Value of prior imaging review before ordering renal sonography in the evaluation of abnormal renal function.

BACKGROUND: To determine the prognostic relevance of prior imaging studies in the evaluation of patients referred for renal ultrasound (US) examination to investigate abnormal renal function tests. METHODS: We conducted a retrospective study of 208 consecutive renal US examinations performed for abnormal renal function tests. RESULTS: 68% (142/208) of patients reviewed for the study had prior abdominal imaging with 15% (21/142) receiving that imaging within 1 month prior to the renal US study and 56% (80/142) within the prior year. Of all patients with prior imaging studies, only 6/142 (4%) demonstrated any significant interval change, with development of hydronephrosis, which was also clinically evident as a substantial rise in serum creatinine level. CONCLUSIONS: Review of prior imaging studies, in addition to other pertinent clinical data, should result in a significant reduction in the number of unnecessary renal US examinations performed in patients with abnormal renal function. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:537-541, 2017.

Improving Infusion Pump Safety Through Usability Testing.

With the recognition that the introduction of new technology causes changes in workflow and may introduce new errors to the system, usability testing was performed to provide data on nursing practice and interaction with infusion pump technology. Usability testing provides the opportunity to detect and analyze potentially dangerous problems with the design of infusion pumps that could cause or allow avoidable errors. This work will reduce preventable harm through the optimization of health care delivery.

An Interdepartmental Care Model to Expedite Admission from the Emergency Department to the Medical ICU.

BACKGROUND: Early evidence suggests that multidisciplinary programs designed to expedite transfer from the emergency department (ED) may decrease boarding times. However, few models exist that provide effective ways to improve the ED- to-ICU transition process. In 2012 Christiana Care Health System (Newark, Delaware) created and implemented an interdepartmental program designed to expedite the transition of care from the ED to the medical ICU (MICU). METHODS: This quasi-experimental study compared ED length of stay (LOS), MICU LOS, and overall hospital LOS before and after the MICU Alert Team (MAT) intervention program. The MAT consisted of a MICU nurse and physician assistant, with oversight by a MICU attending physician. The ED triggered the MAT after patients were stabilized and determined to require MICU admission. Following bedside face-to-face hand off, the MAT providers then assumed responsibly of a patient's care. If no MICU bed was available, the MAT cared for patients in the ED until they were transferred to the MICU. RESULTS: ED LOS was reduced by 30% (2.6 hours) from baseline (p < .001). There were no significant differences in MICU LOS (p = .26), overall hospital LOS (p = .43), or mortality (p = .59). ED LOS was shortened (p < .001) at each increasing level of MICU bed availability (31% when 0 MICU beds available; 26% when 1 or more MICU beds available). Time series analysis identified a 1.5-hour drop in ED LOS (p = .02) for patients transferred from the MICU immediately following intervention implementation and was sustained over time. CONCLUSION: Early outcomes demonstrate that the MAT intervention can reduce ED LOS for critically ill patients. Additional studies should determine optimal approaches to improve clinical outcomes.

Learning Collaboratives in Medical Education: Exploring the Impact of Collaboratives' Structure and Resources and Teams' Experience.

The Alliance of Independent Academic Medical Centers (AIAMC) organized and coordinated a multicenter learning collaborative, National Initiative V (NI V), focused on community health and health inequity. A pre-post descriptive study was designed to examine the outcomes of the AIAMC NI V. Data were collected from pre- and post-assessment surveys as well as a project milestone self-assessment survey. Twenty-nine institutions participated. By the conclusion of the NI, the majority of institutions had completed at least 1 of the milestones in each of the pre-work/background (65.52%), measurement (62.07%), methods (62.07%), and implement/sustain (20.69%) domains. Institutions reported a significant association between their readiness assessments prior to the start of the NI compared with their status of activities on completion. Milestone achievement is significantly associated with 3 of the assessment items. Learning collaboratives with thoughtfully integrated structure and support can be impactful on topic readiness for the participating organizations.

A phylogenetic study of Laeliinae (Orchidaceae) based on combined nuclear and plastid DNA sequences.

BACKGROUND AND AIMS: Laeliinae are a neotropical orchid subtribe with approx. 1500 species in 50 genera. In this study, an attempt is made to assess generic alliances based on molecular phylogenetic analysis of DNA sequence data. METHODS: Six DNA datasets were gathered: plastid trnL intron, trnL-F spacer, matK gene and trnK introns upstream and dowstream from matK and nuclear ITS rDNA. Data were analysed with maximum parsimony (MP) and Bayesian analysis with mixed models (BA). KEY RESULTS: Although relationships between Laeliinae and outgroups are well supported, within the subtribe sequence variation is low considering the broad taxonomic range covered. Localized incongruence between the ITS and plastid trees was found. A combined tree followed the ITS trees more closely, but the levels of support obtained with MP were low. The Bayesian analysis recovered more well-supported nodes. The trees from combined MP and BA allowed eight generic alliances to be recognized within Laeliinae, all of which show trends in morphological characters but lack unambiguous synapomorphies. CONCLUSIONS: By using combined plastid and nuclear DNA data in conjunction with mixed-models Bayesian inference, it is possible to delimit smaller groups within Laeliinae and discuss general patterns of pollination and hybridization compatibility. Furthermore, these small groups can now be used for further detailed studies to explain morphological evolution and diversification patterns within the subtribe.

Statewide Antibiotic Stewardship: : An eBrightHealth Choosing Wisely Initiative.

OBJECTIVE: To implement a collaborative statewide antibiotic stewardship initiative in both the ambulatory and inpatient settings. METHODS: Five participating Delaware health systems each convened internal team(s) to translate the vision set forth by the eBrightHealth LLC Choosing Wisely Work Group into clinical action through process improvement efforts at their institutions. The teams focused on implementing antibiotic time-outs, and on improving antibiotic prescribing for upper respiratory infections in ambulatory settings. The learning network utilized an "all teach, all learn" methodology via monthly conference calls and quarterly face-to-face meetings. RESULTS: All inpatient teams implemented antibiotic time-outs for at least 1 unit. Other interventions included commitment posters; submitting antibiotic utilization data nationally; provider/patient surveys; local stewardship champions; and provider prescribing data feedback. Barriers to implementation included competing priorities, lack of reliable utilization data, and suboptimal provider engagement. Overall antibiotic utilization decreased by 9%, compared to the pre-intervention period. CONCLUSIONS: This initiative has demonstrated the value of multidisciplinary teams, from varying healthcare systems, coming together to work on a single project. While each team's interventions and specific goals differed slightly, all teams implemented new initiatives to promote appropriate use of antibiotics. POLICY IMPLICATIONS: Antibiotic stewardship is a national priority. Acute care hospitals are required to have antibiotic stewardship programs; similar programs are proposed for ambulatory settings.

Barriers to and facilitators of interprofessional-interdepartmental interventions: unearthing departmental culture.

This study evaluates how emergency department (ED) and medical intensive care unit (MICU) providers interact in the setting of a quality improvement project designed to enhance transport/care for patients from the ED to the MICU. Focus groups were conducted with nurses, residents, physician assistants, and physicians from the ED and MICU at baseline and 6 months regarding their thoughts on and perspectives of the intervention and working with colleagues from another department. Data were then analyzed utilizing a multistep coding scheme that identified key barriers to and facilitators of the interprofessional-interdepartmental intervention. Analysis also showed, however, that variances in departmental culture play a significant role in the willingness and ability of providers to practice interdepartmental team-based care. It is argued that anticipating and acknowledging these differences and designing systems to address them prior to launch will be essential to the development and implementation of effective interdepartmental quality improvement interventions.

Sulfadiazine-induced nephrolithiasis detected by spiral CT scan.

Nephrolithiasis is a known complication of the use of sulfadiazine in the treatment of cerebral toxoplasmosis. Radiographic diagnosis of this complication has historically been challenging. Between March 1999 and June 2002, 11 patients were treated for cerebral toxoplasmosis with sulfadiazine-containing therapy. Four of these patients (36.4%) developed nephrolithiasis during this period. Case patients had received sulfadiazine for a median of 35.5 days prior to nephrolithiasis. All cases were diagnosed by spiral CT scans. Although studies are needed to evaluate the sensitivity and specificity of this modality, spiral CT may aid in the diagnosis of sulfadiazine-induced nephrolithiasis.

Necrotizing and crescentic lupus nephritis with antineutrophil cytoplasmic antibody seropositivity.

BACKGROUND AND OBJECTIVES: Lupus nephritis is a classic immune complex glomerulonephritis. In contrast, antineutrophil cytoplasmic antibodies are associated with necrotizing and crescentic glomerulonephritis, in the absence of significant immune deposits. Antineutrophil cytoplasmic antibodies are detected by indirect immunofluorescence in 20% of patients with systemic lupus erythematosus. We report 10 cases of necrotizing and crescentic lupus nephritis with antineutrophil cytoplasmic antibody seropositivity. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Ten patients with systemic lupus erythematosus, antineutrophil cytoplasmic antibody positivity, and renal biopsy findings of lupus nephritis and antineutrophil cytoplasmic antibody-associated glomerulonephritis were identified. The clinical features, pathologic findings, and outcomes are described. RESULTS: The cohort consisted of eight women and two men with a mean age of 48.4 yr. Perinuclear antineutrophil cytoplasmic antibody was detected by indirect immunofluorescence in nine patients. Four of the nine patients and the single remaining patient were found to have myeloperoxidase-antineutrophil cytoplasmic antibodies by enzyme-linked immunosorbent assay. Clinical presentation included proteinuria, hematuria, and acute renal insufficiency, with mean creatinine of 7.1 mg/dl. All biopsies exhibited prominent necrosis and crescents with absent or rare subendothelial deposits and were interpreted as lupus nephritis and antineutrophil cytoplasmic antibody-associated glomerulonephritis. All patients received cyclophosphamide and prednisone. Three patients died of infectious complications. Among the remaining seven patients, five achieved a complete or near-complete remission, one had a remission with subsequent relapse, and one had no response to therapy. CONCLUSION: Antineutrophil cytoplasmic antibody-associated necrotizing and crescentic glomerulonephritis may occur superimposed on lupus nephritis. In patients with lupus nephritis and biopsy findings of prominent necrosis and crescent formation in the absence of significant endocapillary proliferation or subendothelial deposits, antineutrophil cytoplasmic antibody testing by enzyme-linked immunosorbent assay is recommended.