Identifying cellular RNA-binding proteins during infection uncovers a role for MKRN2 in influenza mRNA trafficking.

Utilisation of RNA-binding proteins (RBPs) is an important aspect of post-transcriptional regulation of viral RNA. Viruses such as influenza A viruses (IAV) interact with RBPs to regulate processes including splicing, nuclear export and trafficking, while also encoding RBPs within their genomes, such as NP and NS1. But with almost 1000 RBPs encoded within the human genome it is still unclear what role, if any, many of these proteins play during viral replication. Using the RNA interactome capture (RIC) technique, we isolated RBPs from IAV infected cells to unravel the RBPome of mRNAs from IAV infected human cells. This led to the identification of one particular RBP, MKRN2, that associates with and positively regulates IAV mRNA. Through further validation, we determined that MKRN2 is involved in the nuclear-cytoplasmic trafficking of IAV mRNA potentially through an association with the RNA export mediator GLE1. In the absence of MKRN2, IAV mRNAs accumulate in the nucleus of infected cells, which may lead to their degradation by the nuclear RNA exosome complex. MKRN2, therefore, appears to be required for the efficient nuclear export of IAV mRNAs in human cells.

Comparing ethanol lock therapy versus vancomycin lock in a salvation strategy for totally implantable vascular access device infections due to coagulase-negative staphylococci (the ETHALOCK study): a prospective double-blind randomized clinical trial.

OBJECTIVES: Little is known about efficacy and safety of ethanol lock therapy (ELT) to treat totally implantable venous access device (TIVAD) infections. The objective of this trial was to evaluate the effectiveness and safety profile of a local treatment with ELT without removal for TIVAD infection due to coagulase-negative staphylococci. METHODS: We performed a prospective, multicenter, double-blind, randomized clinical trial comparing the efficacy of 40% ELT versus vancomycin lock therapy (VLT) in TIVAD infections due to coagulase-negative staphylococci, complicated or not by bloodstream infection. RESULTS: Thirty-one patients were assigned to the ELT group and 30 to the VLT arm. Concomitant bacteremia was present in 41 patients (67.2%). Treatment success was 58.1 % (18 of 31) for the ELT arm and 46.7% (14 of 30) for the VLT arm (p = 0.37). The overall treatment success was 52.5% (32). The risk of treatment failure due to uncontrolled infections, superinfections, and mechanical complications did not differ significantly between participants receiving ELT (13 out of 31 [42%]) and those receiving VLT (16 out of 30 [53%]) with a hazard ratio of 0.70 (p = 0.343; 95% CI [0.34-1.46], Cox model). Catheter malfunctions were significantly more frequent in the ELT arm (11 patients versus 2 in the VLT group, p = 0.01). CONCLUSIONS: We found an overall high rate of treatment failure that did not differ between the ELT arm and the VLT arm. TIVAD removal must be prioritized to prevent complications (uncontrolled infections, superinfections, and catheter malfunctions) except in exceptional situations.

First case of Abiotophia defectiva infectious endocarditis treated with a combination of amoxicillin and daptomycin.

Abiotophia defectiva (A. defectiva) infectious endocarditis (IE) is a serious disease that usually requires lengthy treatment with a combination of amoxicillin and gentamicin. Since severe nephrotoxicity can be associated with prolonged administration of gentamicin, the alternative use of daptomycin in combination with amoxicillin can be considered. We present the case of a 51-year-old man that presented an A. defectiva endocarditis on an aortic bicuspidy. Diagnosis of cirrhosis was made simultaneously, and therefore gentamicin was counter-indicated. A combination of amoxicillin 12 g per day and daptomycin 700 mg (10 mg/kg) was administrated, with resolution of clinical, biological and echographic abnormalities, and no relapse after 1 year. In our experience, amoxicillin with daptomycin could be an alternative in case of A. defectiva IE with counter-indication to aminoglycosides.

Acute mesenteric ischemia in an African American patient with heterozygous factor V Leiden deficiency.

It is well documented that factor V Leiden mutation (FVL) is a common hypercoagulable risk factor in the Caucasian population. Patients with homozygous FVL mutation have an increased risk for venous thromboembolism. However, there have been few cases of heterozygous FVL mutation associated with arterial thrombosis described in the literature. Our case report presents an African American (AA) female with heterozygous FVL mutation who presented with acute arterial mesenteric ischemia.

A Model for Catalyzing Educational and Clinical Transformation in Primary Care: Outcomes From a Partnership Among Family Medicine, Internal Medicine, and Pediatrics.

PURPOSE: To report findings from a national effort initiated by three primary care certifying boards to catalyze change in primary care training. METHOD: In this mixed-method pilot study (2012-2014), 36 faculty in 12 primary care residencies (family medicine, internal medicine, pediatrics) from four institutions participated in a professional development program designed to prepare faculty to accelerate change in primary care residency training by uniting them in a common mission to create effective ambulatory clinical learning environments. Surveys administered at baseline and 12 months after initial training measured changes in faculty members' confidence and skills, continuity clinics, and residency training programs. Feasibility evaluation involved assessing participation. The authors compared quantitative data using Wilcoxon signed-rank and Bhapkar tests. Observational field notes underwent narrative analysis. RESULTS: Most participants attended two in-person training sessions (92% and 72%, respectively). Between baseline and 12 months, faculty members' confidence in leadership improved significantly for 15/19 (79%) variables assessed; their self-assessed skills improved significantly for 21/22 (95%) competencies. Two medical home domains ("Continuity of Care," "Support/Care Coordination") improved significantly (P < .05) between the two time periods. Analyses of qualitative data revealed that interdisciplinary learning communities formed during the program and served to catalyze transformational change. CONCLUSIONS: Results suggest that improvements in faculty perceptions of confidence and skills occurred and that the creation of interdisciplinary learning communities catalyzed transformation. Lengthening the intervention period, engaging other professions involved in training the primary care workforce, and a more discriminating evaluation design are needed to scale this model nationally.

Transforming primary care residency training: a collaborative faculty development initiative among family medicine, internal medicine, and pediatric residencies.

PROBLEM: The scope and scale of developments in health care redesign have not been sufficiently adopted in primary care residency programs. APPROACH: The interdisciplinary Primary Care Faculty Development Initiative was created to teach faculty how to accelerate revisions in primary care residency training. The program focused on skill development in teamwork, change management, leadership, population management, clinical microsystems, and competency assessment. The 2013 pilot program involved 36 family medicine, internal medicine, and pediatric faculty members from 12 residencies in four locations. OUTCOMES: The percentage of participants rating intention to implement what was learned as "very likely to" or "absolutely will" was 16/32 (50%) for leadership, 24/33 (72.7%) for change management, 23/33 (69.7%) for systems thinking, 25/32 (75.8%) for population management, 28/33 (84.9%) for teamwork, 29/33 (87.8%) for competency assessment, and 30/31 (96.7%) for patient centeredness.Content analysis revealed five key themes: leadership skills are key drivers of change, but program faculty face big challenges in changing culture and engaging stakeholders; access to data from electronic health records for population management is a universal challenge; readiness to change varies among the three disciplines and among residencies within each discipline; focusing on patients and their needs galvanizes collaborative efforts across disciplines and within residencies; and collaboration among disciplines to develop and use shared measures of residency programs and learner outcomes can guide and inspire program changes and urgently needed educational research. NEXT STEPS: Revise and reevaluate this rapidly evolving program toward widespread engagement with family medicine, internal medicine, and pediatric residencies.

Error rates in physician dictation: quality assurance and medical record production.

PURPOSE: The purpose of the paper is to determine the instance of errors made in physician dictation of medical records. DESIGN/METHODOLOGY/APPROACH: Purposive sampling method was employed to select medical transcriptionists (MTs) as "experts" to identify the frequency and types of medical errors in dictation files. Seventy-nine MTs examined 2,391 dictation files during one standard work day, and used a common template to record errors. FINDINGS: The results demonstrated that on the average, on the order of 315,000 errors in one million dictations were surfaced. This shows that medical errors occur in dictation, and quality assurance measures are needed in dealing with those errors. RESEARCH LIMITATIONS/IMPLICATIONS: There was no potential for inter-coder reliability and confirming the error codes assigned by individual MTs. This study only examined the presence of errors in the dictation-transcription model. Finally, the project was done with the cooperation of MTSOs and transcription industry organizations. PRACTICAL IMPLICATIONS: Anecdotal evidence points to the belief that records created directly by physicians alone will have fewer errors and thus be more accurate. This research demonstrates this is not necessarily the case when it comes to physician dictation. As a result, the place of quality assurance in the medical record production workflow needs to be carefully considered before implementing a "once-and-done" (i.e. physician-based) model of record creation. ORIGINALITY/VALUE: No other research has been published on the presence of errors or classification of errors in physician dictation. The paper questions the assumption that direct physician creation of medical records in the absence of secondary QA processes will result in higher quality documentation and fewer medical errors.

Understanding the work of medical transcriptionists in the production of medical records.

Efforts to improve healthcare by reducing medical errors often center on the accuracy of medical records. At the same time, the impact of new technologies such as speech recognition technology on the process of producing medical records has not been sufficiently examined. In this article we analyzed interview data from medical transcriptionists (MTs) describing how they do the work of transcription to produce accurate medical records from doctors' dictation. We found that medical transcriptionists rely on several types of skills that current speech recognition technology lacks. We conclude with a discussion of the implications of these findings for the design and implementation of SRT systems for the production of medical records and for how the work of MTs can help reduce medical errors.

Listening to what is said--transcribing what is heard: the impact of speech recognition technology (SRT) on the practice of medical transcription (MT).

Medical records have become central to nearly all aspects of healthcare. However, little research exists on their creation. Using data from an ongoing ethnographic study of healthcare documentation production, this paper examines the process of medical record creation through the use of speech recognition technology (SRT) and subsequent editing by medical transcriptionists (MTs). Informed by ethnomethodology (EM) and conversation analysis (CA), the results demonstrate the professional knowledge involved in the work of medical transcription, which includes a combination of skilled worksite practices and an orientation toward the social order properties of recorded dictation. Furthermore, we examine how the advantages and limitations of SRTs can impact the work of transcription. We conclude with strategic recommendations for using SRTs to support medical records production and recommend against total automation.

Viewpoint: envisioning the successful integration of EBM and humanism in the clinical encounter: fantasy or fallacy?

Some authors challenge the dominance of evidence-based medicine (EBM) in current medical practice because of its tendency to disregard the patient in the clinical process and thus distort the clinician's view of the patient as the primary focus. This tendency to "scientize" the clinician-patient encounter threatens to seriously reduce the role of humanistic elements in medicine. Although the pendulum shift toward the epistemology of EBM is worrisome, it is only one aspect of the problems facing modern medicine in the process of discovering-or rediscovering-the human dimension in medical care. The author uses his own and others' interpretation of the philosophy of an underappreciated thinker, Michael Polanyi, as a springboard to envision the research required for the development of models of medical education and clinical practice that appropriately acknowledge both EBM and humanism. Striking the right balance between these two elements will require much additional research, but those who simply demonize EBM as the major barrier to humanistic practice fail to appreciate the essential role for critical thinking in responding to the demands of patient safety and health care quality. All may agree that the current medical landscape needs immediate attention but this author argues that such work needs to use the available tools such as EBM and Polanyi's Theory of Tacit Knowing as well as products of future research efforts. Failure to do less will prevent us from reaching the ideal of a truly humanistic encounter firmly embedded in practices that maximize patient safety and health care quality.

Secondary pulmonary syphilis: report of a likely case and literature review.

We report the case of a homosexual, HIV-positive man with typical secondary syphilis and multiple excavated pulmonary subpleural nodules. Syphilis with direct pulmonary involvement was suggested by a positive result of PCR of a bronchoalveolar lavage fluid specimen, then confirmed by a positive therapeutic test result. Only 9 reports of pulmonary involvement in secondary syphilis have been reported to date in the English-language literature. Clinicians should be aware of this atypical localization of syphilis.