Journal Article Phage 8–10 identifies an RFLP on 11q23-qter [HGM9 no. D11S286] Get access J. Luty, J. Luty Search for other works by this author on: Oxford Academic PubMed Google Scholar J. Kellogg, J. Kellogg Search for other works by this author on: Oxford Academic PubMed Google Scholar C. Maslen, C. Maslen Search for other works by this author on: Oxford Academic PubMed Google Scholar C. Jones, C. Jones 1Eleanor Roosevelt Institute for Cancer ResearchDenver, CO, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar T. Glaser, T. Glaser 2Center for Cancer Research, Massachussetts Institute of TechnologyCambridge, MA, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar M. Litt M. Litt Search for other works by this author on: Oxford Academic PubMed Google Scholar Nucleic Acids Research, Volume 16, Issue 14, 25 July 1988, Page 7210, https://doi.org/10.1093/nar/16.14.7210 Published: 25 July 1988
ABSTRACT Paging and text messaging to request new orders remain common means of communication between clinicians and nurses in the hospital setting. However, sending and triaging multiple pages can lead to interruptions in other clinical duties. A medication order delegation protocol allowing for nurse-driven ordering of low-risk medications was developed with an objective of decreasing potentially avoidable pages. The aim of this study was to evaluate the impact of implementing this protocol on nurse and clinician perceptions of clerical burden and satisfaction. A survey assessing satisfaction with the process of obtaining medications in this protocol and the perception of clerical burden associated with ordering them before and after delegation protocol implementation was completed by over 160 clinicians and nurses. Survey respondents reported increased satisfaction and decreased clerical burden associated with the implementation of the delegation protocol. These results suggest the potential for delegation protocols to limit clerical burden associated with paging.
INTRODUCTION: Human papillomavirus (HPV) vaccination decreases rates of cervical cancer and pre-cancer, yet many remain undervaccinated. This quality improvement initiative aims to increase HPV vaccination postpartum. METHODS: Institutional review board exemption was obtained. Patients aged 26 years or younger who delivered viable fetus(es) at a tertiary care center were screened for HPV vaccination eligibility. Patients were included if HPV vaccine data was available in the electronic medical record. Eligible patients were counseled and offered the HPV vaccine in the immediate postpartum period, defined as within 6 weeks postpartum. Additionally, physicians from the obstetrics and gynecology and Family Medicine departments were given a 1-question survey three times during the study period to assess clinician-reported patient screening for HPV vaccine eligibility. A program evaluation was conducted after 4 and 8 months. RESULTS: Three hundred twenty one women aged 26 years and younger delivered during the study period, with 260 meeting inclusion criteria. A total of 185 (71.2%) previously completed the HPV vaccine series. Of the 75 undervaccinated patients, 38 (50.7%) received at least one HPV vaccine postpartum, a significant increase from 2.3% in the 1 year prior to program initiation ( P <.001). Seventeen percent of physicians surveyed reported screening at least half of their prenatal patients for HPV vaccine eligibility prior to the program's initiation, which significantly increased to 34% at 4 months and 47% at 8 months during the initiative ( P <.001). CONCLUSION: Postpartum is a crucial and often overlooked period to optimize maternal health care. Counseling and offering HPV vaccination in the postpartum period is efficacious in increasing vaccine uptake among women aged 26 years and younger.
Documenting surrogate decision makers (SDMs) is an important step in advance care planning (ACP) for hospitalized adults. The authors performed a quality improvement study of clinical and electronic health record (EHR) workflows aiming to increase SDM documentation for hospitalized adults. The intervention included an ACP education module, audit and feedback, as well as workflow and EHR adaptations. The authors prospectively tracked SDM documentation using control charts and used chart review to assess secondary outcome, process, and balancing measures. SDM documentation significantly increased from 69.5% to 80.2% ( P < 0.001) for intervention patients, sustained over 3 years, and was unchanged for control patients (34.6% to 36.3%; P = 0.355). There were no significant differences in secondary ACP outcomes in intervention or control patients. Clinical and EHR adaptations increased SDM documentation for hospitalized adults with minimal risk, although did not affect other ACP metrics. Future studies are needed to determine the effects of such changes on goal-concordant care.
Identification of surrogate decision makers (SDMs) is an important part of advance care planning for hospitalized patients. Despite its importance, the best methods for engaging residents to sustainably improve SDM documentation have not been identified.We implemented a hospital-wide quality improvement initiative to increase identification and documentation of SDMs in the electronic health record (EHR) for hospitalized patients, utilizing a Housestaff Quality and Safety Council (HQSC).EHR documentation of SDMs for all adult patients admitted to a tertiary academic hospital, excluding psychiatry, were tracked and grouped by specialty in a weekly run chart during the intervention period (July 2015 through April 2016). This also continued postintervention. Interventions included educational outreach for residents, monthly plan-do-study-act cycles based on performance feedback, and a financial incentive of a one-time payment of 0.75% of a resident's salary put into the retirement account of each resident, contingent on meeting an SDM documentation target. Comparisons were made using statistical process control and chi-square tests.At baseline, SDMs were documented for 11.1% of hospitalized adults. The intervention period included 9146 eligible admissions. Hospital-wide SDM documentation increased significantly and peaked near the financial incentive deadline at 48% (196 of 407 admissions, P < 001). Postintervention, hospital-wide SDM documentation declined to 30% (134 of 446 admissions, P < .001), but remained stable.This resident-led intervention sustainably increased documentation of SDMs, despite a decline from peak rates after the financial incentive period and notable differences in performance patterns by specialty admitting service.
Dysregulation of the hypothalamic–pituitary–adrenal ( HPA ) axis pathway is associated with several neuropsychiatric disorders, including post‐traumatic stress disorder ( PTSD ), major depressive disorder ( MDD ), schizophrenia and alcohol abuse. Studies have demonstrated an association between HPA axis dysfunction and gene variants within the cortisol, serotonin and opioid signaling pathways. We characterized polymorphisms in genes linked to these three neurotransmitter pathways and tested their potential interactions with HPA axis activity, as measured by dexamethasone ( DEX ) suppression response. We determined the percent DEX suppression of adrenocorticotropic hormone ( ACTH ) and cortisol in 62 unrelated, male rhesus macaques. While DEX suppression of cortisol was robust amongst 87% of the subjects, ACTH suppression levels were broadly distributed from −21% to 66%. Thirty‐seven monkeys from the high and low ends of the ACTH suppression distribution (18 ‘high’ and 19 ‘low’ animals) were genotyped at selected polymorphisms in five unlinked genes (rh CRH , rh TPH2 , rh MAOA , rh SLC6A4 and rh OPRM ). Associations were identified between three variants (rh CRH ‐2610C>T, rh TPH2 2051A>C and rh 5‐HTTLPR ) and level of DEX suppression of ACTH. In addition, a significant additive effect of the ‘risk’ genotypes from these three loci was detected, with an increasing number of ‘risk’ genotypes associated with a blunted ACTH response ( P = 0.0009). These findings suggest that assessment of multiple risk alleles in serotonin and cortisol signaling pathway genes may better predict risk for HPA axis dysregulation and associated psychiatric disorders than the evaluation of single gene variants alone.
PROBLEM Requirements for experiential education in quality improvement and patient safety (QI/PS) in graduate medical education (GME) have recently expanded. Major challenges to meeting these requirements include a lack of faculty with the needed expertise, paucity of standardized curricular models allowing for skill demonstration, and inconsistent access to data for iterative improvement. APPROACH In October 2017, the authors began development of a centralized QI/PS flipped-classroom simulation-based medical education (SBME) curriculum for GME trainees across multiple disciplines at Oregon Health & Science University (OHSU). The curriculum development team included OHSU and Veterans Affairs faculty with experience in QI/PS and SBME, as well as house officers. The curriculum consisted of a pre-assessment and pre-work readings and videos (sent 3 weeks before the simulation day) and an 8-hour simulation day, with introductory activities, 4 linked simulation sessions, and concluding activities. The 4 linked simulation sessions followed the same medical error from disclosure and reporting to root cause analysis, iterative implementation of an action plan, and consolidation of lessons learned into routine operations with Lean huddles. OUTCOMES In academic year 2018-2019, 71 residents and fellows of various postgraduate years from 23 training programs enrolled in 2 pilot sessions. Learners reacted favorably to the simulation curriculum. Learner attitudes, confidence, knowledge, and skills significantly increased across all QI/PS domains studied. NEXT STEPS This approach focuses a small cadre of educators toward the creation of a centralized resource that, owing to its experiential SBME foundation, can accommodate many learners with data-driven practice-based learning and improvement cycles in a shorter timeframe than traditional QI initiatives. Next steps include the addition of a control group, assessment of the sustainability of learner outcomes, translation of learning to behavior change and improvements in patient and health system outcomes, and adapting the materials to include learners from different professions and levels.
Acromegaly is a rare disorder of unregulated hypersecretion of growth hormone that causes cardiovascular, metabolic and respiratory complications. Herein, we describe the case of a middle-aged man admitted to the hospital with severe COVID-19 found to have clinical and biochemical evidence of acromegaly. His respiratory status declined despite initiation of standard treatments, prompting initiation of subcutaneous octreotide. Following initiation of this therapy, he rapidly improved and was discharged from the hospital 2 days later. Subsequent workup revealed a pituitary macroadenoma that was surgically removed, with improvement in his acromegaly symptoms. COVID-19 disease severity is increased by pre-existing diabetes, lung disease and immunosuppression. Although this patient had obstructive sleep apnoea and pre-diabetes, we hypothesise that our patient's acromegaly contributed to his severe course, as reflected by his rapid improvement after starting treatment with subcutaneous octreotide. Acromegaly may predispose to more severe outcomes in patients with COVID-19.
