Push notifications for critical labs results: a pilot study in the intensive care unit (ICU).

Objective: We developed a push notification allowing for an electronic acknowledgment of critical lab results to providers in the intensive care unit. Materials and Methods: This project was conducted over a 3-month period at a large academic safety net hospital. A push notification and acknowledgment system were created to comply with the existing critical results notification requirements. We monitored the number of acknowledged results, time to acknowledgment, and lab type. Results: Prior to the push notification, lab services paged the provider. This resulted in many critical lab results relayed to the clinician beyond the expected 10-minute window. With the push notification workflow, we found that, during the 3-month period, 82, or 5.8%, of the 1414 results were acknowledged. This represented 82 less pages/calls lab services had to make. Discussion: The push notification alert was easy to use and there was quicker results notification when acknowledged. There were limitations due to hand-offs for clinicians and some were not familiar with the mobile technology and the electronic acknowledgment. Conclusions: Although the acknowledgment rate was low, every electronic acknowledgment saved lab service technicians an average of 10 minutes compared to the existing workflow. As familiarity with the technology and workflow increases, this novel form of communication has the potential to have significant cost savings for lab services, in addition to efficiency gains for lab, clinicians, and more timely care. The integration of health information technology and push notification of critical labs should be the focus of investigation for further future research.

Diagnostic stewardship for human immunodeficiency virus (HIV) testing using computerized physician order entry.

Altering the appearance of a computerized physician order entry (CPOE) interface reduces misuse of an HIV diagnostic test by 87%, demonstrating that CPOE design is a key component of diagnostic stewardship. Collaboration between infectious disease providers, clinical laboratorians, and information technology (IT) professionals can result in improved quality and decreased costs.

Improving Communication in a Large Urban Academic Safety Net Hospital System: Implementation of Secure Messaging.

Given the complexities of communication within health systems, we investigated how the implementation of secure messaging in addition to traditional paging would impact hospital communication. This study was implemented at Grady Health System (GHS), a large safety net academic hospital system in metro Atlanta that includes inpatient and ambulatory settings. GHS uses Epic Electronic Health Record (EHR), and secure messaging was performed using Epic Haiku Platform. To assess states of communication, we implemented pre- and post-surveys. The secure messaging data tracked from 2018 to 2022 demonstrated a rise in usage from 9,378 chats per month when it went live in August 2018 to greater than 200,000 monthly messages during the pandemic when social distancing measures were enacted. Monthly usage peaked in March 2022 with 378,932 messages. Pre-and-post survey questions using a Likert scale (1-4) showed increased agreement in the ability to reach all team members through secure chat amongst healthcare workers. Within our unit staff, communication improved by being more rapid and reliable, as the Likert scale means increased from 2.18 pre-survey to 2.63 post survey. Pre-and-post survey analysis indicates improved satisfaction across GHS stakeholders with the implementation of secure chat in addition to the existing direct-paging system. Next steps could include exchanging digital media through secure messaging to facilitate faster diagnosis and treatment of certain medical conditions. Secure messaging integrated within the EHR (including mobile devices) enhances communication between healthcare team members in a HIPAA-compliant way reducing the number of pages and phone calls.

Idiopathic remitting seronegative symmetrical synovitis with pitting edema syndrome with underlying history of malignancy.

Key Clinical Message: By reporting this case, we hope to emphasize the importance of maintaining a high index of clinical suspicion for the early recognition of RS3PE in patients presenting with atypical symptoms of PMR and underlying history of malignancy. Abstract: Remitting seronegative symmetrical synovitis with pitting edema is a rare rheumatic syndrome of unknown etiology. It shares qualities with many other common rheumatological disorders such as rheumatoid arthritis and polymyalgia rheumatica, making diagnosis especially challenging. RS3PE has been speculated to be a paraneoplastic syndrome, and those cases associated with underlying malignancy have shown to respond poorly to conventional treatment. Therefore, it is advisable to routinely screen patients with malignancy and presenting with RS3PE for cancer recurrence, even if in remission.

A Case of Cardiac Sarcoidosis Masquerading As Heart Failure With Ventricular Arrhythmia.

Sarcoidosis is a rare cause of cardiomyopathy that can easily be confused for acute heart failure when pulmonary manifestations are absent. We present the case of a 41-year-old female presenting with dyspnea found to have ventricular arrhythmia on arrival at the emergency department. Cardiac magnetic resonance and computed tomography of the chest with contrast were performed, confirming the systemic sarcoidosis diagnosis with cardiac involvement.

Inpatient management of acute decompensated heart failure.

Acute decompensated heart failure (ADHF) is the leading cause of hospital admissions in patients older than 65 years. These hospitalisations are highly risky and are associated with poor outcomes, including rehospitalisation and death. The management of ADHF is drastically different from that of chronic heart failure as inpatient treatment consists primarily of haemodynamic stabilisation, symptom relief and prevention of short-term morbidity and mortality. In this review, we will discuss the strategies put forth in the most recent American College of Cardiology/American Heart Association and Heart Failure Society of America guidelines for ADHF as well as the evidence behind these recommendations.

Safety and efficacy of statin therapy.

The 2013 ACC/AHA guidelines on blood cholesterol management were a major shift in the delineation of the main patient groups that could benefit from statin therapy and emphasized the use of higher-intensity statin therapies. In 2016, an expert consensus panel from the ACC recommended the use of nonstatin therapies (ezetimibe and PCSK9 inhibitors) in addition to maximally tolerated statin therapy in individuals whose LDL-cholesterol and non-HDL-cholesterol levels remained above certain thresholds after statin treatment. Given the substantial benefits of statin therapies in both primary and secondary prevention of cardiovascular disease, their long-term safety has become a concern. The potential harmful effects of statin therapy on muscle and liver have been known for some time, but new concerns have emerged regarding the risk of new-onset diabetes mellitus, cognitive impairment and haemorrhagic stroke associated with the use of statins and the risks of achieving very low levels of LDL cholesterol. The increased media attention on the adverse events associated with statins has unfortunately led to statin therapy discontinuation, nonadherence to therapy or concerns about initiating statin therapy. In this Review, we explore the safety of statin therapy in light of the latest evidence and provide clinicians with reassurance about the safety of statins. Overwhelming evidence suggests that the benefits of statin therapy far outweigh any real or perceived risks.

Role of Non-Statins, LDL-C Thresholds, and Special Population Considerations: A Look at the Updated 2016 ACC Consensus Committee Recommendations.

PURPOSE OF REVIEW: The 2013 ACC/AHA Cholesterol guidelines was a major paradigm shift in the management and treatment of dyslipidemia. The new guidelines outlined "statin benefit groups," highlighted weighing the benefit versus risks of statin therapy ("net benefit"), and discussed the importance of shared decision making between patients and providers in primary prevention. While there was widespread agreement on the main groups benefiting from statin therapy, there was significant controversy regarding LDL-C goals and thresholds, the role of non-statin therapy, and the use of statins in specific populations. The goal of this review is to understand the rationale for the updated 2016 ACC Expert Consensus on Non-Statins and to contrast it with the 2015 NLA Recommendations on the Management of Dyslipidemia. RECENT FINDINGS: The findings of the ACC Expert Consensus Panel were largely influenced by the results of several new clinical trials using non-statin therapy in combination with moderate to high intensity statin therapy. The IMPROVE-IT trial demonstrated that ezetimibe on top of statin therapy lowered ASCVD risk in patients with acute coronary syndromes whose LDL was driven below the previous LDL-C target of <70 mg/dL. In addition, preliminary data assessing the safety of evolocumab and alirocumab on top of statin therapy suggested possible large reductions in ASCVD risk in post hoc analysis. Both the 2016 ACC Consensus Recommendations and the 2015 NLA Recommendations emphasize the importance of maximally tolerated statin therapy, the use of adjunctive non-statin LDL lowering therapy, and the use of LDL-C goals and thresholds to guide intensification of LDL lowering therapy. Although there are some important differences between the ACC Consensus and NLA recommendations in terms of treatment of special populations (i.e., CHF) and on the use of non-HDL-C goals and thresholds, both guidelines support a role for ezetimibe, bile acid sequestrants, and PCSK-9 inhibitors in patients on maximum tolerated statin therapy. The recent positive results of the FOURIER trial gives additional support to the non-statin recommendations of both the ACC and NLA.

An evidence-based review of recent advances in therapy for heart failure with reduced ejection fraction (HFrEF).

An estimated 5.1 million Americans have chronic heart failure and this is expected to increase 25% by 2030. Heart failure is a clinical syndrome that evolves from either functional or structural changes to the ventricles that lead to filling or ejection abnormalities. Thus far, pharmacotherapy has been show to be beneficial in patients only with reduced ejection fraction; however, new therapies have been developed in hopes of reducing the burden of heart failure. In this review, we will discuss current pharmacotherapies recommended in American College of Cardiology/American Heart Association guidelines, the evidence behind these recommendations as well as new and emerging therapies that have been developed.

New Cholesterol Guidelines for the Management of Atherosclerotic Cardiovascular Disease Risk: A Comparison of the 2013 American College of Cardiology/American Heart Association Cholesterol Guidelines with the 2014 National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia.

This review discusses the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults and compares it with the 2014 National Lipid Association (NLA) Recommendations for Patient-Centered Management of Dyslipidemia. The review discusses some of the distinctions between the guidelines, including how to determine a patient's atherosclerotic cardiovascular disease risk, the role of lipoprotein treatment targets, the importance of moderate- and high-intensity statin therapy, and the use of nonstatin therapy in light of the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) trial.

New cholesterol guidelines for the management of atherosclerotic cardiovascular disease risk: a comparison of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines with the 2014 National Lipid Association recommendations for patient-centered management of dyslipidemia.

This review discusses the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults and compares it with the 2014 National Lipid Association (NLA) Recommendations for Patient-Centered Management of Dyslipidemia. The review discusses some of the distinctions between the guidelines, including how to determine a patient's atherosclerotic cardiovascular disease risk, the role of lipoprotein treatment targets, the importance of moderate- and high-intensity statin therapy, and the use of nonstatin therapy in light of the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) trial.

Comparisons of the structural and chemical properties of melanosomes isolated from retinal pigment epithelium, iris and choroid of newborn and mature bovine eyes.

Melanosomes were isolated from the retinal pigment epithelium (RPE), iris and choroid of mature (age >2 years) and newborn (age <1 week) bovine eyes. Scanning electron microscopy was utilized to analyze the morphology of the melanosomes, which were found to vary among different tissues and different ages. While the total content of amino acids differs slightly (ranging from 9% to 15% by mass), the distributions of the amino acids are similar. The pheomelanin content is low in the choroid and the RPE (0.1-0.5%), and moderate in the iris (<2%); therefore, the major melanin component of bovine eye melanosomes is eumelanin, independent of the shape of the melanosomes. The yields of pyrrole-2,3,5-tricarboxylic acid from melanosomes decrease in the following order: choroid > iris > RPE, and exhibit decreasing yields with age. 13C solid-state nuclear magnetic resonance (NMR) spectroscopic analysis of iris and choroid melanosomes indicates the same trends. These observations suggest that the 5,6-dihydroxyindole-2-carboxylic acid contents decrease in the following order: choroid > iris > RPE, and decrease with age. Moreover, the 13C solid-state NMR spectra show (1) for the same age samples, the CH:Cq ratio for choroid is larger than that for iris melanosomes; and (2) an increase in the concentration of carbonyl groups with age within each type of melanosome.

Comparison of structural and chemical properties of black and red human hair melanosomes.

Melanosomes in black and red human hair are isolated and characterized by various chemical and physical techniques. Different yields of 4-amino-hydroxyphenolanaline by HI hydrolysis (a marker for pheomelanin) and pyrrole-2,3,5-tricarboxylic acid by KMnO(4)/H(+) oxidation (a marker for eumelanin) indicate that the melanosomes in black hair are eumelanosomes, whereas those in red hair are mainly pheomelanosomes. Atomic force microscopy reveals that eumelanosomes and pheomelanosomes have ellipsoidal and spherical shapes, respectively. Eumelanosomes maintain structural integrity upon extraction from the keratin matrix, whereas pheomelanosomes tend to fall apart. The black-hair eumelanosomes have an average of 14.6 +/- 0.5% amino acids content, which is attributed to the internal proteins entrapped in the melanosomes granules. The red-hair melanosomes contain more than 44% of amino acid content even after extensive proteolytic digestion. This high content of amino acids and the poorly reserved integrity of red-hair melanosomes suggest that some proteins are possibly covalently bonded with the melanin constituents in addition to those that are entrapped inside the melanin species. Soluene solubilization assay indicates the absorbance of melanin per gram of sample, adjusted for the amino acid content, is a factor of 2.9 greater for the black-hair melanosomes than the red-hair melanosomes. Metal analysis reveals significant amounts of diverse heavy metal ions bound to the two types of melanosomes. The amount of Cu(II) and Zn(II) are similar but Fe(III) content is four times higher in the red-hair melanosomes. (13)C solid-state nuclear magnetic resonance spectra and infrared spectra are presented and are shown to be powerful techniques for discerning differences in the amino acid contents, the 5,6-dihydroxyindole-2-carboxylic acid:5,6-dihydroxyindole ratio, and the degree of cross-linking in the pigment. Excellent agreement is observed between these spectral results and the chemical degradation data.

High capacity production of >65% spin polarized xenon-129 for NMR spectroscopy and imaging.

A rubidium spin exchange optical pumping system for high capacity production of >65% spin polarized 129Xe gas is described. This system is based on a fiber coupled multiple laser diode array capable of producing an unprecedented 210 W of circularly polarized light at the pumping cell with a laser line width of 1.6 nm. The 129Xe nuclear spin polarization is measured as a function of flow rate, pumping cell pressure, and laser power for varying pumping gas compositions. A maximum 129Xe nuclear polarization of 67% was achieved using a 0.6% Xe mixture at a Xe flow rate of 2.45 sccm. The ability to generate 12% polarized 129Xe at rates in excess of 1L-atm/h is also demonstrated. To achieve production of 129Xe gas at even higher polarization will rely on further optimization of the pumping cell and laser beam geometries in order to mitigate problems associated with temperature gradients that are encountered at high laser power and Rb density.