Digitally enabled hemovigilance allows real time response to transfusion reactions.

BACKGROUND: Transfusion carries a risk of transfusion reaction that is often underdiagnosed due to reliance on passive reporting. The study investigated the utility of digital methods to identify potential transfusion reactions, thus allowing real-time intervention for affected patients. METHOD: The hemovigilance unit monitored 3856 patients receiving 43,515 transfusions under the hemovigilance program. Retrospective comparison data included 298,498 transfusions. Transfusion medicine physicians designed and validated algorithms in the electronic health record that analyze discrete data, such as vital sign changes, to assign a risk score during each transfusion. Dedicated hemovigilance nurses remotely monitor all patients and perform real-time chart reviews prioritized by risk score. When a reaction is suspected, a hemovigilance trained licensed clinician responds to manage the patient and ensure data collection. Board-certified transfusion medicine physicians reviewed data and classified transfusion reactions under various categories according to the Centers for Disease Control hemovigilance definitions. RESULTS: Transfusion medicine physicians diagnosed 564 transfusion reactions (1.3% of transfusions)-a 524% increase compared to the previous passive reporting. The rapid response provider reached the bedside on average at 12.4 min demonstrating logistic feasibility. While febrile reactions were most diagnosed, recognition of transfusion-associated circulatory overload demonstrated the greatest relative increase. Auditing and education programs further enhanced transfusion reaction awareness. DISCUSSION: The model of digitally-enabled expert real-time review of clinical data that prompts rapid response improved recognition of transfusion reactions. This approach could be applied to other patient deterioration events such as early identification of sepsis.

Nanosecond-Timescale Dynamics and Conformational Heterogeneity in Human GCK Regulation and Disease.

Human glucokinase (GCK) is the prototypic example of an emerging class of proteins with allosteric-like behavior that originates from intrinsic polypeptide dynamics. High-resolution NMR investigations of GCK have elucidated millisecond-timescale dynamics underlying allostery. In contrast, faster motions have remained underexplored, hindering the development of a comprehensive model of cooperativity. Here, we map nanosecond-timescale dynamics and structural heterogeneity in GCK using a combination of unnatural amino acid incorporation, time-resolved fluorescence, and 19F nuclear magnetic resonance spectroscopy. We find that a probe inserted within the enzyme's intrinsically disordered loop samples multiple conformations in the unliganded state. Glucose binding and disease-associated mutations that suppress cooperativity alter the number and/or relative population of these states. Together, the nanosecond kinetics characterized here and the millisecond motions known to be essential for cooperativity provide a dynamical framework with which we address the origins of cooperativity and the mechanism of activated, hyperinsulinemia-associated, noncooperative variants.

Prevalence of transmitted HIV drug resistance among newly diagnosed antiretroviral therapy-naive pregnant women in Lilongwe and Blantyre, Malawi.

In 2006, a survey of transmitted human immunodeficiency virus (HIV) drug resistance (TDR) was conducted in Lilongwe, Malawi. The survey followed the World Health Organization method to classify TDR to nucleoside reverse transcriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs) among primigravid women aged <25 years. Results of the 2006 survey showed <5% TDR in all drug classes. In 2009, TDR surveys using the same method were repeated in Lilongwe and expanded to Blantyre. Findings show that in Lilongwe TDR to NRTIs and PIs was <5%, whereas TDR to NNRTIs was 5%-15%. In Blantyre, TDR was <5% to all drug classes. Observed moderate TDR in Lilongwe is cause for concern and signals the need for closer monitoring of Malawi's antiretroviral therapy program.

A retrospective survey of HIV drug resistance among patients 1 year after initiation of antiretroviral therapy at 4 clinics in Malawi.

In 2004, Malawi began scaling up its national antiretroviral therapy (ART) program. Because of limited treatment options, population-level surveillance of acquired human immunodeficiency virus drug resistance (HIVDR) is critical to ensuring long-term treatment success. The World Health Organization target for clinic-level HIVDR prevention at 12 months after ART initiation is ≥ 70%. In 2007, viral load and HIVDR genotyping was performed in a retrospective cohort of 596 patients at 4 ART clinics. Overall, HIVDR prevention (using viral load ≤ 400 copies/mL) was 72% (95% confidence interval [CI], 67%-77%; range by site, 60%-83%) and detected HIVDR was 3.4% (95% CI, 1.8%-5.8%; range by site, 2.5%-4.7%). Results demonstrate virological suppression and HIVDR consistent with previous reports from sub-Saharan Africa. High rates of attrition because of loss to follow-up were noted and merit attention.

Prevalence of HIV drug resistance before and 1 year after treatment initiation in 4 sites in the Malawi antiretroviral treatment program.

Since 2004, the Malawi antiretroviral treatment (ART) program has provided a public health-focused system based on World Health Organization clinical staging, standardized first-line ART regimens, limited laboratory monitoring, and no patient-level monitoring of human immunodeficiency virus drug resistance (HIVDR). The Malawi Ministry of Health conducts periodic evaluations of HIVDR development in prospective cohorts at sentinel clinics. We evaluated viral load suppression, HIVDR, and factors associated with HIVDR in 4 ART sites at 12-15 months after ART initiation. More than 70% of patients initiating ART had viral suppression at 12 months. HIVDR prevalence (6.1%) after 12 months of ART was low and largely associated with baseline HIVDR. Better follow-up, removal of barriers to on-time drug pickups, and adherence education for patients 16-24 years of age may further prevent HIVDR.

Cooperativity in monomeric enzymes with single ligand-binding sites.

Cooperativity is widespread in biology. It empowers a variety of regulatory mechanisms and impacts both the kinetic and thermodynamic properties of macromolecular systems. Traditionally, cooperativity is viewed as requiring the participation of multiple, spatially distinct binding sites that communicate via ligand-induced structural rearrangements; however, cooperativity requires neither multiple ligand binding events nor multimeric assemblies. An underappreciated manifestation of cooperativity has been observed in the non-Michaelis-Menten kinetic response of certain monomeric enzymes that possess only a single ligand-binding site. In this review, we present an overview of kinetic cooperativity in monomeric enzymes. We discuss the primary mechanisms postulated to give rise to monomeric cooperativity and highlight modern experimental methods that could offer new insights into the nature of this phenomenon. We conclude with an updated list of single subunit enzymes that are suspected of displaying cooperativity, and a discussion of the biological significance of this unique kinetic response.

Adequacy of early enteral nutrition in adult patients in the intensive care unit.

AIMS AND OBJECTIVES: To evaluate the adequacy of energy and protein intake of patients in a Korean intensive care unit in the first four days after initiation of enteral feeding and to investigate the factors that had impact on adequate intake. BACKGROUND: Underfeeding is a common problem for patients hospitalised in the intensive care unit and is associated with severe negative consequences, including increased morbidity and mortality. DESIGN: A prospective, cohort study was conducted in a medical intensive care unit of a university hospital in Korea. METHODS: A total of 34 adult patients who had a primary medical diagnosis and who had received bolus enteral nutrition for the first four days after initiation of enteral nutrition were enrolled in this study. The data on prescription and intake of energy and protein, feeding method and feeding interruption were recorded during the first four days after enteral feeding initiation. Underfeeding was defined as the intake <90% of required energy and protein. RESULTS: Most patients (62%) received insufficient energy, although some (29%) received adequate energy. More than half of patients (56%) had insufficient protein intake during the first four days after enteral feeding was initiated. Logistic regression analysis showed that the factors associated with underfeeding of energy were early initiation of enteral nutrition, under-prescription of energy and prolonged interruption of prescribed enteral nutrition. CONCLUSION: Underfeeding is frequent in Korean critically ill patients owing to early initiation, under-prescription and prolonged interruption of enteral feeding. RELEVANCE TO CLINICAL PRACTICE: Interventions need to be developed and tested that address early initiation, under-prescription and prolonged interruption of enteral nutrition. Findings from this study are important as they form the foundation for the development of evidence-based care that is badly needed to eliminate underfeeding in this large vulnerable Korean intensive care unit population.

Use of dolls as a therapeutic intervention: relationship to previous negative behaviors and pro re nata (prn) Haldol use among geropsychiatric inpatients.

This exploratory study was conducted to determine the effects of use of dolls as a therapeutic intervention with geriatric inpatients. The sample included 115 patients, 29 of whom had an order for prn Haldol. Among patients who had previous negative behaviors, there was a lower average number of prn Haldol doses with those who had dolls. Recommendations for practice and future research are included.

Global nursing leadership: a practical guide.

Nursing leaders of today must be prepared for a nursing practice environment inclusive of local, national, and global work and issues. The educational preparation of nursing leaders should incorporate a fundamental curriculum that offers a broad preparation and basic leadership skills along with guidelines and experiences to support global outreach and collaboration with many cultures and health care environments. This article provides a practical guide on entry into Global Nursing Leadership for nursing leaders from the nurse executive including all levels of nursing management.

Increased risk for non-melanoma skin cancer in patients with inflammatory bowel disease.

BACKGROUND & AIMS: Patients with inflammatory bowel disease (IBD) might be at increased risk for certain malignancies. We evaluated the risk of non-melanoma skin cancer (NMSC) in patients with IBD and determined how immunosuppressive and biologic medications affect this risk. METHODS: We performed retrospective cohort and nested case-control studies by using administrative data from PharMetrics Patient Centric Database. In the cohort study, 26,403 patients with Crohn's disease (CD) and 26,974 patients with ulcerative colitis (UC) were each matched to 3 non-IBD controls. NMSC risk was evaluated by incidence rate ratio (IRR). In the nested case-control study, 387 CD patients and 355 UC patients with NMSC were each matched to 4 IBD patients without NMSC by using incidence density sampling. Conditional logistic regression was used to determine the association between specific IBD medication use and NMSC. RESULTS: In the cohort study, the incidence of NMSC was higher among patients with IBD compared with controls (IRR, 1.64; 95% confidence interval [CI], 1.51-1.78). In the nested-case control study, recent thiopurine use (< or =90 days) was associated with NMSC (adjusted odds ratio [OR], 3.56; 95% CI, 2.81-4.50), as was recent biologic use among patients with CD (adjusted OR, 2.07; 95% CI, 1.28-3.33). Persistent thiopurine use (>365 days) was associated with NMSC (adjusted OR, 4.27; 95% CI, 3.08-5.92), as was persistent biologic use among patients with CD (adjusted OR, 2.18; 95% CI, 1.07-4.46). CONCLUSIONS: Patients with IBD, especially those who receive thiopurines, are at risk for NMSC. Appropriate counseling and monitoring of such patients with IBD are recommended.

Isotretinoin use and the risk of inflammatory bowel disease: a case-control study.

OBJECTIVES: Isotretinoin is commonly prescribed for the treatment of severe acne. Although cases of inflammatory bowel disease (IBD) have been reported in isotretinoin users, a causal association remains unproven. METHODS: We performed a case-control study using a large insurance claims database. Incident cases of IBD were identified and matched to three controls on the basis of age, gender, geographical region, health plan, and length of enrollment. Isotretinoin exposure was assessed in a 12-month period before case ascertainment. Conditional logistic regression was used to adjust for matching variables. RESULTS: The study population comprised 8,189 cases (3,664 Crohn's disease (CD), 4,428 ulcerative colitis (UC), and 97 IBD unspecified) and 21,832 controls. A total of 60 subjects (24 cases and 36 controls) were exposed to isotretinoin. UC was strongly associated with previous isotretinoin exposure (odds ratio (OR) 4.36, 95% confidence interval (CI): 1.97, 9.66). However, there was no apparent association between isotretinoin and CD (OR 0.68, 95% CI: 0.28, 1.68). Increasing dose of isotretinoin was associated with elevated risk of UC (OR per 20 mg increase in dose: 1.50, 95% CI: 1.08, 2.09). Compared with non-users, the risk of UC was highest in those exposed to isotretinoin for more than 2 months (OR 5.63, 95% CI: 2.10, 15.03). CONCLUSIONS: UC but not CD is associated with previous isotretinoin exposure. Higher dose of isotretinoin seems to augment this risk. Although the absolute risk of developing UC after taking isotretinoin is likely quite small, clinicians prescribing isotretinoin as well as prospective patients should be aware of this possible association.

A nursing labor management partnership model.

Clinical nurses and nursing management strive for a collaborative relationship that supports nursing practice. When collaboration exists between labor and management, the joint focus moves toward provision of quality patient care and a positive work environment. The author describes a Nursing Labor Management Partnership implemented in a major teaching hospital with Magnet(R) designation. Examples of each dimension of the partnership are included.

The effect of a nursing labor management partnership on nurse turnover and satisfaction.

OBJECTIVE: The effects of a nursing labor management partnership (NLMP) on nurse turnover and nurse satisfaction were examined. BACKGROUND: Job satisfaction and retention are among the factors related to the nursing shortage. The NLMP was a specific intervention where nursing leaders, both nonbargaining and bargaining, worked collaboratively to improve patient care and outcomes. METHODS: The study was conducted in a large, Magnet-designated urban academic medical center in the Northeastern United States. The hospital has more than 1,000 inpatient beds and more than 2,200 registered nurses, 2,107 of whom are members of a nursing union. Nurse turnover and satisfaction were studied before (2005) and after (2008) the implementation of the NLMP model. RESULTS: There was a significant decrease in nurse turnover and a significant increase in nurse satisfaction (from moderate to high) post-NLMP. CONCLUSIONS: This study establishes a basis for further nursing research on the implementation of an NLMP in union environments.

Suboptimal rates of cervical testing among women with inflammatory bowel disease.

BACKGROUND & AIMS: Women with IBD have a high incidence of abnormal cervical cytology. However, little is known about how frequently women with IBD are tested for cervical abnormalities. We aimed to determine cervical testing rates among women with IBD, specifically those on immunosuppressant medications, and to identify risk factors associated with low incidence of screening. METHODS: With the PharMetrics Patient-Centric Database from 1996-2005, we identified cases of IBD and matched controls via a validated algorithm. With logistic regression, we compared utilization of cervical testing with IBD case status, patients' age, use of immunosuppressive medications, Medicaid insurance status, and use of primary care services. RESULTS: Only 70.4% of women with IBD (n = 9356) and 65.2% of matched controls (n = 25,849) received cervical testing (at least once every 3 years). Women with IBD who used primary care services had increased odds of cervical testing (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.19-1.59). Factors associated with reduced testing included Medicaid insurance (OR, 0.28; 95% CI, 0.19-0.41), immunosuppressant medication use (OR, 0.81; 95% CI, 0.74-0.88), and increased age (P for trend < .01). Among women on immunosuppressive medications (n = 7415), 50.1% were tested during a 15-month period. Women on immunosuppressive medications who used primary care services have improved odds of cervical testing (OR, 1.28; 95% CI, 1.14-1.45), whereas those with Medicaid insurance had reduced odds (OR, 0.54; 95% CI, 0.39-0.74). CONCLUSIONS: Women with IBD are tested for cervical abnormalities at suboptimal rates. Quality improvement initiatives are needed to improve disease prevention services for women with IBD.

Direct health care costs of Crohn's disease and ulcerative colitis in US children and adults.

BACKGROUND & AIMS: Data regarding the health care costs of inflammatory bowel disease (IBD) in the United States are limited. The objectives of this study were to estimate the direct costs of Crohn's disease (CD) and ulcerative colitis (UC) in the United States, describe the distribution of costs among inpatient, outpatient, and pharmaceutical services, and identify sociodemographic factors influencing these costs. METHODS: We extracted medical and pharmacy claims from an administrative database containing insurance claims from 87 health plans in 33 states, occurring between 2003 and 2004. We identified cases of CD and UC using an administrative definition. For each case, we selected up to 3 non-IBD controls. Claims were classified as inpatient, outpatient, or pharmaceutical according to Current Procedural Terminology codes or National Drug Codes. Costs were based on the paid amount of each claim. IBD-attributable costs were estimated by subtracting costs for non-IBD patients from those for patients with IBD. Logistic regression was used to identify the sociodemographic factors affecting these costs. RESULTS: We identified 9056 patients with CD and 10,364 patients with UC. Mean annual costs for CD and UC were $8265 and $5066, respectively. For CD, 31% of costs were attributable to hospitalization, 33% to outpatient care, and 35% to pharmaceutical claims. The corresponding distribution for UC was 38%, 35%, and 27%, respectively. Costs were significantly higher for children younger than 20 years compared with adults, but this did not vary substantially by sex or region. CONCLUSIONS: This study demonstrates a substantial economic burden of IBD and can be used to inform health policy.

Diagnostic ionizing radiation exposure in a population-based sample of children with inflammatory bowel diseases.

OBJECTIVES: The degree of diagnostic radiation exposure in children with inflammatory bowel diseases (IBD) is largely unknown. In this study, we describe this exposure in a population-based sample of children with IBD and determine the characteristics associated with moderate radiation exposure. METHODS: We ascertained radiological study use, demographic characteristics, IBD medication use, and the requirement for hospitalization, emergency department (ED) encounter, or inpatient gastrointestinal surgery among children with IBD within a large insurance claims database. Characteristics associated with moderate radiation exposure (at least one computed tomography (CT) or three fluoroscopies over 2 years) were determined using logistic regression models. RESULTS: We identified 965 children with Crohn's disease (CD) and 628 with ulcerative colitis (UC). Over 24 months, 34% of CD subjects and 23% of UC subjects were exposed to moderate diagnostic radiation (odds ratio (OR) 1.71, 95% confidence interval (CI), 1.36 - 2.14). CT accounted for 28% and 25% of all studies in CD and UC subjects, respectively. For CD subjects, moderate radiation exposure was associated with hospitalization (OR 4.89, 95% CI 3.37 - 7.09), surgery (OR 2.93, 95% CI 1.59 - 5.39), ED encounter (OR 2.65, 95% CI 1.93 - 3.64), oral steroids (OR 2.25, 95% CI 1.50 - 3.38), and budesonide (OR 1.80, 95% CI 1.10 - 3.06); an inverse association was seen with immunomodulator use (OR 0.67, 95% CI 0.47 - 0.97). Except for oral steroids and immunomodulators, similar relationships were seen in UC. CONCLUSIONS: A substantial proportion of children with IBD are exposed to moderate amounts of radiation as a result of diagnostic testing. This high utilization may impart long-term risk, given the chronic nature of the disease.

Improving patient satisfaction with pain management using Six Sigma tools.

BACKGROUND: Patient satisfaction as a direct and public measure of quality of care is changing the way hospitals address quality improvement. The feasibility of using the Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) methodology to improve patient satisfaction as it relates to pain management was evaluated. METHODS: This project used the DMAIC methodology to improve patients' overall satisfaction with pain management on two inpatient units in an urban academic medical center. Pre- and postintervention patient surveys were conducted. The DMAIC methodology provided a data-driven structure to determine the optimal improvement strategies, as well as a long-term plan for maintaining any improvements. In addition, the Change Acceleration Process (CAP) was used throughout the project's various DMAIC stages to further the work of the team by creating a shared need to meet the objectives of the project. RESULTS: Overall satisfaction with pain management "excellent" ratings increased from 37% to 54%. Both units surpassed the goal of at least 50% of responses in the "excellent" category. Several key drivers of satisfaction with pain management were uncovered in the Analyze phase of the project, and each saw rating increases from the pre-intervention to postintervention surveys. Ongoing monitoring by the hospital inpatient satisfaction survey showed that the pain satisfaction score improved in subsequent quarters as compared with the pre-intervention period. DISCUSSION: The Six Sigma DMAIC methodology can be used successfully to improve patient satisfaction. The project led to measurable improvements in patient satisfaction with pain management, which have endured past the duration of the Six Sigma project. The Control phase of DMAIC allows the improvements to be incorporated into daily operations.

Postoperative Urinary Tract Infection Quality Assessment and Improvement: The S.T.O.P. UTI Program and Its Impact on Hospitalwide CAUTI Rates.

BACKGROUND: Postoperative urinary tract infection (UTI) is a frequent complication that diminishes patient experience and incurs substantial costs. The purpose of this project was to develop a urinary tract care assessment tool that would lead to actionable quality improvement initiatives. METHODS: Multidisciplinary teams at a single institution developed the S.T.O.P. UTI algorithm to assess elements related to urinary catheter care: Sterile catheter placement, Timely catheter removal, Optimal collection bag position, and Proper urine sampling for urinalysis and culture. Based on this evaluation, a targeted intervention was applied to address deficient areas in surgical patients. UTI rates were monitored. RESULTS: The assessment revealed that best practice for sterile placement was being performed but that time to removal, optimal positioning, and proper sampling could be improved. Providers were educated on best practice for catheter removal, nurses placed a reminder note on the chart, personnel were taught about optimal catheter positioning, and nursing assistants were educated on best practices for collection of urine. From 2012 to 2015, non-risk-adjusted UTI rates in surgical patients decreased from 2.90% to 0.46% (p = 0.0003), and the American College of Surgeons National Surgical Quality Improvement Program risk-adjusted comparison improved from the 8th to the 4th decile. Simultaneously, hospitalwide catheter-associated UTI rates also decreased, from 2.24/1,000 catheter-days in 2014 to 0.70/1,000 catheter-days in 2016 (p < 0.001). CONCLUSION: The S.T.O.P. UTI algorithm is a tool that hospitals can use to systematically assess UTI processes. The program can identify areas for improvement specific to an institution, directing the allocation of quality improvement resources to decrease both surgical and medical UTIs.

Comparison of the ability of feline calicivirus (FCV) vaccines to neutralise a panel of current UK FCV isolates.

Feline calicivirus (FCV) comprises a large number of strains which are related antigenically to varying degrees. The antigenic variability creates problems for choosing antigens to include in vaccines. Historically, these have been selected for use based on their cross-reactivity with a high proportion of field strains. However, it is important to determine the current level of cross-reactivity of vaccines and whether or not this may be decreasing owing to widespread vaccine use. In this in vitro study, we have compared the ability of antisera to two vaccine viruses (FCV strain F9 and FCV strain 255) to neutralise a panel of 40 recent UK field isolates. These 40 isolates were obtained by randomised, cross-sectional sampling of veterinary practices in different geographical regions of the UK so as to ensure they were representative of viruses circulating in the veterinary-visiting population of cats in the UK. Virus neutralisation assays showed that both vaccine strains are still broadly cross-reactive, with F9 antiserum neutralising 87.5% and 255 antiserum 75% of isolates tested with antiserum dilutions of 1 in 2 or greater. However, when antibody units were used, in order to take account of differences in homologous titres between antisera, fewer isolates were neutralised, with F9 antiserum showing a slightly higher proportion of isolates neutralised than 255. Multivariable analysis of the sample population of 1206 cats from which the 40 isolates were derived found that vaccinated cats were at a decreased risk of being positive for FCV, whereas cats from households with more than one cat, and cats with mouth ulcers were at increased risk. In addition as cats became older their risk of shedding FCV decreased.

Risk for low weight in community-dwelling, older adults.

PURPOSE: The purpose of this study was to describe nutritional risk and low weight in community-dwelling elderly. METHOD: This cross-sectional exploratory study used in-depth interviews conducted on older adults with a body mass index <24 kg/m. Depression, mental state, nutrition, and demographic data were measured. RESULTS: These elders (n = 130) were mostly female (55%, n = 71), married, white (84%, n = 109), and had a greater than a high school education. In a multivariate logistic regression analysis, 3 variables were statistically significantly associated with being severely underweight: those who self-reported having an illness or condition that changed the kind and/or amount of food eaten, unintentional weight loss of 10 lb in the last 6 months, and needing assistance with traveling outside the home. CONCLUSION: Awareness of the high nutritional risk should prompt consideration of early, appropriate assessment and therapy to prevent malnutrition and a declining quality of life.