397 Medical Reconciliation in Acute Surgical Patients – Are We Letting Our Patients Down?

Introduction

NICE guidelines state that medication reconciliation should occur within 24 hours of admission or as soon after as possible. Accurate and timely prescription of these medications is crucial to ensure optimal care. Due to the COVID-19 pandemic, primary care is busier and thus difficult to contact and with neck of kin not present, the challenges of accurate medicine reconciliation may be exacerbated.

Method

A retrospective audit was performed over a fortnight of all acute surgical admissions to a district general hospital. Data was collected as to the time regular medications were prescribed, the source of medical reconciliation and the access to GP network systems for patients.

Results

A total of 66 patients were admitted during the time period. 44 patients had regular prescriptions. Of those 68% had regular medications prescribed within 24 hours. 22% did not have regular prescriptions prescribed throughout their inpatient stay. 91% of the patients prescribed medications within 24hours had a working link to the GP network whereas only 58% of those who were never prescribed had a working system.

Conclusions

Although a good proportion of acute surgical admissions are prescribed their medications within 24 hours, the proportion who are prescribed past this point is low and a sizeable proportion are never prescribed. A significant contributing factor to this could be poor infrastructure relating to the connection between secondary and primary care and poor handover between on-call and post-take teams. Accurate drugs history during the initial clerking is crucial to mitigate these errors long term.

394 Gentamicin Guidelines – Available but Are They Followed? a Retrospective Audit

Introduction

Many hospitals include gentamicin as part of prescribing protocols for clinical situations such as bacterial septicemia and urinary tract infections. High doses of gentamicin can lead to nephrotoxicity and/or auditory dysfunction. To prevent this, most hospital guidelines advise to adjust dosing according to age, renal function and if the patient is overweight. With therefore quite a complex prescribing protocol, an audit of the prescribing practices at the trust was deemed necessary to determine if clinical protocol was being followed for inpatient gentamicin dosing.

Method

A retrospective audit of all patients prescribed gentamicin as an inpatient between 1st of August and 31st of October 2020 was performed. Data was collected from two separate electronic record systems and combined.

Results

2224 doses of Gentamicin (to 1224 patients) were given in the study period. Gentamicin dosing was not adjusted for obesity in either the <70 or >70 age group (p<0.05 for both). Dosing was not adjusted for Creatine clearance (p<0.05). 86% of patients that needed a gentamicin level had one taken but 15% had it taken too early. Of those who had a Gentamicin level >1, 100% had their next dose held.

Conclusions

Although gentamicin levels are taken and acted on effectively in most cases, a large proportion of patients are not being dosed as per protocol and therefore at risk of the side effects of overdosing or being clinically under treated. With such a complex prescribing protocol, electronic tools need to be implemented to improve compliance across the trust.

449 Burden of Epistaxis - Room for Improvement?

Aim

We conducted an audit at a large tertiary hospital of the measures and information given to patients admitted with Epistaxis. The aim of this audit was to identify factors for prolonged inpatient admissions and elucidate the extent of patient suitable information provided.

Method

A retrospective audit was conducted collecting data over two months on all patients admitted with epistaxis. Data was collected on demographics, co-morbidities, length of stay, discussions with other specialities and the extent (verbal/written) of information given to patients with regard to management of epistaxis in the community and how to reduce the risk of further episodes of epistaxis.

Results

Sixty patients were identified with an average age of 68 years. The patients were inpatients for an average of 41 hours. 10% had a form of haematological disorder, 40% were on warfarin/DOAC and 45% had hypertension. 40% had neither verbal nor written information given about either management or reducing risk. 10% had written information about both. 8% were re-admitted within 30 days of discharge and 17% had previously been admitted with epistaxis in the last 6 months.

Conclusions

Epistaxis is a common inpatient admission in ENT with a significant bed burden on the department. A significant proportion of patients are co-morbid and thus easily understandable trust guidelines on management of epistaxis on warfarin/doac should be available to reduce length of stay. The low proportion of patients provided with information to help self-care is significant and is likely to play an important role in the re-admission rates.

450 Low Dose CT Protocols - The Future for Paediatric Foreign Body Aspiration?

Aim

Suspected foreign body aspiration is a common attendance at the paediatric emergency department. Low dose Computer tomography (CT) protocols (0.06-2mSv) have been developed to be able to diagnose these patients more effectively.

Method

All paediatric low dose CT protocols for foreign body aspiration from a large tertiary level hospital were identified retrospectively over a year. Data was collected on prior imaging, result, further intervention and subsequent follow up of patients.

Results

Eight patients were identified. Three (37.5%) identified a foreign body on CT. All three had subsequent microlaryngoscopy and all found a foreign body present. Of the five negative scans, none re-presented or had any associated symptoms of a foreign body at follow up. Five had previous Chest X-ray, all of which were inconclusive.

Conclusions

Although need for ongoing research into the area, low dose CT thorax protocols for suspected foreign body aspiration is a promising and effective tool. Its use across the country will likely lead to reduced negative microlaryngoscopy rates with huge associated benefits for both the patient and the ENT department.

451 Metastatic Cervical Cancer to the Duodenum: A Learning Point

Background

Carcinoma of the Cervix is the second most common gynaecological malignancy. It usually spreads in a predictable manner with most via direct extension to surrounding structures. When distant metastases present, they usually spread haematogenously and via the lymphatics to the liver, lung and bone marrow. Metastatic spread to the duodenum is rare with only 15 reported cases identifying spread to the bowel.

Case Presentation

An 81-year-old lady presented with signs and symptoms consistent with bowel obstruction with a background of renal cell carcinoma and cervical cancer. Investigations identified gastric outlet obstruction. Subsequent oesophago-gastroduodenoscopy showed structuring at D1/D2 and a enteric stent was inserted. Biopsies taken at the time showed lymphovascular permeation of the mucosa and submucosa by nests of tumour cells resembling squamous cells. The cells were P16 and P63 positive and FISH analysis detected Human papilloma virus 16. The tissue was identified as metastatic cervical cancer. The patient subsequently did not want further interventions and was referred to palliative care and subsequently passed away due to her illness.

Conclusions

Few reported cases of metastatic cervical cancer to the bowel have been reported. Of these, most commonly they have presented with obstructive bowel symptoms and metastasised to the duodenum such as in this case. The pathophysiology for this manner of transmission is poorly understood in literature. Obstructive bowel symptoms on the background of cervical cancer should raise the possibility of metastases in future practice.

New ^{59}Fe Stellar Decay Rate with Implications for the ^{60}Fe Radioactivity in Massive Stars

The discrepancy between observations from γ-ray astronomy of the ^{60}Fe/^{26}Al γ-ray flux ratio and recent calculations is an unresolved puzzle in nuclear astrophysics. The stellar β-decay rate of ^{59}Fe is one of the major nuclear uncertainties impeding us from a precise prediction. The important Gamow-Teller strengths from the low-lying states in ^{59}Fe to the ^{59}Co ground state are measured for the first time using the exclusive measurement of the ^{59}Co(t,^{3}He+γ)^{59}Fe charge-exchange reaction. The new stellar decay rate of ^{59}Fe is a factor of 3.5±1.1 larger than the currently adopted rate at T=1.2  GK. Stellar evolution calculations show that the ^{60}Fe production yield of an 18 solar mass star is decreased significantly by 40% when using the new rate. Our result eliminates one of the major nuclear uncertainties in the predicted yield of ^{60}Fe and alleviates the existing discrepancy of the ^{60}Fe/^{26}Al ratio.

Establishing the Maximum Collectivity in Highly Deformed N=Z Nuclei

The lifetimes of the first excited 2^{+} states in the N=Z nuclei ^{80}Zr, ^{78}Y, and ^{76}Sr have been measured using the γ-ray line shape method following population via nucleon-knockout reactions from intermediate-energy rare-isotope beams. The extracted reduced electromagnetic transition strengths yield new information on where the collectivity is maximized and provide evidence for a significant, and as yet unexplained, odd-odd vs even-even staggering in the observed values. The experimental results are analyzed in the context of state-of-the-art nuclear density-functional model calculations.

LUCY results show females have equivalent outcomes to males following endovascular abdominal aortic aneurysm repair despite more complex aortic morphology

OBJECTIVE

Females remain underrepresented in studies of endovascular aneurysm repair (EVAR) owing to anatomic ineligibility for EVAR devices. The aim of the LUCY study is to explore the comparative safety and effectiveness of EVAR using a low-profile stent graft (Ovation; Endologix, Inc, Irvine, Calif) in females as well as males.

METHODS

The LUCY registry was a prospective, nonrandomized, multicenter study where patient enrollment was stratified by sex in a two-to-one ratio (male-to-female). Main outcomes were procedural data, 30-day major adverse events, device-related adverse events confirmed with contrast-enhanced computed tomography scans, secondary interventions, and hospital readmissions. Adverse events were adjudicated by a clinical events committee. Patients were followed at their 1-month and 1-year follow-up visits.

RESULTS

A total of 225 patients (76 females, 149 males) were enrolled at 39 U.S. centers. No statistically significant sex differences were observed in demographics or medical history. Females presented with smaller access vessels (6.2 vs 7.7 mm; P < .001), statistically smaller neck diameter (22 mm vs 23 mm; P = .001), similar neck angulation (11% vs 9% angulation >45°; P = .81), and smaller maximum abdominal aortic aneurysm (AAA) diameter (50 mm vs 53 mm; P = .01), however, these factors do not seem to be clinically significant. Technical success was 99%, and the median hospital stay was 1 day. The incidence of MAE through 30 days was 1.3% in females and 2.0% in males. There were no differences between sexes observed among the 30-day perioperative outcomes. The 30-day secondary intervention rate was 0.4%. The all-cause readmission rate through 30 days was 5.3% in females and 6.7% in males. There were no reports of limb occlusion or deaths within the first 30 days. At 1 year, there were no deaths in the female arm but nine deaths (6.0%) were observed in males, two of which were AAA related (1.3%). Through 1 year, there were eight type IA endoleaks (one female, seven males; P = .27) and three cases with limb occlusion (one female, two males). There were no reports of migration, AAA rupture, or surgical conversion through the end of follow-up.

CONCLUSIONS

Despite more complex aortic morphology in females than males, EVAR with a low-profile stent graft was associated with comparable procedural and perioperative outcomes through 1 year between the sexes.

Localizing the Shape Transition in Neutron-Deficient Selenium

Neutron-deficient selenium isotopes are thought to undergo a rapid shape change from a prolate deformation near the line of beta stability towards oblate deformation around the line of N=Z. The point at which this shape change occurs is unknown, with inconsistent predictions from available theoretical models. A common feature in the models is the delicate nature of the point of transition, with the introduction of even a modest spin to the system sufficient to change the ordering of the prolate and oblate configurations. We present a measurement of the quadrupole moment of the first-excited state in radioactive ^{72}Se-a potential point of transition-by safe Coulomb excitation. This is the first low-energy Coulomb excitation to be performed with a rare-isotope beam at the reaccelerated beam facility at the National Superconducting Cyclotron Laboratory. By demonstrating a negative spectroscopic quadrupole moment for the first-excited 2^{+} state, it is found that any low-spin shape change in neutron-deficient selenium does not occur until ^{70}Se.

New Unintended Adverse Consequences of Electronic Health Records

Although the health information technology industry has made considerable progress in the design, development, implementation, and use of electronic health records (EHRs), the lofty expectations of the early pioneers have not been met. In 2006, the Provider Order Entry Team at Oregon Health & Science University described a set of unintended adverse consequences (UACs), or unpredictable, emergent problems associated with computer-based provider order entry implementation, use, and maintenance. Many of these originally identified UACs have not been completely addressed or alleviated, some have evolved over time, and some new ones have emerged as EHRs became more widely available. The rapid increase in the adoption of EHRs, coupled with the changes in the types and attitudes of clinical users, has led to several new UACs, specifically: complete clinical information unavailable at the point of care; lack of innovations to improve system usability leading to frustrating user experiences; inadvertent disclosure of large amounts of patient-specific information; increased focus on computer-based quality measurement negatively affecting clinical workflows and patient-provider interactions; information overload from marginally useful computer-generated data; and a decline in the development and use of internally-developed EHRs. While each of these new UACs poses significant challenges to EHR developers and users alike, they also offer many opportunities. The challenge for clinical informatics researchers is to continue to refine our current systems while exploring new methods of overcoming these challenges and developing innovations to improve EHR interoperability, usability, security, functionality, clinical quality measurement, and information summarization and display.

The Unintended Consequences of Health Information Technology Revisited

INTRODUCTION

The introduction of health information technology into clinical settings is associated with unintended negative consequences, some with the potential to lead to error and patient harm. As adoption rates soar, the impact of these hazards will increase.

OBJECTIVE

Over the last decade, unintended consequences have received great attention in the medical informatics literature, and this paper seeks to identify the major themes that have emerged.

RESULTS

Rich typologies of the causes of unintended consequences have been developed, along with a number of explanatory frameworks based on socio-technical systems theory. We however still have only limited data on the frequency and impact of these events, as most studies rely on data sets from incident reporting or patient chart reviews, rather than undertaking detailed observational studies. Such data are increasingly needed as more organizations implement health information technologies. When outcome studies have been done in different organizations, they reveal different outcomes for identical systems. From a theoretical perspective, recent advances in the emerging discipline of implementation science have much to offer in explaining the origin, and variability, of unintended consequences.

CONCLUSION

The dynamic nature of health care service organizations, and the rapid development and adoption of health information technologies means that unintended consequences are unlikely to disappear, and we therefore must commit to developing robust systems to detect and manage them.

Measuring genetic knowledge: a brief survey instrument for adolescents and adults

Basic knowledge of genetics is essential for understanding genetic testing and counseling. The lack of a written, English language, validated, published measure has limited our ability to evaluate genetic knowledge of patients and families. Here, we begin the psychometric analysis of a true/false genetic knowledge measure. The 18-item measure was completed by parents of children with congenital heart defects (CHD) (n = 465) and adolescents and young adults with CHD (age: 15-25, n = 196) with a mean total correct score of 12.6 [standard deviation (SD) = 3.5, range: 0-18]. Utilizing exploratory factor analysis, we determined that one to three correlated factors, or abilities, were captured by our measure. Through confirmatory factor analysis, we determined that the two factor model was the best fit. Although it was necessary to remove two items, the remaining items exhibited adequate psychometric properties in a multidimensional item response theory analysis. Scores for each factor were computed, and a sum-score conversion table was derived. We conclude that this genetic knowledge measure discriminates best at low knowledge levels and is therefore well suited to determine a minimum adequate amount of genetic knowledge. However, further reliability testing and validation in diverse research and clinical settings is needed.

Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial

OBJECTIVE

To compare the effectiveness of carbetocin and oxytocin when they are administered after caesarean section for prevention of postpartum haemorrhage (PPH).

STUDY DESIGN

Double-blind randomised single centre study (1:1 ratio).

SETTING

Teaching hospital in Bristol, UK with 6000 deliveries per annum.

POPULATION

Women at term undergoing elective or emergency caesarean section under regional anaesthesia, excluding women with placenta praevia, multiple gestation and placental abruption.

METHODS

Women were randomised to receive either carbetocin 100 microg or oxytocin 5 IU intravenously after the delivery of the baby. Perioperative care was otherwise normal and use of additional oxytocics was at the discretion of the operating obstetrician. Analysis was by intention to treat.

PRIMARY OUTCOME MEASURE

The proportion of women in each arm of the trial that needed additional pharmacological oxytocic interventions.

RESULTS

Significantly more women needed additional oxytocics in the oxytocin group (45.5% versus 33.5%, Relative risk 0.74, 95% CI 0.57-0.95). The majority of women had oxytocin infusions. There were no significant differences in the secondary outcomes, including major PPH, blood transfusions and fall in haemoglobin.

CONCLUSIONS

Carbetocin is associated with a reduced use of additional oxytocics. It is unclear whether this may reduce rates of PPH and blood transfusions.

The value of resident teaching to improve student perceptions of surgery clerkships and surgical career choices

BACKGROUND

A fundamental function of attending faculty is to teach and mentor medical students, but the benefit of the resident's role is recognized increasingly.

METHODS

Our Standardized Institutional Clinical Clerkship Assessment allows students to rate 27 factors relative to a clinical clerkship. Scores from 1998 to 2005 were used to evaluate our surgical clerkship program and to compare resident and attending teachers. Student surgery career choices also were monitored.

RESULTS

Medical students routinely scored residents more highly than attending faculty. Attendings' scores did not improve; however, residents' teaching and overall clerkship scores improved during the study period and paralleled students' increased selection of a surgical career.

CONCLUSIONS

Students perceived residents as teachers more than attendings. Residents may have significant influence over students' career choice by their teaching and mentoring activities, which benefit attending efforts.

Investigating physician order entry in the field: lessons learned in a multi-center study

The progress of studies by this team of researchers concerning computerized physician order entry (POE), beginning with a mail survey and moving to qualitative multi-center studies, is reviewed, with emphases on lessons learned and future directions. While mail surveys were appropriate to answer initial research questions about diffusion of POE in the U.S., multiple qualitative methods became the methods of choice for answering more complex questions. Results of the latter include articulation of multiple perspectives on both positive and negative aspects of POE and a description of what may be important for successful implementation of POE in the future. The present economic environment of hospitals may be inhibiting widespread diffusion of POE, not only because of the direct cost, but also indirectly by affecting relations with practitioners. Analysis of successful past implementations can provide guidance when the time is right.

A survey of academic and industry professionals regarding the preferred skillset of graduates of medical informatics programs

Identification of the skills needed by graduates of medical informatics masters degree programs is needed so that students will know what is desired in the workplace and curriculum designers can assure that courses cover relevant areas. We conducted a mail survey of representatives of the informatics job market to discover what they think is most important. A survey instrument was designed after analyses of job ads and curricula in the U.S. and interviews with representative employers. The survey was mailed to 1000 randomly selected members of AMIA and HIMMS plus EMR vendors. Respondents were asked to rank skills and groups of skills according to perceived utility. The results indicate higher rankings for organizational and interpersonal skills than for more technical credentials. Statistical analysis indicates the existence of relatively few underlying constructs to the skill list.

The dissemination of clinical practice guidelines over an intranet: an evaluation

This study compares two clinical practice guideline dissemination systems. It was hypothesized that placing guidelines on an intranet would make this information easier to retrieve. Retrieval time, retrieval accuracy, and ease of use were empirically evaluated. Sixteen clinicians from Kaiser Permanente volunteered to complete tasks that measured these variables. Time values were significantly longer for tasks completed with intranet guidelines (Intranet = 6.7 minutes, Paper = 5.7 minutes). Tasks completed with paper guidelines had a significantly higher percentage of perfect scores than those completed with the intranet (Paper = 85%, Intranet = 59%). There was no significant difference in reported ease of use. Simply placing clinical information on an electronic system does not guarantee that the information will be easier to retrieve. Such information needs to be fully integrated into the clinical decision making process. Computerizing guidelines may provide a necessary initial step toward this goal, but it does not represent the final solution.

Multi-disciplinary audit and the mental health nurse

Research advances knowledge; audit is a way of ensuring that this new knowledge is applied to practice. Uni-disciplinary audit is well-established; multi-disciplinary audit presents other challenges. Jonathan Ash outlines and illustrates how nurses working in a multi-disciplinary mental health team can initiate, design and use audit to improve the quality of the service, and to ensure it meets users' wants and needs.

Virulence and hyphal formation of Candida albicans require the Ste20p-like protein kinase CaCla4p

BACKGROUND

The pathogenic fungus Candida albicans is capable of a morphological transition from a unicellular budding yeast to a filamentous form. Extensive filamentous growth leads to the formation of mycelia displaying hyphae with branches and lateral buds. Hyphae have been observed to adhere to and invade host tissues more readily than the yeast form, suggesting that filamentous growth may contribute to the virulence of this major human pathogen. A molecular and genetic understanding of the potential role of morphological switching in the pathogenicity of C. albicans would be of significant benefit in view of the increasing incidence of candidiasis.

RESULTS

The CaCLA4 gene of C. albicans was cloned by functional complementation of the growth defect of cells of the budding yeast Saccharomyces cerevisiae deleted for the STE20 gene and the CLA4 gene. CaCLA4 encodes a member of the Ste20p family of serine/threonine protein kinases and is characterized by a pleckstrin homology domain and a Cdc42p-binding domain in its amino-terminal non-catalytic region. Deletion of both alleles of CaCLA4 in C. albicans caused defects in hyphal formation in vitro, in both synthetic liquid and solid media, and in vivo in a mouse model for systemic candidiasis. The gene deletions reduced colonization of the kidneys in infected mice and suppressed C. albicans virulence in the mouse model.

CONCLUSIONS

Our results demonstrate that the function of the CaCla4p protein kinase is essential for virulence and morphological switching of C. albicans in a mouse model. Thus, hyphal formation of C. albicans mediated by CaCla4p may contribute to the pathogenicity of this dimorphic fungus, suggesting that regulators of morphological switching may be useful targets for antifungal drugs.

Organizational factors that influence information technology diffusion in academic health sciences centers

OBJECTIVE

To identify the organizational factors which influence the diffusion of end user online literature searching, the computer-based patient record, and electronic mail systems in academic health sciences centers in the United States.

DESIGN

A total of 1335 individuals working in informatics and library areas at 67 academic health sciences centers in the U.S. were surveyed. Multivariate techniques were used to evaluate the relationship between the set of six organizational factors and two measures of innovation diffusion.

MEASUREMENTS

A Guttman-like scale was developed to measure infusion, or depth or sophistication, of each of the three innovations at each institution. Diffusion was measured by a question previously developed for another study. Six independent variables were measured via five formerly developed scales and one new one.

RESULTS

The overall response rate was 41%. The set of organizational variables produced significant results in the diffusion of each of the three innovations, with individual variables influencing diffusion to varying degrees. The same set produced significant results in relation to infusion only for online searching. There was little or no correlation between infusion and diffusion for each innovation.

CONCLUSION

Organizational attributes are important predictors for diffusion of information technology innovations. Individual variables differ in their effect on each innovation. The set of attributes seems less able to predict infusion. It is recommended that both infusion and diffusion be measured in future studies because there is little relation between them. It is further recommended that individuals charged with implementing information technology in the health sciences receive training in managing organizational issues.

Splicing signals are required for S-phase regulation of the mouse thymidylate synthase gene

The thymidylate synthase (TS) gene is expressed at a much higher level in cells undergoing DNA replication than in nondividing cells. In growth-stimulated mammalian cells, TS mRNA content increases 10 to 20-fold as cells progress from G1 through S phase. However, the rate of transcription of the TS gene does not increase during this interval, indicating that the gene is regulated at the posttranscriptional level. We have shown that both the promoter of the mouse TS gene and TS introns are necessary (although neither is sufficient) for S-phase-specific regulation of TS mRNA content. In the present study, we examined in more detail the role of introns in regulating TS mRNA levels in growth-stimulated cells. TS minigenes that contain normal or modified introns were stably transfected into mouse 3T6 fibroblasts, and the regulation of the minigenes was compared with that of the endogenous TS gene. TS minigenes that contain TS intron 1 or 2 maintain S-phase regulation. Deletion of most of the interior of the introns had only minor effects on regulation. However, when splicing of the intron was inhibited by alteration of the splice donor and acceptor sites, the minigene was expressed at a constant level following growth stimulation. Minigenes consisting of the TS promoter linked to either a luciferase or a human beta-globin indicator gene were growth regulated when spliceable introns were included in the minigenes. However, when the introns were eliminated, the minigenes were expressed at a constant level. These observations indicate that the splicing reaction itself, rather than a control sequence within the intron, is important for growth-regulated expression of the TS gene. Possible mechanisms to account for the dual requirement for the TS promoter and intron splicing for proper regulation of the TS gene are discussed.

Promoting inpatient directives about life-sustaining treatments in a community hospital. Results of a 3-year time-series intervention trial

BACKGROUND

Hospitalization presents an opportunity for physicians to discuss advance directives with patients and to encourage completion of health care proxies.

OBJECTIVE

To prospectively promote discussion and documentation of treatment-specific directives about life-sustaining interventions (cardiopulmonary resuscitation, admission to critical care units, mechanical ventilation, electrical cardioversion, and vasopressor therapy) among unselected medical inpatients in a community teaching hospital.

METHODS

We conducted a time-series intervention trial from January 1, 1991, through June 30 1993, divided into three phases. During the education phase, we provided reminders, education, and feedback to attending physicians; during the intervention phase, we promoted a new documentation form for directives to be used by attending physicians; during the control phase, no interventions occurred. We studied consecutive patients (N = 1780) admitted to the hospital acute medical service in each of the following 10 periods: three in the education phase (n = 598), three in the intervention phase (n = 826), and four in the control phase (n = 356). The primary outcome measures were the frequency and content of directives documented by attending physicians in their patients' hospital charts. Secondary outcome measures included physicians' and patients' attitudes about directives, surveyed repeatedly.

RESULTS

The proportion of inpatients with directives increased significantly during the intervention phase (62.5% vs 23.6% during the education phase and 25.3% during the control period, P < .001, Pearson chi 2 test). During the final intervention phase, 227 (83.2%) of 273 inpatients had directives documented in the hospital chart. Increases in clinically important ("impact") directives usually involved intensive care, not do-not-resuscitate status. Overall, 366 (86.7%) of 422 physician-attested directives agreed with the treatment preferences of interviewed patients (kappa ranges, 0.53 to 0.79). Physicians' attitudes about and interest in directives improved.

CONCLUSIONS

Institutional interventions can facilitate attending physicians' documentation of treatment-specific directives about life-sustaining care for most medical inpatients. More research is needed to confirm the effect of these efforts on quality and cost of hospital care, patients' autonomy, and their eventual execution of durable directives and proxies.

Regulation of mouse thymidylate synthase gene expression in growth-stimulated cells: upstream S phase control elements are indistinguishable from the essential promoter elements

Expression of the mammalian thymidylate synthase (TS) gene in growth-stimulated cells is closely coordinated with entry into S phase. Previous studies with transfected TS minigenes have shown that sequences upstream of the coding region as well as an intron in the transcribed region are both necessary for proper regulation of TS mRNA content in growth-stimulated cells. The goal of the present study was to identify the upstream regulatory elements. Minigenes consisting of TS 5' flanking sequences linked to the TS coding region (interrupted by introns 1 and 2) were stably transfected into mouse 3T6 cells. Deletion and site-directed mutagenesis of the 5' flanking region revealed that there is a close correspondence between the upstream sequences that are necessary for S phase regulation and the 30 nucleotide region that is essential for promoter activity. These observations raised the possibility that regulation of the TS gene occurs at the transcriptional level. However, nuclear run-on assays showed that the rate of transcription of the TS gene changed very little during the G1-S phase transition. Furthermore, when the TS promoter was linked to an intron-less luciferase indicator gene, there was no change in expression following growth-stimulation. Therefore it appears that the TS gene is controlled primarily at the posttranscriptional level, and that the TS essential promoter region is necessary (although not sufficient) for proper S phase regulation.

Promoting completion of health care proxies following hospitalization. A randomized controlled trial in a community hospital

BACKGROUND

The wider use of written advance directives is popular but problematic. We have shown previously that acute hospitalization in the era of the Patient Self-Determination Act can facilitate directive discussions and documentation. We investigated whether a simple educational intervention following hospitalization would increase patients' execution of durable health care proxies.

METHODS

We studied a consecutive series of patients (n = 162) recently discharged from the acute care medical service of a community hospital where they had been interviewed about advance directives. The intervention group was randomized to receive an educational brochure and encouragement to execute durable health care proxies. The primary outcome was the proportion of patients in each group with completed durable health care proxies on file in their primary physicians' offices.

RESULTS

Overall, only 20 (12.3%) of 162 patients had documented proxies, 17 of whom (85%) were 65 years of age or older, with no difference between the intervention and control groups (11 [13.3%] of 83 vs nine [11.4%] of 79, respectively). Subgroup analysis of elderly patients also revealed no intervention effect. Univariate analysis revealed three significant predictors of patients' proxy completion: patient age, whether patients had discussed directives in hospital with their physicians, and whether patients' physicians completed proxies for themselves. Multiple logistic regression analysis showed that these three variables interact to predict the probability of patients' executing proxies.

CONCLUSIONS

Simple educational interventions, like those mandated by the Patient Self-Determination Act, are unlikely to increase patients' completion of durable healthcare proxies. Multidimensional interventions that target both elderly patients and their personal physicians should be tested in the future. Discussion in hospital about advance directives can be a useful component of such efforts.

The impact of IAIMS on the work of information experts. Integrated Advanced Information Management Systems

Integrated Advanced Information Management Systems (IAIMS) programs differ but have certain characteristics in common. Technological and organizational integration are universal goals. As integration takes place, what happens to those implementing the vision? A survey of 125 staff members, or information experts, involved in information or informatics at an IAIMS-funded institution was conducted during the last year of the implementation phase. The purpose was to measure the impact of IAIMS on the jobs of those in the library and related service units, and the computing, telecommunications, and health informatics divisions. The researchers used newly developed scales measuring levels of integration (knowledge of and involvement with other departments), customer orientation (focus on the user), and informatedness (changes in the nature of work beyond automation of former routines). Ninety-four percent of respondents indicated that their jobs had changed a great deal; the changes were similar regardless of division. To further investigate the impact of IAIMS on librarians in particular, a separate skills survey was conducted. The IAIMS librarians indicated that technology and training skills are especially needed in the new, integrated environment.

The yeast proprotein convertase encoded by YAP3 is a glycophosphatidylinositol-anchored protein that localizes to the plasma membrane

The yeast YAP3 gene encodes an aspartyl endoprotease that cleaves precursor proteins at selected pairs of basic amino acids and after single arginine residues. Biosynthetic studies of this proprotein processing enzyme indicate that Yap3 is predominantly cell-associated and migrates as a approximately 160-kDa protein on SDS-polyacrylamide gel electrophoresis. Nearly equal amounts of Yap3 are immunodetected in a-haploid, alpha-haploid, and a/alpha-diploid yeast, demonstrating that the expression of YAP3 is not mating type-specific. As shown by endoglycosidase H treatment, which drastically reduces both the estimated molecular mass and the heterogeneity of the protein on SDS-polyacrylamide gel electrophoresis (68 versus 160 kDa), the oligosaccharides N-linked to the protein are subjected to extensive outer chain mannosylation. Outer chain sugar mannosylation takes place in the Golgi apparatus and is commonly found on yeast secreted glycoproteins and/or cell wall mannoproteins. Treatment of the total yeast membranes with chemical agents known to disrupt protein-protein and protein-lipid interactions reveal that Yap3 is membrane-associated. Based upon the release of the membrane-bound form by bacterial phosphatidylinositol phospholipase C digestion and metabolic labeling of the protein with myo-[3H]inositol, Yap3 owes its association with the membrane to the addition of a glycophosphatidylinositol anchor. The cellular localization of Yap3 has been addressed by subcellular fractionation studies. In both differential centrifugation of intracellular organelles and sucrose density gradients, the bulk of Yap3 at steady state co-localizes with the plasma membrane azide-insensitive ATPase. Furthermore, consistent with the transport of Yap3 to the plasma membrane, the endoprotease sediments with secretory vesicles which accumulate at restrictive temperature in the late secretory mutant sec1-1. We therefore conclude that the endoprotease encoded by YAP3 is a glycophosphatidylinositol-anchored protein, which can process substrates both intracellularly and at the cell surface.

Cross-site study of the implementation of information technology innovations in health sciences centers

An interpretive oral history technique was used to identify factors most important in the implementation stage of information technology innovation diffusion. Electronic mail, end user literature searching, and aspects of the computer-based patient record were the innovations selected for study at academic health sciences centers. Transcripts of thirty-four interviews with key individuals were analyzed to determine six categories of factors. Word counts were then used to determine underlying emphases. Analysis of variance tested whether there were significant differences in uses of words by categories of individuals, by those at different institutions, and when different innovations were described. Results indicate that the innovations themselves correlate significantly with different word categories, where category of individual and institution do not. Words related to the computer based patient record characterize further critical factors in implementing that particular innovation.

Can we talk? Inpatient discussions about advance directives in a community hospital. Attending physicians' attitudes, their inpatients' wishes, and reported experience

BACKGROUND

The attitudes of hospitalized patients and their attending physicians about advance directives have not been well studied. We compared these attitudes and explored relationships between them and the frequency of actual directives and directive discussions during hospitalization.

METHODS

We conducted scripted interviews with 258 (94.5%) of 273 patients admitted consecutively to the acute medical service of a community teaching hospital in Rochester, NY, and contemporaneously surveyed their attending physicians (n = 68) regarding attitudes about advance directives. Primary outcome measures were patients' willingness to discuss directives, actual physician-patient directive discussions, and patients' preferences for life-sustaining treatments. Also measured were physicians' indications for directive discussions, their reasons not to discuss directives, and their knowledge and attitudes about life-sustaining treatments.

RESULTS

Eighty-one percent (172/212) of competent interviewed patients either did (100) or wanted to (72) discuss advance directives in hospital. Forty-one percent of patients chose to forgo cardiopulmonary resuscitation; 24% to 41% refused other life-sustaining interventions (intensive care unit admission, mechanical ventilation, cardioversion, vasopressors). Overall, 90% (246/273) of all patients met at least one of three criteria reported by their physicians as indications for advance directive discussions: age at least 75 years, critical or potentially fatal illness, and patients' desire to discuss directives. Multiple logistic regression revealed that these same variables predicted patients' willingness to discuss cardiopulmonary resuscitation, their preferences to receive or forgo cardiopulmonary resuscitation, and the frequency of physician-patient discussions about these issues.

CONCLUSIONS

Most medical inpatients in a community hospital want to, are able to, and meet their own physicians' indications to discuss advance directives. Hospitalization presents an unrealized opportunity for physicians and patients to initiate these discussions.

Bidirectional promoter of the mouse thymidylate synthase gene

The promoter of the mouse thymidylate synthase (TS) gene lacks both a TATAA box and an initiator element and directs transcriptional initiation at multiple sites over a 90 nucleotide initiation window. Earlier studies defined an essential region near the 5' end of the initiation window that is required for promoter activity. The essential region contains possible binding sites for Sp1 and Ets transcription factors. In the present study we show that this essential region stimulates transcription with approximately equal strength in both directions. Transcription is initiated over a broad initiation window in the reverse direction. The same elements are important for the reverse promoter and for the normal TS promoter. Sequences upstream of the essential region partially suppress expression in the reverse direction. The TS 5' flanking region, in either the normal or inverted orientation, directs S phase-specific expression of a TS minigene. This raises the possibility that an upstream gene and the TS gene may be coordinately induced at the G1/S phase boundary by a common set of control elements.

Can primary care physicians' questions be answered using the medical journal literature?

Medical librarians and informatics professionals believe the medical journal literature can be useful in clinical practice, but evidence suggests that practicing physicians do not share this belief. The authors designed a study to determine whether a random sample of "native" questions asked by primary care practitioners could be answered using the journal literature. Participants included forty-nine active, nonacademic primary care physicians providing ambulatory care in rural and nonrural Oregon, and seven medical librarians. The study was conducted in three stages: (1) office interviews with physicians to record clinical questions; (2) online searches to locate answers to selected questions; and (3) clinician feedback regarding the relevance and usefulness of the information retrieved. Of 295 questions recorded during forty-nine interviews, 60 questions were selected at random for searches. The average total time spent searching for and selecting articles for each question was forty-three minutes. The average cost per question searched was $27.37. Clinician feedback was received for 48 of 56 questions (four physicians could not be located, so their questions were not used in tabulating the results). For 28 questions (56%), clinicians judged the material relevant; for 22 questions (46%) the information provided a "clear answer" to their question. They expected the information would have had an impact on their patient in nineteen (40%) cases, and an impact on themselves or their practice in twenty-four (51%) cases. If the results can be generalized, and if the time and cost of performing searches can be reduced, increased use of the journal literature could significantly improve the extent to which primary care physicians' information needs are met.

Cleavage of prosomatostatins by the yeast Yap3 and Kex2 endoprotease

A previous in vivo study implicated the YAP3 and KEX2 genes in the proteolytic maturation of anglerfish prosomatostatins which were heterologously expressed in the yeast Saccharomyces cerevisiae. In the present report, we have determined the cleavage specificity of these enzymes by incubating them in vitro with synthetic peptides mimicking the potential processing sites present in the somatostatin precursors and with full length prosomatostatin I. The Yap3 enzyme was prepared from a membrane fraction of a YAP3-overexpressing yeast, and a soluble form of Kex2 obtained from the culture medium of insect cells which had been infected with a recombinant baculovirus expressing the KEX2 gene. The identity of the cleavage products was confirmed by amino acid analysis. Our results show that both endoproteases generate mature SRIF-28 from prosomatostatin-II but that only Yap3 can process the homologous monobasic cleavage site (ie single arginine residue) found in prosomatostatin-I. Both enzymes were also shown to recognize the Arg-Lys doublet found in prosomatostatin-I producing a lysine-extended form of SRIF-14, which indicates that cleavage occurred C-terminal to the arginine residue. In addition, Kex2 also hydrolyzed C-terminal to the Pro-Arg motif to release a tripeptide-extended form of SRIF-14. However, neither endoprotease could cleave after the Arg-Lys doublet to release mature SRIF-14. Taken together, our results indicate that the yeast Kex2 and Yap3 endoproteases have distinct, though overlapping, substrate specificities. The results also strongly support the role of Yap3 as a proprotein convertase which perhaps defines a new family of processing enzymes.

Influence of ventricular morphology on diastolic filling performance in double-inlet ventricle after the Fontan procedure

OBJECTIVES

The purpose of this study was to define the influence of dominant chamber morphology on ventricular performance after the Fontan procedure in patients with double-inlet ventricle.

BACKGROUND

Previous studies have reported the impact of ventricular morphology on preoperative ventricular performance and surgical outcome. However, the influence on postoperative ventricular performance has not been addressed.

METHODS

Twenty-six clinically asymptomatic patients > 1 year after repair (mean age at procedure 6.1 +/- 3.7 years) were evaluated with ventricular cineangiography and radionuclide blood pool studies (18 with a dominant left ventricular morphology [LV group], 8 with a dominant right ventricular morphology [RV group]) and compared with normal control subjects.

RESULTS

Ventricular volume, mass and systolic variables were similar between patient groups. In the LV group, however, the mass/volume ratio was significantly elevated compared with values in control subjects (1.11 +/- 0.28, 0.97 +/- 0.19, p < 0.05), whereas this ratio in the RV group (0.90 +/- 0.11) was within the normal range and significantly lower than that in the LV group (p < 0.05). Mean right atrial and pulmonary artery pressures in the RV group were significantly higher than those in the LV group (p < 0.05). Peak filling rates (2.87 +/- 0.70, 2.41 +/- 1.15 and 3.84 +/- 0.51 end-diastolic volume/s [LV and RV groups and control subjects, respectively]) were significantly lower in both groups than in control subjects (p < 0.001), without intergroup difference.

CONCLUSIONS

Ventricular filling abnormalities after atrial to pulmonary anastomosis are common regardless of the type of dominant ventricular morphology, and these abnormalities in patients with dominant right ventricular morphology do not coexist with ventricular hypertrophy. Such diastolic abnormalities may be related to either intrinsic myocardial or acquired factors, not to excessive hypertrophy alone. Those differences may become clinically more apparent with longer follow-up and may raise concerns over the long-term course.

Introns are essential for growth-regulated expression of the mouse thymidylate synthase gene

The thymidylate synthase (TS) gene is expressed at much higher levels in proliferating cells than in quiescent cells. We have been studying the sequences that are important for regulating the mouse TS gene. We previously showed that DNA sequences upstream of the essential promoter elements as well as downstream of the ATG codon are both necessary (but neither is sufficient) for normal regulation in growth-stimulated cells. In the present study, we examined the possible roles of the coding region, polyadenylation signal, and introns as downstream regulatory elements. Minigenes consisting of 1 kb of the TS 5'-flanking region, the coding region (with or without various introns at their normal locations), and polyadenylation signals from the TS gene, the human beta-globin gene, and the bovine growth hormone gene were stably transfected into wild-type mouse 3T6 cells. Minigenes that contained introns 5 and 6, 1 and 2, or 1 alone were regulated regardless of which polyadenylation signal was included. A minigene that contained an internally deleted version of intron 1 was also regulated in response to growth stimulation. However, when all introns were omitted, there was little if any change in the level of minigene expression as cells progressed from G1 through S phase. These observations indicate that TS introns contain sequences that are necessary for normal growth-regulated expression of the mouse TS gene. These sequences appear to be associated with sequences that are important for splicing and to function in cooperation with upstream regulatory elements to bring about normal S-phase-specific expression.