Assessing an innovative method to promote learning from patient narratives: Findings from a field experiment in ambulatory care

OBJECTIVE

To assess whether an online interactive report designed to facilitate interpretation of patients' narrative feedback produces change in ambulatory staff learning, behavior at the individual staff and practice level, and patient experience survey scores.

DATA SOURCES AND SETTING

We studied 22 ambulatory practice sites within an academic medical center using three primary data sources: 333 staff surveys; 20 in-depth interviews with practice leaders and staff; and 9551 modified CG-CAHPS patient experience surveys augmented by open-ended narrative elicitation questions.

STUDY DESIGN

We conducted a cluster quasi-experimental study, comparing 12 intervention and 10 control sites. At control sites, narratives were delivered free-form to site administrators via email; at intervention sites, narratives were delivered online with interactive tools for interpretation, accompanied by user training. We assessed control-versus-intervention site differences in learning, behavior, and patient experience scores.

DATA COLLECTION

Staff surveys and interviews were completed at intervention and control sites, 9 months after intervention launch. Patient surveys were collected beginning 4 months pre-launch through 9 months post-launch. We used control-versus-intervention and difference-in-difference analyses for survey data and thematic analysis for interview data.

PRINCIPAL FINDINGS

Interviews suggested that the interface facilitated narrative interpretation and use for improvement. Staff survey analyses indicated enhanced learning from narratives at intervention sites (29% over control sites' mean of 3.19 out of 5 across eight domains, p < 0.001) and greater behavior change at staff and practice levels (31% and 21% over control sites' means of 3.35 and 3.39, p < 0.001, respectively). Patient experience scores for interactions with office staff and wait time information increased significantly at intervention sites, compared to control sites (3.7% and 8.2%, respectively); however, provider listening scores declined 3.3%.

CONCLUSIONS

Patient narratives presented through structured feedback reporting methods can catalyze positive changes in staff learning, promote behavior change, and increase patient experience scores in domains of non-clinical interaction.

Orbital compartment syndrome as the first manifestation of SLE

The occurrence of orbital compartment syndrome is a rare and unusual complication of systemic lupus erythematosus (SLE). Patients will present with symptoms of ocular pain and diplopia and visible signs of proptosis. The condition is considered an ophthalmological emergency because the myositis involving the ocular muscles can cause irrevocable damage to the retina and optic disk, potentially leading to blindness. We report a case of a young African American male who developed orbital myositis with compartment syndrome as his initial manifestation of SLE. The patient underwent an emergent orbital decompression, followed by prompt initiation of immunosuppressant medications. To our knowledge, this is the first report of a case of myositis secondary to SLE complicated by compartment syndrome of the orbit.

High Pressure Liquid Chromatographic Determination of Monoand Disaccharides in Presweetened Cereals: Collaborative Study

A collaborative study was conducted using a modified AOAC method (sugars in chocolate) for the determination of fructose, glucose, sucrose, and maltose in presweetened cereals by high pressure liquid chromatography (HPLC). Eight samples consisting of 6 products were analyzed in duplicate by the HPLC method and the AOAC Lane-Eynon method. The AOAC method was modified to use water-alcohol (1 + 1) and Sep-Pak C18 cartridges for sample cleanup. The HPLC results indicate precision comparable to the Lane-Eynon method and the chocolate method. The modified HPLC method has been adopted official first action.

Dual oxidase1 ameliorates survival, viral clearance and pulmonary pathology during influenza infection

Influenza virus infections cause severe morbidity and mortality, especially in high-risk patient populations. Bronchoepithelial cells orchestrate an oxidative antimicrobial system present in the airway liquid consisting of lactoperoxidase, the thiocyanate ion, and hydrogen peroxide. Dual Oxidase 1 (Duox1), an enzyme highly expressed in these cells, is the source of hydrogen peroxide. While in vitro studies suggest an anti-influenza, and a general antimicrobial role of Duox1, its antiviral role in vivo has not been addressed so far. We hypothesized that Duox1 has a protective effect in vivo against influenza. To test this hypothesis, we infected wild-type C57BL/6 and Duox1-deficient mice intranasally with the mouse-adapted A/Puerto Rico/8/1934 H1N1 (PR8) influenza virus strain. To evaluate the clinical and immunological significance of Duox1 in influenza infection, multicolor flow cytometry, multiplex ELISA, viral titration, histology and immunostaining techniques were used. Our results indicate that Duox1-deficient mice have increased mortality following influenza infection. Weight loss of Duox1-deficient mice post-infection was also significantly higher than in Duox1-expressing animals. Duox1 also limited influenza virus replication in the lung. Characterization of infiltrated leukocyte subsets following influenza infection revealed impaired natural killer cell recruitment in Duox1-deficient animals while other lymphoid or myeloid leukocyte subsets were not affected In summary, our results provide the first evidence for the in vivo antiviral role of Duox1, and also implicate that targeting the Duox1-based system has the potential to provide novel treatment or prophylactic strategies against influenza.

Phenolic content and antioxidant activity of olive by-products and antioxidant film containing olive leaf extract

The antioxidant activity of olive leaf (OL) and cake (OC) extracts with different solvents was evaluated. 70% of aqueous ethanol extract of OL was chosen as the most antioxidant extract based on antiradical activity (DPPH) (95.4±0.3%) and oxygen radical absorbance capacity (ORAC) (0.82±0.07g equivalent Trolox per g of solution) assays. This OL extract was incorporated in two multilayer materials consisting of (i) polyethylene/polyethylene (PE/PE) film and (ii) polyethylene/paper (PE/P). These multilayers were exposed to a gas stream enriched in free radicals to evaluate the scavenging capacity of both materials. PE/PE film exhibited the highest scavenging activity of free radicals (78.8%). Migration of the phenolic compounds from olive by-products into two simulants was performed and demonstrated a non-migrating behavior. The limits of detection and quantification for oleuropein were 0.5μgkg(-1) and 1.7μgkg(-1) and for Luteolin-7-O-glucoside 1.3μgkg(-1) and 4.3μg kg(-1) respectively.

Role of catechins in the antioxidant capacity of an active film containing green tea, green coffee, and grapefruit extracts

The oxygen radical absorbance capacity (ORAC) method was used to characterize the antioxidant capacity of natural extracts of green tea, green coffee, and grapefruit. These natural extracts were incorporated into a plastic film layer, which was subsequently subjected to a free radical gas stream in order to determine the antioxidant capacity directly in the active film. The green tea extract (GTE) afforded the strongest antioxidant activity. To identify the active compounds in the extract, concentration of the diverse catechins in samples were determined by HPLC-UV analysis. The results showed that the content of catechins in the GTE is around 77% (w/w), the major components being (-)-epigallocatechin gallate, (-)-epicatechin gallate, and (-)-epicatechin. A variation in the concentration profile of catechins was detected during the oxidation process. The chromatographic study demonstrated that (-)-gallocatechin, (-)- epigallocatechin, (+)-catechin, and (-)-catechin gallate exhibited the most radical scavenging.

Effects of magnesium on central arterial compliance in preeclampsia

OBJECTIVE

The objective of the study was to investigate the effect of MgSO4 infusion on central arterial compliance, using radial artery applanation tonometry in women with preeclampsia.

STUDY DESIGN

Seventy women with preeclampsia were prospectively recruited. Radial pulse waveforms were obtained and the aortic waveforms constructed. The arterial compliance surrogates, augmentation pressure (AP) and augmentation index (AIx-75), were derived from the aortic waveform and then compared: prior to MgSO4 (t1), 1 hour after MgSO4 bolus (t2), 4 hours after MgSO4 infusion (t3), and 24 hours after MgSO4 cessation (t4). Statistical analysis was performed using differences of least squared means with Tukey Kramer adjustments.

RESULTS

The AP and AIx-75 at t2-t4 were significantly lower compared with t1, with the greatest decrease in arterial stiffness at t3 (P<.05).

CONCLUSION

In preeclampsia, MgSO4 improved central arterial compliance. This effect was most exaggerated after 4 hours of infusion and remained 24 hours following MgSO4 completion, suggesting either a sustained arterial compliance effect or resolution of the vasoconstrictive effect of preeclampsia.

Discussion: 'Microcephaly associated with congenital heart defect' by Barbu et al

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Barbu D, Mert I, Kruger M, Bahado-Singh RO. Evidence of fetal central nervous system injury in isolated congenital heart defect: microcephaly at birth. Am J Obstet Gynecol 2009;201:43.e1-7.

Identification of supportive care needs in a sample of Puerto Rican cancer patients with the Supportive Care Needs Survey-34 (SCNS-34)

e20697

Background: The assessment of supportive care needs is important in the management of cancer patients. The Supportive Care Needs Survey (SCNS-34) was administered to a population of Puerto Rican cancer patients to assess their perceived needs in five domains (psychological, health system and information, physical and daily living, patient care and support, and sexuality.) Methods: Patients attending the surgical, radiation and medical oncology clinics at the Puerto Rico Medical Center participated in the study. After informed consent, patients completed the Spanish- Puerto Rican translation of the SCNS-34. A second instrument to measure the quality of the SCNS-34 was administered. Demographic and clinical data was obtained from medical records. Descriptive, univariate and multivariate analysis was performed to assess correlation between reported needs and demographic and clinical data. To assess the validity and consistency of the Spanish Puerto Rican translation of the SCNS-34, the Cronbach's alpha test was used. Results: A total of 103 patients participated in the study (female n=66; male n=37). Median age was 54 years. The most common malignancies were breast cancer (29 patients), gynecologic cancers (22 patients), prostate cancer (17 patients) and gastrointestinal cancers (14 patients). The overall internal consistency of the instrument was 0.882. Patients perceived needs were highest in the domains of sexuality (67%), physical and daily living (55.3%), and psychological (38.8%). Logistic regression analysis demonstrated that younger age was an independent predictor of perceived needs in the psychologic domain (p=0.010). Also, a diagnosis of breast cancer was a significant predictor of perceived needs in the health system and information domain (p=0.020). Being a female was correlated with reporting needs in the domain of physical and daily living (p=0.009). Educated patients were more prone to perceive needs in the domains of sexuality (p=0.045). Conclusions: The Spanish- Puerto Rican translation of the Supportive Care Needs Survey (SCNS-34) showed satisfactory internal consistency and validity. The supportive care needs of Puerto Ricans cancer patients seem to be affected by age, gender, and cancer site.

No significant financial relationships to disclose.

Mycobacterium tuberculosis 38-kDa lipoprotein is apoptogenic for human monocyte-derived macrophages

Mycobacterium tuberculosis is the main aetiologic agent of tuberculosis, a disease of great concern in less-developed regions. Apoptosis is a conspicuous event in macrophages infected in vitro with mycobacteria, a phenomenon also observed in vivo in granulomas of patients with tuberculosis. To determine its significance, it is important to define the mycobacterial moieties involved and how they cause apoptosis. Here we show that the 38-kDa lipoprotein induces macrophage caspase-dependent apoptosis involving TNF-alpha and FasL and, interestingly, with the upregulation of cell-death receptors TNFR1, TNFR2 and Fas. A role for the Toll-like receptor 2 was also demonstrated. In conclusion, the ability to induce apoptosis of host cells is another property of the 38-kDa lipoprotein, a molecule that has focused attention for being an immunodominant antigen that participates in phosphate transport.

Minimally invasive surgery for splenic malignancies

While minimally invasive surgery, i.e. laparoscopy, has become well-accepted in the treatment algorithm for malignancies of the gastrointestinal tract and gynecologic tumors, the role of laparoscopy for malignancies involving the spleen is less clear. Initially described in 1992 for benign hematologic disease, laparoscopic splenectomy (LS) for splenic malignancy was avoided secondary to the severe hematologic disease, profound cytopenia, and massive splenomegaly frequently seen in these patients. As experience with LS grew and larger data were generated, it became clear that hematologic malignancy and splenomegaly could be safely managed laparoscopically. In experienced hands, LS can be used for the diagnosis and treatment of both lymphoproliferative and myeloproliferative disorders affecting spleen, in addition to splenic tumors of both primary and metastatic origin. LS can be performed from a lateral or anterior approach, and hand-assisted laparoscopic splenectomy can provide significant benefit in cases of massive splenomegaly. Preoperative imaging for accurate splenic measurement is invaluable to guide surgical planning. Triple vaccination should be given to all patients prior to surgery, and splenic artery embolization before surgery should be considered in patients with massive splenomegaly to reduce intraoperative bleeding. LS can be performed safely for nearly all cases of malignancy involving the spleen, and potentially offers significant advantages of decreased pain and recovery time while maintaining equivalent complications and survival compared to open splenectomy.

An increase of acidic isoform of catalase in red blood cells from HIV(+) population

A systemic oxidative stress of HIV (+) individuals has been recognized from a low glutathione level and a high level of inflammatory cytokines such as TNF alpha. Previously, we demonstrated that the catalase enzyme activity in HIV (+) population is significantly altered depending on the cell types; the level was significantly high in red blood cells while the enzymes in white blood cells were remarkably low (Res Commun Subs Abuse 16: 161-176, 1995). In this study, we further characterized the difference in RBC catalase molecules between HIV (+) and control population. We have found that RBC from HIV (+) population, whether they were asymptomatic or symptomatic, contained a significantly elevated catalase protein accompanied by the enzyme activities, and that the majority of the elevated protein were acidic pI of the molecules with an identical subunit mass of approximately 60 KDa. These results suggest that catalase is induced prior to and/or during erythroid differentiation lineage in HIV (+) population as a somatic defense to respond and compensate for a systemic oxidative stress and for an anemic condition.

Ventral mesencephalic and cortical transplants into the rat striatum display enhanced activity for neutral endopeptidase 24.11 ('enkephalinase'; CALLA)

A role for neutral endopeptidase 24.11 (NEP) in growth and development is supported by the demonstration that NEP hydrolyses and inactivates a number of peptide growth factors including atrial natriuretic peptide, endothelins, bombesin-like peptides, and opioid peptides, including the enkephalins. In the present study, suspensions of cells obtained from the ventral mesencephalon or cortex of rat embryos (ED14) were implanted into the striatum of the adult rat brain. Three to 15 weeks after transplantation the relative distribution of NEP-positive cellular elements was visualized histochemically. NEP staining in the transplants consistently appeared before NEP staining in the surrounding host striatum supporting a relative increase in NEP activity in the transplants. The NEP staining richly visualized cells of varying size and morphology which lacked the normal organization of the host striatum. The histochemical staining in the transplants and the surrounding host tissue was completely blocked by a 100 nM concentration of the selective NEP inhibitors phosphoramidon or JHF-26, supporting the exclusive localization of NEP by this method. NEP localization in the embryonic (ED14) cortex and ventral mesencephalon was also confirmed, suggesting one possible origin for the NEP-positive cells visualized in the transplants. Fluorescent double-labeling studies for NEP and glial fibrillary acidic protein (GFAP) or transforming growth factor alpha precursor (TGF alpha p) revealed the presence of rich glial labeling within the transplants for both GFAP and TGFap. NEP-labeled cells in the transplants were closely associated with glial elements, however, only occasional glial elements in the transplants stained for NEP; supporting a non-astrocytic localization for the NEP in the transplants. The marked enhancement of NEP staining in the transplants may have significance for controlling the rate or pattern of growth of the transplanted cells through inactivation of peptide growth factors produced by, or in response to, the transplants.

Treatment of urinary tract infection with norfloxacin. Analysis of cost

Twenty-five patients with urinary tract infection were treated with norfloxacin, a fluoroquinolone antibacterial with a wide spectrum of activity for an oral agent. Of 22 patients who were evaluable, 20 had complicated urinary tract infection; infection was cured in 19 patients at one week after treatment. Optimal alternative treatments were also selected in norfloxacin's stead, based on each patient's characteristics and the results of susceptibility testing for each isolated pathogen. Direct costs for alternative treatment ranged from $7 to $970. The results indicated that for those patients with suspected or proven urinary tract infection caused by multiresistant bacteria, therapy with norfloxacin may represent a cost-effective choice.

Liquid Chromatographic Determination of Chlorpropamide in Tablet Dosage Forms: Collaborative Study

A reverse-phase liquid chromatographic method was developed for determining chlorpropamide in tablet dosage forms. Linearity was established over the range 0.2-2.0 μg at a wavelength of 240 nm. The Associate Referee obtained a mean recovery for a synthetic tablet mixture of 99.2%, with a relative standard deviation (RSD) of 1.41. For an authentic tablet mixture, collaborators obtained a mean recovery of 99.6% with an RSD of 0.60%. RSDs were 1.24% for 250 mg/tablet commercial product and also for 100 mg/tablet commercial product. The method has been adopted official first action.

High pressure liquid chromatographic determination of mono- and disaccharides in presweetened cereals: Collaborative study

A collaborative study was conducted using a modified AOAC method (sugars in chocolate) for the determination of fructose, glucose, sucrose, and maltose in presweetened cereals by high pressure liquid chromatography (HPLC). Eight samples consisting of 6 products were analyzed in duplicate by the HPLC method and the AOAC Lane-Eynon method. The AOAC method was modified to use water-alcohol (1 + 1) and Sep-Pak C18 cartridges for sample cleanup. The HPLC results indicate precision comparable to the lane-Eynon method and the chocolate method. The modified HPLC method has been adopted official first action.

General practitioners' evaluation of side-effects and efficacy of oxamethacin as compared with indomethacin

Sixteen general practitioners conducted a multicentre double-blind clinical trial to compare oxamethacin (100 mg t.i.d.) with indomethacin (50 mg t.i.d.) for a maximum duration of 2 weeks. Each drug was administered to 339 patients suffering from various pathological conditions requiring a non-steroidal anti-inflammatory drug. When focusing on patients without associated drug therapy, 126/259 patients (50%) presented a good response on inflammation under oxamethacin and 98/236 patients (42%) a good response under indomethacin (p less than 10(-2)); 141/250 patients (56%) presented a good response on pain under oxamethacin and 117/236 (50%) under indomethacin (p less than 5.10(-2)). Side effects and complaints were reported by 34/250 patients (14%) under oxamethacin and by 67/236 (28%) under indomethacin (p less than 5.10(-5)). Some patients stopped treatment because of side-effects: 14/250 (6%) under oxamethacin and 32/236 (14%) under indomethacin (p less than 2.10(-3)).

Oxamethacin: a pilot field survey

Two hundred sixty-four general practice patients were treated with oxamethacin (100 mg b.i.d.) and 261 with indomethacin (50 mg b.i.d.) for a maximum period of two weeks. Both drugs showed equally good analgesic and anti-inflammatory effects. Thirty-six patients (14%) treated with oxamethacin and sixty patients (23%) treated with indomethacin reported side-effects. Among them, seventeen patients on oxamethacin (6%) and forty-tree patients on indomethacin (16.5%) reported gastro-intestinal disorders. Side-effects necessitated interruption of treatment in fourteen patients (5%) on oxamethacin and in thirty-three patients (13%) on indomethacin.