Identifying barriers and enablers for a robust independent second check of medication in adult intensive care.

BACKGROUND: Independent second-checking of medication is part of everyday practice across many parts of the NHS. A robust, independent second check is built into medication administration protocols to reduce the risk of drug errors affecting patients. AIM: This work aims to determine the barriers and facilitators regarding a robust independent second check of medication before administration to patients within adult critical care. METHOD: Nurses in adult critical care were invited to participate in focus groups. They were asked to discuss factors that they felt enabled or prevented a robust second check of medication. Thematic analysis was undertaken by three critical care pharmacists. FINDINGS: The major themes identified as barriers to an independent second check were: geography of the critical care unit; IT; routine; complex process; and personnel. CONCLUSION: There are complex barriers to undertaking a robust second check and addressing some of these could improve patient safety.

Adverse Patient Safety Events During the COVID-19 Epidemic.

METHODS: A retrospective descriptive analysis of patient safety events related to COVID-19 was performed on data that were submitted in the Joint Patient Safety Event Reporting System and Root Cause Analysis databases to the VHA National Center for Patient Safety from March 2020 to February 2021. Events were coded for type of event, location, and cause of event. RESULTS: Delays in care and staff/patients exposed to COVID-19 were the most common types of patient safety events, followed by COVID-19-positive patients eloping, laboratory processing errors, and one wrong procedure. The most frequently cited locations where events took place were emergency departments, medical units, community living centers, and intensive care units. Confusion over procedures, care not provided because of COVID-19, and failure to identify COVID-positive patient before they exposed others to COVID were the most common causes for patient safety events. DISCUSSION: Our results are similar to other studies of patient safety during the first year of the COVID-19 pandemic. Based on these results, we recommend the following: (1) focus on patient safety culture, leadership, and governance; (2) proactively develop competency checklists, cognitive aids, and other tools for healthcare staff who are working in new or unfamiliar clinical settings; (3) augment or enhance communication efforts with patient safety huddles or briefings at all levels within a healthcare organization to proactively uncover risk and mitigate fear by explaining changes in policies and procedures; and (4) maximize the use of quality and patient safety experts who are knowledgeable in system and human factor theories as well as change management to assist in redesigning clinical workflows and processes.

"Opening eyes to real interprofessional education": results of a national faculty development initiative focused on interprofessional education in oncology palliative care.

The purpose of this study was to evaluate participants' feedback related to their experience in the Interprofessional Education Exchange (iPEX) program, a training initiative for faculty development in interprofessional oncology palliative care education. Participants voluntarily submitted a written reflection using a guide. The research team used qualitative content template analysis techniques to determine codes and categories based on the reflections and selected representative quotations (meaning units) from the data. Fifty-three reflections (100%) submitted by those completing the training were included in the analysis. The most appreciated aspects of the training were the opportunity for exchange of ideas and programs and the time allowed during the workshop for each team to work on developing their unique plan for interprofessional education (IPE) in oncology palliative care at their home institution. The iPEX program proved to be feasible, well-accepted, and valued by participants who reported personal, professional, and team growth and expressed appreciation for program support, content, and the exchange of ideas in a face-to-face setting. The results demonstrate that a faculty development program built on recommendations in the literature contributed to successful efforts to plan and initiate IPE in oncology palliative care.

The Interprofessional Education Exchange: The Impact of a Faculty Development Program in Interprofessional Palliative Oncology Education on Trainee Competencies, Skills, and Satisfaction.

Background: The interprofessional education exchange (iPEX) provides education, training, and mentoring to select interprofessional faculty trainee teams for development and implementation of interprofessional education (IPE) in palliative oncology. Objective: To evaluate the impact of the iPEX project on trainees' self-efficacy in IPE skills and IPE competencies. Design: A pre-/post-test design was used to evaluate trainees' progress. Trainees rated project components and developed IPE curricula in palliative oncology. Setting/Subjects: Sixteen United States-based faculty teams consisting of four to five members representing three or more disciplines completed the one-year faculty development project consisting of webinars, online interactive modules, a face-to-face workshop, mentoring, and assistance. The exchange of ideas, means for overcoming obstacles, collaborative teaching techniques, and curriculum development guidelines were integrated into the program. Measurements: Standardized measures of self-efficacy in IPE skills (Interprofessional Facilitation Skills Checklist) and IPE competencies (Core Competencies for Interprofessional Practice Individual Competency Assessment Tool) were used. Trainees rated the effectiveness of the project components on a scale of 1-5 (1 = not at all effective, 5 = extremely effective) and reported their plan for IPE palliative care curricula at their home institution. Results: Pre and post-paired samples t-test scores (n = 78) on both standardized instruments for IPE skills and competencies were significantly different (p < 0.001). Ratings of project components ranged from 3.97 to 4.90. Each team successfully developed a unique plan for IPE in palliative oncology. Conclusions: Multimodal faculty development and mentoring are successful means for improving self-assessed IPE skills and competencies.

A protocol for representative sampling of solid tumors to improve the accuracy of sequencing results.

Owing to spatial segregation of tumor subclones, solid tumor sampling using formalin-fixed, paraffin-embedded blocks is often inadequate to represent the genomic heterogeneity of solid tumors. We present an approach, representative sampling, to dissect and homogenize leftover residual surgical tissue prior to sequencing. We also detail optional tumor cell enrichment and DNA preparation. This method, applicable only to surgically removed tumors with leftover tissue, facilitates robust sampling to avoid missing or over-representing actionable variants. For complete details on the use and execution of this protocol, please refer to Litchfield et al. (2020).

Performance comparison of anti-p504s (SP116) Rabbit Monoclonal Primary Antibody vs. Monoclonal Rabbit Anti-Human AMACR clone 13H4 when duplexed with VENTANA Basal Cell Cocktail (34ßE12+p63) as a diagnostic aid for prostatic adenocarcinoma using immunohistochemistry.

Alpha-methylacyl-coenzyme A-racemase (AMACR), also known as p504s, is overexpressed in prostatic adenocarcinoma and is frequently used in combination with basal cell markers to aid in diagnosing difficult prostate adenocarcinoma cases. In this retrospective method comparison study, we examined the sensitivity and specificity of the ready-to-use anti-p504s (SP116) Rabbit Monoclonal Primary Antibody compared to the monoclonal rabbit anti-human AMACR clone 13H4 in prostatic adenocarcinoma samples. De-identified prostatic adenocarcinoma tissue samples were stained with either the SP116 or 13H4 antibody clone in combination with the VENTANA Basal Cell Cocktail (34ßE12+p63) and scored as positive or negative for prostatic adenocarcinoma. The scoring pathologist was blinded to the known historical diagnosis of each sample. The scoring pathologist correctly diagnosed each sample regardless of which p504s clone was used. Both assays using either clone were 100% concordant in their sensitivity and specificity. This study demonstrates that the ready-to-use anti-p504s (SP116) Rabbit Monoclonal Primary Antibody is equivalent to clone 13H4 concentrate when used according to package insert instructions in combination with the VENTANA Basal Cell Cocktail (34ßE12+p63) to aid pathologists in the diagnosis of prostatic adenocarcinoma.

Structured hypertension education program for people with type 2 diabetes, the SHED study.

OBJECTIVES: There is enough evidence that patient education and lifestyle modification has shown benefits in diabetes care, however the evidence is less for improving care of hypertension. Our study is the first in the UK to assess the impact of a structured hypertension education program in subjects with type 2 diabetes. DESIGN: Prospective randomised controlled study. SETTING AND INTERVENTION: From a diabetes clinic in a district and general hospital in UK 132 participants were equally randomised into intervention group and control group. Intervention included a once weekly education session for 4 weeks together with home blood pressure monitoring and dose changes in antihypertensives. Base line data was recorded with follow up after 3 and 6 months. RESULTS: More participants achieved target BP in the intervention group versus control. This difference appeared early at the 3rd months (48.8% versus 20.4% respectively, p = 0.007) and remained at the 6th month (58.1% versus 20.4% respectively, p < 0.001). The change in number of pills was significantly lower in the intervention group. The mean increase in antihypertensive pills was 0.22 ± 0.48 (13 ± 30% increase) in the intervention group versus 0.62 ± 0.68 (41 ± 60% increase) in the routine group (p = 0.014), denoting less need to escalate treatment. CONCLUSION: We demonstrated that our structured education program has led to a significantly higher percentage of participants achieving the BP target, early after intervention, together with a significant reduction in the number of antihypertensive pills.

Cortisol level dysregulation and its prevalence-Is it nature's alarm clock?

This review examines the stress hormone cortisol which plays an important role in regulating and supporting different bodily functions. Disruption in cortisol production has an impact on health and this review looks at a wide range of papers where cortisol has been indicated as a factor in numerous chronic conditions-especially those which are classed as "noncommunicable diseases" (NCDs). Timely detection, screening, and treatment for NCDs are vital to address the growing problem of NCDs worldwide-this would have health and socioeconomic benefits. Interestingly, many of the papers highlight the pro-inflammatory consequences of cortisol dysregulation and its deleterious effects on the body. This is particularly relevant given the recent findings concerning COVID-19 where pro-inflammatory cytokines have been implicated in severe inflammation.

Management of Irritable Bowel Syndrome: Physician-Dietitian Collaboration.

Irritable bowel syndrome (IBS) affects 10%-15% of adults in the United States and 12% of the worldwide population. Gastroenterologists as well as primary care practitioners are likely to be the first resource for patients with gastrointestinal (GI) symptoms. IBS is difficult to diagnose, as it is a functional GI disorder, determined after ruling out a myriad of other diagnoses. The 2016 Rome IV criteria define IBS as "a functional bowel disorder in which recurrent abdominal pain is associated with defecation or a change in bowel habits. Disordered bowel habits are typically present (ie, constipation, diarrhea, or a mix of constipation and diarrhea), as are symptoms of abdominal bloating/distension occurring over at least 6 months and not less than 3 months." Treatment of IBS historically has been through medical management; however, nutrition management of IBS using the FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) elimination diet is now a recommended, first-line therapy. FODMAPs are short-chain, poorly absorbed carbohydrates that are associated with symptoms in people with IBS. This diet intervention can be quite challenging, and therefore, patients should meet with a qualified dietitian who can provide the complex diet information in a practicable form. Physician-dietitian collaboration is invaluable for IBS patients to achieve a successful outcome.

Representative Sequencing: Unbiased Sampling of Solid Tumor Tissue.

Although thousands of solid tumors have been sequenced to date, a fundamental under-sampling bias is inherent in current methodologies. This is caused by a tissue sample input of fixed dimensions (e.g., 6 mm biopsy), which becomes grossly under-powered as tumor volume scales. Here, we demonstrate representative sequencing (Rep-Seq) as a new method to achieve unbiased tumor tissue sampling. Rep-Seq uses fixed residual tumor material, which is homogenized and subjected to next-generation sequencing. Analysis of intratumor tumor mutation burden (TMB) variability shows a high level of misclassification using current single-biopsy methods, with 20% of lung and 52% of bladder tumors having at least one biopsy with high TMB but low clonal TMB overall. Misclassification rates by contrast are reduced to 2% (lung) and 4% (bladder) when a more representative sampling methodology is used. Rep-Seq offers an improved sampling protocol for tumor profiling, with significant potential for improved clinical utility and more accurate deconvolution of clonal structure.

Plasma HbA1c in the investigation of suspected heart failure in general practice: An audit of the 2018 NICE guidelines update.

INTRODUCTION: Diabetes mellitus is a known risk factor for heart failure (HF); nevertheless, many HF patients remain undiagnosed. The National Institute for Health and Care Excellence in England updated their HF guidelines in 2018, replacing the use of fasting plasma glucose with glycated hemoglobin (HbA1c), in suspected HF investigation. This audit aimed to assess this update's uptake at a general practice partnership in Colchester, England. MATERIALS AND METHODS: The audit cycle consisted of a two-round electronic record search, for approximately 29,000 patients registered at the partnership. From November 1, 2017 to November 1, 2018 for the first round and from November 1, 2018 to March 6, 2019 for the second round, patients who had their NT pro-brain natriuretic peptide levels measured for the initial investigation of suspected HF were included in the study. Interventions put in place after the first round included an oral presentation and an illustrated guide for the general practitioners (GPs). RESULTS: One hundred and ten patients, 19 in cycle 1 and 91 in cycle 2, were identified and included in the analysis. At the first round, only 31.6% of the patients had their HbA1c level measured, while 36.8% had no diabetic investigation done. At the second round, the percentage of patients who had their HbA1c level assessed increased to 59.3%. A decrease from 36.8% of patients without diabetic status assessment to 20% was observed. CONCLUSIONS: Lack of awareness among GPs regarding this guideline update was identified and simple interventions achieved an increase in the guideline's uptake. Regular and complete audit cycles can help GPs adhere to up-to-date guidelines. Primary care can help other organizations such as pathology laboratories keep up to date with guidelines, while primary care technology can be amended in-house to help adherence to new guidelines. We recommend the National UK Heart Failure Audit considers auditing the use of HbA1c testing in inpatients investigated for new HF.

Pregnancy-associated Inflammatory Myofibroblastic Tumors of the Uterus Are Clinically Distinct and Highly Enriched for TIMP3-ALK and THBS1-ALK Fusions.

As inflammatory myofibroblastic tumors (IMTs) have become more widely recognized in the female genital tract, an intriguing subset of uterine tumors associated with pregnancy has emerged. Whether uterine IMTs occurring in the setting of pregnancy are clinically or biologically distinct from other uterine IMTs is unknown. Furthermore, little is known about the perinatal factors that may influence the development of these tumors. Here, we report the largest case series of 8 pregnancy-associated IMTs. All pregnancy-associated IMTs in this series occurred in association with pregnancy complications, including abnormal implantation (n=1), gestational diabetes (n=2), preeclampsia and/or HELLP syndrome (n=2), antiphospholipid syndrome (n=1), premature rupture of membranes (n=1), and hepatitis B (n=1). Notably, all IMTs were expelled at the time of delivery or immediately postpartum and were either adherent to the placenta or presented as separate, detached tissue. Tumors ranged from 2.0 to 6.0 cm (median, 3.9 cm), were well-circumscribed and showed classic histologic features of IMTs, including myxoid stroma and a lymphoplasmacytic infiltrate. Seven of 8 cases were positive by ALK immunohistochemistry and confirmed to have an ALK gene rearrangement by fluorescent in situ hybridization and RNA sequencing. The ALK-rearranged IMTs were found to be particularly enriched for TIMP3-ALK (n=5) and THBS1-ALK (n=2) fusions. The single case that was negative for an ALK rearrangement exhibited the classic morphology of an IMT. None of the 4 cases with available clinical follow-up recurred. The clinicopathologic features of pregnancy-associated IMTs in this series in conjunction with those reported in the literature suggests that these may be transient tumors that develop during pregnancy and shed at parturition; they appear to have a relatively indolent clinical course and favorable outcome, although studies with a longer duration of follow-up are still required.

Enteral and Parenteral Order Writing Survey-A Collaborative Evaluation Between the Academy of Nutrition and Dietetics' Dietitians in Nutrition Support Dietetics Practice Group and the American Society for Parenteral and Enteral Nutrition (ASPEN) Dietetics Practice Section.

INTRODUCTION: In 2014 and 2017, the Centers for Medicare and Medicaid Services authorized nutrition-related ordering privileges for registered dietitian nutritionists (RDNs) in hospital and long-term care settings, respectively. Despite this practice advancement, information describing current parenteral nutrition (PN) and enteral nutrition (EN) ordering practices is lacking. Dietitians in Nutrition Support, a dietetic practice group of the Academy of Nutrition and Dietetics and the Dietetics Practice Section of the American Society of Parenteral and Enteral Nutrition (ASPEN) utilized a survey to describe PN and EN ordering practices among RDNs in the United States. METHODS: A cross-sectional study design was utilized to describe RDN PN and EN ordering privileges. Respondents were asked to describe PN and EN ordering privileges, primary practice setting, primary patient population served, nutrition specialty certification, highest degree earned, career length, and, if applicable, the nature of prior denials for ordering privileges or reasons for not applying for ordering privileges. RESULTS: Seven hundred two RDNs completed the survey (12% response rate), with 664 RDNs providing complete data. The majority of respondents (n=558) cared for adult/geriatric patients. Among this subset, 47% had no PN ordering privileges; 14% could order and sign PN; 28% could order PN with provider cosignature; and 10% could order partial PN with provider cosignature. Nineteen percent of RDNs had no EN ordering privileges; 37% could order and sign EN; and 44% could order EN with provider cosignature. RDNs with ordering privileges were more likely to have a nutrition specialty certification and work in an academic or community hospital setting. CONCLUSION: PN and EN ordering privileges are varied because of institution and state requirements. Future research describing the outcomes associated with RDN ordering privileges is needed. This article has been approved by the Academy's Research, International, and Scientific Affairs team and Council on Research and the ASPEN Board of Directors. This article has been co-published with permission in Nutrition in Clinical Practice. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article.

Enteral and Parenteral Order Writing Survey-A Collaborative Evaluation Between the Academy of Nutrition and Dietetics' Dietitians in Nutrition Support Dietetics Practice Group and the American Society for Parenteral and Enteral Nutrition (ASPEN) Dietetics Practice Section.

INTRODUCTION: In 2014 and 2017, the Centers for Medicare and Medicaid Services authorized nutrition-related ordering privileges for registered dietitian nutritionists (RDNs) in hospital and long-term care settings, respectively. Despite this practice advancement, information describing current parenteral nutrition (PN) and enteral nutrition (EN) ordering practices is lacking. Dietitians in Nutrition Support, a dietetic practice group of the Academy of Nutrition and Dietetics and the Dietetics Practice Section of the American Society of Parenteral and Enteral Nutrition (ASPEN) utilized a survey to describe PN and EN ordering practices among RDNs in the United States. METHODS: A cross-sectional study design was utilized to describe RDN PN and EN ordering privileges. Respondents were asked to describe PN and EN ordering privileges, primary practice setting, primary patient population served, nutrition specialty certification, highest degree earned, career length, and if applicable, the nature of prior denials for ordering privileges or reasons for not applying for ordering privileges. RESULTS: Seven hundred two RDNs completed the survey (12% response rate), with 664 RDNs providing complete data. The majority of respondents (n = 558) cared for adult/geriatric patients. Among this subset, 47% had no PN ordering privileges; 14% could order and sign PN; 28% could order PN with provider cosignature; 10% could order partial PN with provider cosignature. Nineteen percent of RDNs had no EN ordering privileges; 37% could order and sign EN; 44% could order EN with provider cosignature. RDNs with ordering privileges were more likely to have a nutrition specialty certification and work in an academic or community hospital setting. CONCLUSION: PN and EN ordering privileges are varied because of institution and state requirements. Future research describing the outcomes associated with RDN ordering privileges is needed. This paper has been approved by the Academy's Research, International, and Scientific Affairs team and Council on Research and the ASPEN Board of Directors. This article has been co-published with permission in the Journal of the Academy of Nutrition and Dietetics. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article.

Circulating Tumor DNA Dynamics Predict Benefit from Consolidation Immunotherapy in Locally Advanced Non-Small Cell Lung Cancer.

Circulating tumor DNA (ctDNA) molecular residual disease (MRD) following curative-intent treatment strongly predicts recurrence in multiple tumor types, but whether further treatment can improve outcomes in patients with MRD remains unclear. We applied CAPP-Seq ctDNA analysis to 218 samples from 65 patients receiving chemoradiation therapy (CRT) for locally advanced NSCLC, including 28 patients receiving consolidation immune checkpoint inhibition (CICI). Patients with undetectable ctDNA after CRT had excellent outcomes whether or not they received CICI. Among such patients, one died from CICI-related pneumonitis, highlighting the potential utility of only treating patients with MRD. In contrast, patients with MRD after CRT who received CICI had significantly better outcomes than patients who did not receive CICI. Furthermore, the ctDNA response pattern early during CICI identified patients responding to consolidation therapy. Our results suggest that CICI improves outcomes for NSCLC patients with MRD and that ctDNA analysis may facilitate personalization of consolidation therapy.

Targeted deep sequencing of cell-free DNA in serous body cavity fluids with malignant, suspicious, and benign cytology.

BACKGROUND: Liquid biopsy using cell-free DNA (cfDNA) presents new opportunities for solid tumor genotyping. While studies have demonstrated the utility of cfDNA from plasma, cfDNA from other body fluids remains underexplored. METHODS: We evaluated the molecular features and clinicopathologic correlates of cfDNA from serous body cavity fluids by performing hybrid capture-based next-generation sequencing (NGS) on cfDNA isolated from residual effusion supernatants. Twenty-one serous effusions from pleural (n = 15), peritoneal (n = 5), and pericardial (n = 1) cavity were analyzed. RESULTS: The supernatants provided a median cfDNA concentration of 10.3 ng/µL. Notably, all effusions were sequenced successfully to a median depth >1000×, revealing a broad range of genetic alterations including single nucleotide variants, small insertions and deletions, amplifications, and fusions. Specifically, pathogenic alterations were identified in all malignant fluids (13/13), all fluids suspicious for malignancy (2/2), and 1 benign fluid (1/6) from a patient with metastatic cancer. To validate our findings, we examined matching results from 11 patients who underwent additional testing using formalin-fixed, paraffin-embedded (FFPE) specimens. In 8 patients, the paired results between FFPE and supernatant testing were concordant, whereas in the remaining 3 patients, supernatant analysis identified additional variants likely associated with resistance to targeted therapies. Additional comparison between FFPE and supernatant testing showed no difference in DNA concentration (P = .5), depth of coverage (P = .6), or allele frequency of pathogenic mutations (P = .7). CONCLUSION: cfDNA isolated from serous body cavity fluids represents a promising source of genomic input for targeted NGS.

Barriers and enablers to the implementation of a complex quality improvement intervention for acute kidney injury: A qualitative evaluation of stakeholder perceptions of the Tackling AKI study.

BACKGROUND: Acute kidney injury in hospital patients is common and associated with reduced survival and higher healthcare costs. The Tackling Acute Kidney Injury (TAKI) quality improvement project aimed to reduce mortality rates in patients with acute kidney injury by implementing a multicomponent intervention comprising of an electronic alert, care bundle and education in five UK hospitals across a variety of wards. A parallel developmental evaluation using a case study approach was conducted to provide the implementation teams with insights into factors that might impact intervention implementation and fidelity. The qualitative element of the evaluation will be reported. METHODS: 29 semi-structured interviews with implementation teams across the five hospitals were carried out to identify perceived barriers and enablers to implementation. Interviews were taped and transcribed verbatim and Framework analysis was conducted. RESULTS: Interviews generated four 'barriers and enablers' to implementation themes: i) practical/contextual factors, ii) skills and make-up of the TAKI implementation team, iii) design, development and implementation approach, iv) staff knowledge, attitudes, behaviours and support. Enablers included availability of specialist teams (e.g. educational teams), multi-disciplinary implementation teams with strong leadership, team-based package completion and proactive staff. Barriers were frequently the converse of facilitators. CONCLUSIONS: Despite diversity of sites, a range of common local factors-contextual, intervention-based and individual-were identified as potential barriers and enablers to fidelity, including intervention structure/design and process of/approach to implementation. Future efforts should focus on early identification and management of barriers and tailored optimisation of known enablers such as leadership and multidisciplinary teams to encourage buy-in. Improved measures of real-time intervention and implementation fidelity would further assist local teams to target their support during such quality improvement initiatives.

An Organizational-Level Program of Intervention for AKI: A Pragmatic Stepped Wedge Cluster Randomized Trial.

BACKGROUND: Variable standards of care may contribute to poor outcomes associated with AKI. We evaluated whether a multifaceted intervention (AKI e-alerts, an AKI care bundle, and an education program) would improve delivery of care and patient outcomes at an organizational level. METHODS: A multicenter, pragmatic, stepped-wedge cluster randomized trial was performed in five UK hospitals, involving patients with AKI aged ≥18 years. The intervention was introduced sequentially across fixed three-month periods according to a randomly determined schedule until all hospitals were exposed. The primary outcome was 30-day mortality, with pre-specified secondary endpoints and a nested evaluation of care process delivery. The nature of the intervention precluded blinding, but data collection and analysis were independent of project delivery teams. RESULTS: We studied 24,059 AKI episodes, finding an overall 30-day mortality of 24.5%, with no difference between control and intervention periods. Hospital length of stay was reduced with the intervention (decreases of 0.7, 1.1, and 1.3 days at the 0.5, 0.6, and 0.7 quantiles, respectively). AKI incidence increased and was mirrored by an increase in the proportion of patients with a coded diagnosis of AKI. Our assessment of process measures in 1048 patients showed improvements in several metrics including AKI recognition, medication optimization, and fluid assessment. CONCLUSIONS: A complex, hospital-wide intervention to reduce harm associated with AKI did not reduce 30-day AKI mortality but did result in reductions in hospital length of stay, accompanied by improvements in in quality of care. An increase in AKI incidence likely reflected improved recognition.

Essential Fatty Acid Requirements and Intravenous Lipid Emulsions.

Linoleic acid (LA) and α-linolenic acid (ALA) must be supplied to the human body and are therefore considered essential fatty acids. This narrative review discusses the signs, symptoms, diagnosis, prevention, and treatment of essential fatty acid deficiency (EFAD). EFAD may occur in patients with conditions that severely limit the intake, digestion, absorption, and/or metabolism of fat. EFAD may be prevented in patients requiring parenteral nutrition by inclusion of an intravenous lipid emulsion (ILE) as a source of LA and ALA. Early ILEs consisted solely of soybean oil (SO), a good source of LA and ALA, but being rich in LA may promote the production of proinflammatory fatty acids. Subsequent ILE formulations replaced part of the SO with other fat sources to decrease the amount of proinflammatory fatty acids. Although rare, EFAD is diagnosed by an elevated triene:tetraene (T:T) ratio, which reflects increased metabolism of oleic acid to Mead acid in the absence of adequate LA and ALA. Assays for measuring fatty acids have improved over the years, and therefore it is necessary to take into account the particular assay used and its reference range when determining if the T:T ratio indicates EFAD. In patients with a high degree of suspicion for EFAD, obtaining a fatty acid profile may provide additional useful information for making a diagnosis of EFAD. In patients receiving an ILE, the T:T ratio and fatty acid profile should be interpreted in light of the fatty acid composition of the ILE to ensure accurate diagnosis of EFAD.