learning and completion of professionally authentic tasks. Though faculty development has been noted to be key for successful portfolios, there are few available resources. As part of an interinstitutional collaborative project, we have developed online faculty development modules that provide pedagogical information about portfolios, practical advice, and resources from the available literature. METHODS: The materials associated with this publication include downloadable modules, which take approximately 45 minutes to complete and can be paused at any time, and sample questions to facilitate small-group discussion with faculty either in the planning stage of portfolios or as part of program evaluation of an institution's portfolios. RESULTS: A survey taken by faculty from four medical schools after completion of the modules showed that they were well received, with 41% of participants stating that they were very knowledgeable after undertaking the modules compared to 11% before undertaking the modules. Faculty reported increased interest in the topic and increased confidence in their ability to undertake planning for development of portfolios at their institution and considered using the modules as a mandatory curriculum for portfolio coaches at their institutions. DISCUSSION: We suggest that these modules be used for individual self-development, as part of faculty development sessions for portfolio coaches and mentors, or to provide faculty with background information about portfolios during the planning phase of portfolios at an institution.

Maghemite, silver, ceragenin conjugate particles for selective binding and contrast of bacteria.

New synthesis techniques are providing increasing control over many inorganic nanoparticle characteristics, facilitating the creation of new multifunctional theranostics. This report proposes the synthesis and testing of a combination nanoparticle comprised of a maghemite core for enhanced T2 MRI contrast diagnostics, a colloidal silver shell acting as an antimicrobial and therapeutic vehicle, and a ceragenin (CSA-124) surfactant providing microbial adhesion. A polyacrylic acid functionalized maghemite nanoparticle is synthesized by a high temperature organic phase reduction followed by thiol functionalization and gold cluster seeding. A silver shell is formed through AgNO3 reduction, and an oriented monolayer of the thiolated ceragenin, is bound through a self-assembly process. The process and products are characterized throughout synthesis through TEM, DLS, FT-IR, UV-Vis, ICP-OES, HPLC-ESI-TOF-MS, DC magnetization and susceptibility, X-ray diffraction, and in vitro MRI. Synthesized Diagnostic Antimicrobial Nanoparticles (DANs) were found to have a spherical morphology with a diameter of 32.47±1.83 nm, hydrodynamic diameter of 53.05±1.20 nm, maximum magnetic moment of 12 emu/g NP (54 emu/g Fe) with little variation due to temperature, and are predominantly paramagnetic. In vitro MRI studies show that DANs contrast well at concentrations as low as 9 ppm, and successfully adhere to Staphylococcus aureus. DAN MIC was determined to be approximately 12 ppm and 24 ppm against S. aureus and Escherichia coli respectively.

Novel fluorimetric assay of trace analysis of epinephrine in human serum.

A simple, rapid, and sensitive spectrofluorimetric technique for the microdetermination of epinephrine in human serum is described. The investigation shows that trace amounts of epinephrine, antidepressant of clinical importance, can be determined without the conventional derivatization or use of fluorophores by diazotization. The method is based on the optimization of experimental parameters, such as pH, temperature, careful selection of excitation and emission wavelengths and on the use of anionic surfactant, sodium dodecyl sulfate (SDS), to enhance sensitivity. The measurement was carried out at 360 nm with excitation at 286 nm. Under the optimum conditions, a linear relationship was obtained between the fluorescence intensity and epinephrine concentration in the range of 0.10 and 1.0 microg/mL; the correlation coefficient and detection limit are 0.9953 and 0.05 microg/mL, respectively. Recovery tests indicated an efficiency of 95.5-98.7% by using known amounts of epinephrine spiked with human serum.