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Simpson HJ, Eide DB, Helmers RA, Craig JE, Salimes BG. One Hospital-Five Doors: A Model for Critical Access Hospital Sustainability. WMJ 2023; 122:44-47. [PMID: 36940121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
BACKGROUND We wanted to assess whether a regional approach to bed management and staffing could improve financial sustainability without reducing services in rural communities. METHODS Regional approaches to patient placement, hospital throughput, and staffing were coupled with enhanced services at 1 hub hospital and 4 critical access hospitals. RESULTS We improved the use of patient beds in the 4 critical access hospitals, increased hub hospital capacity, and improved the health system's financial performance while maintaining or enhancing services at the critical access hospitals. DISCUSSION Sustainability of critical access hospitals can be attained without a decrease in services for rural patients and communities. One way to achieve this result is to invest in and enhance care at the rural site.
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Affiliation(s)
- Henry J Simpson
- Mayo Clinic Health System - Northwest Wisconsin Region, Menomonie, Wisconsin,
| | - Dean B Eide
- Mayo Clinic Health System - Northwest Wisconsin Region, Osseo, Wisconsin
| | - Richard A Helmers
- Mayo Clinic Health System - Northwest Wisconsin Region, Eau Claire, Wisconsin
| | - Jason E Craig
- Mayo Clinic Health System - Northwest Wisconsin Region, Eau Claire, Wisconsin
| | - Bailey G Salimes
- Mayo Clinic Health System - Northwest Wisconsin Region, Eau Claire, Wisconsin
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2
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Singh G, Lenhart JG, Helmers RA, Eberle MR, Costley H, Roberts JB, Kaplan RS. Collaborative Rooming: An Innovative Pilot Project to Overcome Primary Care Challenges. WMJ 2022; 121:306-309. [PMID: 36637843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Primary care physicians are overburdened with growing complexities and increasing expectations for primary care visits. To meet expectations, primary care physicians must multitask during visits and spend extra hours in the office for charting, billing, and documentation. This impacts the physician's quality of life and may affect the quality of patient care. Many of the administrative tasks performed by physicians could, alternatively, be performed by nonphysician staff, leading to the adoption of team-based collaborative models. METHODS Mayo Clinic Health System piloted a team-based collaborative model in a small physician practice in Osseo, Wisconsin, where which staff could be trained quickly and efficiently. The model used medical assistants/licensed practical nurses (MA/LPN) to partner with primary care physicians during a patient visit. The LPN/MA, under physician supervision, ordered and monitored pending orders/labs, coordinated patient care, provided after-visit educational needs, and communicated other urgent messages to team members. RESULTS After 6 months, a comparison of pre- and posttrial data showed improved staff and patient satisfaction, decreased physician administrative work, and no cost-effectiveness improvement. Screening of medical conditions in the elderly improved, but no change was noted with chronic disease metrics. CONCLUSIONS Data showed improved staff and patient satisfaction, decreased physician clerical burden, increased appointment slots, mixed clinical outcomes, and did not demonstrate cost-effectiveness. The authors recommend that similar models be conducted in large settings to see if these results are reproducible.
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Affiliation(s)
| | - Jill G Lenhart
- Mayo Clinic Health System Northwest Wisconsin, Eau Claire, Wisconsin
| | - Richard A Helmers
- Mayo Clinic Health System Northwest Wisconsin, Eau Claire, Wisconsin
| | | | - Heather Costley
- Mayo Clinic Health System Northwest Wisconsin, Eau Claire, Wisconsin
| | - Joel B Roberts
- Mayo Clinic Health System Northwest Wisconsin, Eau Claire, Wisconsin
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3
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Grando MA, Vellore V, Duncan BJ, Kaufman DR, Furniss SK, Doebbeling BN, Poterack KA, Miksch T, Helmers RA. Study of EHR-mediated workflows using ethnography and process mining methods. Health Informatics J 2021; 27:14604582211008210. [PMID: 33853396 DOI: 10.1177/14604582211008210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rapid ethnography and data mining approaches have been used individually to study clinical workflows, but have seldom been used together to overcome the limitations inherent in either type of method. For rapid ethnography, how reliable are the findings drawn from small samples? For data mining, how accurate are the discoveries drawn from automatic analysis of big data, when compared with observable data? This paper explores the combined use of rapid ethnography and process mining, aka ethno-mining, to study and compare metrics of a typical clinical documentation task, vital signs charting. The task was performed with different electronic health records (EHRs) used in three different hospital sites. The individual methods revealed substantial discrepancies in task duration between sites. Specifically, means of 159.6(78.55), 38.2(34.9), and 431.3(283.04) seconds were captured with rapid ethnography. When process mining was used, means of 518.6(3,808), 345.5(660.6), and 119.74(210.3) seconds were found. When ethno-mining was applied instead, outliers could be identified, explained and removed. Without outliers, mean task duration was similar between sites (78.1(66.7), 72.5(78.5), and 71.7(75) seconds). Results from this work suggest that integrating rapid ethnography and data mining into a single process may provide more meaningful results than a siloed approach when studying of workflow.
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Love EA, Degen SC, Craig JE, Helmers RA. Activating the Hospital Incident Command System Response in a Community Specialty Practice: The Mayo Clinic Experience. WMJ 2021; 120:137-141. [PMID: 34255954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The COVID-19 pandemic presented health care organizations with a unique challenge in determining effective management of a large-scale incident across an extended time period. CASE PRESENTATION This report describes the response of a multisite integrated system to the COVID-19 pandemic through activation of the Hospital Incident Command System. DISCUSSION A robust emergency response plan with multidisciplinary involvement can help to ensure clear lines of accountability and expedite decision-making. Consistent physician input across affected specialties allows for a robust understanding of impacted areas, peer-to-peer communication, and a sense of ownership across the medical staff. The necessity of effective communication with staff and patients during times of crisis cannot be understated. The potential for information overload in a pandemic is significant but can be overcome through consistent and transparent communication from leadership. CONCLUSION Health systems should have a well-organized emergency response system prepared to launch in small-scale or large-scale situations. The threshold to implement the response system and accountability to make that decision must be a clearly defined organizational policy.
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Affiliation(s)
- Ellen A Love
- Mayo Clinic Health System Northwest Wisconsin, Eau Claire, Wisconsin,
| | - Susanne C Degen
- Mayo Clinic Health System Northwest Wisconsin, Eau Claire, Wisconsin
| | - Jason E Craig
- Mayo Clinic Health System Northwest Wisconsin, Eau Claire, Wisconsin
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Craig JE, Martin-Krajewski CA, Bledsoe JM, Wensink LJ, Crawford NS, Eberhardt AM, Grottke KL, Helmers RA. Regional Specialty Surgical Practice Efficiencies Gained as a Result of COVID-19. Mayo Clin Proc Innov Qual Outcomes 2021; 5:693-699. [PMID: 34151194 PMCID: PMC8205250 DOI: 10.1016/j.mayocpiqo.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To identify opportunities for discontinuing elective and nonemergency surgical cases in a regional surgical practice in response to coronavirus disease 2019 (COVID-19). Patients and Methods COVID-19 began to affect surgical practices across the United States in March 2020. On March 17, 2020, all elective and nonemergency surgical care was deferred to prepare the Mayo Clinic Health System sites in northwestern Wisconsin for an anticipated surge in patients with COVID-19. When the decision was made to reactivate the surgical practice, several major structural and operational changes were made to the regional surgical practice to optimize efficiencies. Results The structural and operational changes implemented during reactivation resulted in improved utilization of surgical resources including improvement in operating room (OR) block utilization, increased available OR time, and increased case volumes. Conclusion Surgical and procedural leaders should consider a limited-time deferral of elective surgical cases to implement widespread OR efficiency strategies. The time selected for deferral of surgical cases should target a period of historically low surgical volume to minimize disruption to patient care and impact on overall OR functions.
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Zheng L, Duncan BJ, Kaufman DR, Furniss SK, Grando A, Poterack KA, Helmers RA, Miksch TA, Doebbeling BN. EHR Conversion on the PreOp Care: A Pre-Post Workflow Comparison. AMIA Annu Symp Proc 2021; 2020:1402-1411. [PMID: 33936516 PMCID: PMC8075530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The impact of EHRs conversion on clinicians' daily work is crucial to evaluate the success of the intervention for Hospitals and to yield valuable insights into quality improvement. To assess the impact of different EHR systems on the preoperative nursing workflow, we used a structured framework combining quantitative time and motion study and qualitative cognitive analysis to characterize, visualize and explain the differences before and after an EHR conversion. The results showed that the EHR conversion brought a significant decrease in the patient case time and a reduced percentage of time using EHR. PreOp nurses spent a higher proportion of time caring for the patient, while the important tasks were completed in a more continuous pattern after the EHR conversion. The workflow variance was due to different nurse's cognitive process and the task time change was reduced because of some new interface features in the new EHR systems.
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Affiliation(s)
- Lu Zheng
- College of Health Solutions, Arizona State University, AZ, US
| | | | | | - Stephanie K Furniss
- College of Health Solutions, Arizona State University, AZ, US
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Adela Grando
- College of Health Solutions, Arizona State University, AZ, US
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Karl A Poterack
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
- Department of Anesthesiology, Mayo Clinic, AZ, US
| | - Richard A Helmers
- Department of Pulmonary Medicine, Mayo Clinic Health System, Northwest, Wisconsin, Eau Claire, WI, US
| | - Timothy A Miksch
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Brad N Doebbeling
- College of Health Solutions, Arizona State University, AZ, US
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
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7
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Duncan BJ, Kaufman DR, Zheng L, Grando A, Furniss SK, Poterack KA, Miksch TA, Helmers RA, Doebbeling BN. A micro-analytic approach to understanding electronic health record navigation paths. J Biomed Inform 2020; 110:103566. [PMID: 32937215 DOI: 10.1016/j.jbi.2020.103566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022]
Abstract
Clinician task performance is significantly impacted by the navigational efficiency of the system interface. Here we propose and evaluate a navigational complexity framework useful for examining differences in electronic health record (EHR) interface systems and their impact on task performance. The methodological approach includes 1) expert-based methods-specifically, representational analysis (focused on interface elements), keystroke level modeling (KLM), and cognitive walkthrough; and 2) quantitative analysis of interactive behaviors based on video-captured observations. Medication administration record (MAR) tasks completed by nurses during preoperative (PreOp) patient assessment were studied across three Mayo Clinic regional campuses and three different EHR systems. By analyzing the steps executed within the interfaces involved to complete the MAR tasks, we characterized complexities in EHR navigation. These complexities were reflected in time spent on task, click counts, and screen transitions, and were found to potentially influence nurses' performance. Two of the EHR systems, employing a single screen format, required less time to complete (mean 101.5, range 106-97 s), respectively, compared to one system employing multiple screens (176 s, 73% increase). These complexities surfaced through trade-offs in cognitive processes that could potentially influence nurses' performance. Factors such as perceptual-motor activity, visual search, and memory load impacted navigational complexity. An implication of this work is that small tractable changes in interface design can substantially improve EHR navigation, overall usability, and workflow.
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Affiliation(s)
- Benjamin J Duncan
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, USA.
| | - David R Kaufman
- Medical Informatics, SUNY Downstate Health Sciences University, Brooklyn, NY, USA.
| | - Lu Zheng
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, USA
| | - Adela Grando
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, USA; Informatics and Knowledge Management Services, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Stephanie K Furniss
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, USA; Informatics and Knowledge Management Services, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Karl A Poterack
- Informatics and Knowledge Management Services, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Department of Anesthesiology, Mayo Clinic, AZ, USA
| | - Timothy A Miksch
- Informatics and Knowledge Management Services, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Richard A Helmers
- Informatics and Knowledge Management Services, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Bradley N Doebbeling
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, USA; Informatics and Knowledge Management Services, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; School for the Science of Healthcare Delivery, Arizona State University, AZ, USA
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Bonnette KL, Smart JA, Morrey MA, Eide DB, Knospe CL, White PK, Helmers RA. The Development of a Daily Comprehensive and Multidisciplinary Health Care Leadership Huddle. WMJ 2020; 119:205-210. [PMID: 33091291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Consistent and concise communication in a large health care organization that is geographically dispersed is a challenge. Issues often are not addressed with the appropriate individuals in the most timely and effective manner, which results in patient flow disruptions, service gaps, and provider and administrator frustration. CASE PRESENTATION This report describes the development of a daily leadership huddle with regional leadership and middle management to inform of daily operations, safety, quality, and service concerns, in order to allow for quicker action and issue resolution. DISCUSSION Huddles have proven effective in organizations of similar size, but few organizations have attempted a multisite daily huddle. CONCLUSION To ensure their success, key steps must be taken during the formation of daily leadership huddles, including buy-in from leaders and stakeholders at multiple levels. In our organization, the huddles have proven to be a forum for effective communication, quicker issue resolution, and an increased sense of camaraderie.
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Affiliation(s)
| | | | | | - Dean B Eide
- Mayo Clinic Health System, Eau Claire, Wisconsin
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9
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Vellore VR, Grando MA, Duncan B, Kaufman DR, Furniss SK, Doebbeling BN, Poterack KA, Miksch T, Helmers RA. Process Mining and Ethnography Study of Medication Reconciliation Tasks. AMIA Annu Symp Proc 2020; 2019:1167-1176. [PMID: 32308914 PMCID: PMC7153070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
We studied the medication reconciliation (MedRec) task through analysis of computer logs and ethnographic data. Time spent by healthcare providers performing MedRec was compared between two different EHR systems used at four different regional perioperative settings. Only one of the EHRs used at two settings generated computer logs that supported automatic discovery of the MedRec task. At those two settings, 53 providers generated 383 MedRec instances. Findings from the computer logs were validated with ethnographic data, leading to the identification and removal of 47 outliers. Without outliers, one of the settings had slightly smaller mean (SD) time in seconds 67.3 (40.2) compared with the other, 92.1 (25). The difference in time metrics was statistically significant (p<.001). Reusability of an existing task-based analytic method allowed for rapid study of EHR-based workflow and task.
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Affiliation(s)
| | - M Adela Grando
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, US
| | - Benjamin Duncan
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, US
| | - David R Kaufman
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, US
| | - Stephanie K Furniss
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, US
- Kern Center Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Bradley N Doebbeling
- Biomedical Informatics, College of Health Solutions, Arizona State University, AZ, US
- Science of Healthcare Delivery, Arizona State University, AZ, US
| | - Karl A Poterack
- Kern Center Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
- Department of Anesthesiology, Mayo Clinic, AZ, US
| | - Timothy Miksch
- Kern Center Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
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10
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Bobade RA, Helmers RA, Jaeger TM, Odell LJ, Haas DA, Kaplan RS. Time-driven activity-based cost analysis for outpatient anticoagulation therapy: direct costs in a primary care setting with optimal performance. J Med Econ 2019; 22:471-477. [PMID: 30744455 DOI: 10.1080/13696998.2019.1582058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To determine how overall cost of anticoagulation therapy for warfarin compares with that of Novel Oral Anticoagulants (NOACs). Also, to demonstrate a scientific, comprehensive, and an analytical approach to estimate direct costs involved in monitoring and management of anticoagulation therapy for outpatients in an academic primary care clinic setting, post-initiation of therapy. METHODS A population-based cross-sectional study was conducted in conjunction with observations of patient care processes between August 2014 and January 2015. The study was conducted in an academic primary care outpatient setting at Mayo Clinic's warfarin anticoagulation clinic, Rochester, MN. The anticoagulation clinic serves patients 18 years of age or older in Warfarin therapy management, for any indication, after referral from the patient's primary care provider. The study included anticoagulation clinic enrollment data on a population of 5,526 patients. Time-Driven Activity-Based Costing (TDABC) technique was applied. Detailed process flow maps which showed process steps for all the anticoagulation program components and care continuum phases were created. Staff roles associated with each of the process steps were identified and displayed on the maps. Process times and costs were captured and analyzed. The main outcome was direct cost of monitoring and management of anticoagulation therapy, post-initiation of therapy. RESULTS The cost of warfarin management for patients who display unstable International Normalized Ratio (INR) is more than three times those who display stable INR over time. (Comparator to distinguish stability: Frequency of point-of-care visits needed by patients.) For complex anticoagulation patients, total cost of medication and monitoring for warfarin anticoagulation therapy is similar to that for NOACs. CONCLUSION Despite warfarin being significantly less expensive to purchase than NOACs, overall warfarin management incurs higher costs due to laboratory monitoring and provider time than NOACs. NOAC treatment, therefore, may not be more expensive than warfarin therapy management for complex anticoagulation patients.
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Affiliation(s)
- Rohit A Bobade
- a Surgical Specialties Division , Mayo Clinic Health System , La Crosse , WI , USA
| | - Richard A Helmers
- b Critical Care Medicine , College of Medicine , Mayo Clinic, Eau Claire , WI , USA
| | - Thomas M Jaeger
- c Community Internal Medicine , College of Medicine , Rochester , MN , USA
| | - Laura J Odell
- d Global Business Solutions , Mayo Clinic , Rochester , MN , USA
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11
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Heaton HA, Nestler DM, Barry WJ, Helmers RA, Sir MY, Goyal DG, Haas DA, Kaplan RS, Sadosty AT. A Time-Driven Activity-Based Costing Analysis of Emergency Department Scribes. Mayo Clin Proc Innov Qual Outcomes 2019; 3:30-34. [PMID: 30899906 PMCID: PMC6408681 DOI: 10.1016/j.mayocpiqo.2018.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/20/2018] [Accepted: 11/30/2018] [Indexed: 11/24/2022] Open
Abstract
Objective To apply time-driven activity-based costing (TDABC) methodology to determine emergency medicine physician documentation costs with and without scribes. Methods This was a prospective observation cohort study in a large academic emergency department. Two research assistants with experience in physician–scribe interactions and ED workflow shadowed attending physicians for a total of 64 hours in the adult emergency department. A tablet-based time recorded was used to obtain estimates for physician documentation time on both control (no scribe) and intervention (scribe) shifts. Results Control shifts yielded approximately 3 hours of documentation time per 8 hours of clinical time (2 hours during the shift, 1 hour following the shift). When paired with a scribe, attending physician documentation decreased to 1 hour and 45 minutes during a shift and 15 minutes of postshift documentation. The physician cost estimate for documentation without and with a scribe is 644 and 488 dollars, respectively. Conclusions When one looks at the time saved by the provider, scribes appear to be a financially sound decision. TDABC methodology demonstrated that scribes afford a cost-effective solution to ED clinical documentation and serves as a tool to develop an accurate costing system, based on actual resources and processes, and allowed for understanding of resource use at a more granular level.
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Affiliation(s)
| | - David M Nestler
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - William J Barry
- Management Engineering and Internal Consulting, Mayo Clinic, Rochester, MN
| | | | - Mustafa Y Sir
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Deepi G Goyal
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Derek A Haas
- Harvard Business School, Boston, MA.,Avant-garde Health, Boston, MA
| | | | - Annie T Sadosty
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
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Grando A, Manataki A, Furniss SK, Duncan B, Solomon A, Kaufman D, Hirn S, Sunday R, Bouchereau J, Doebbeling B, Burton MM, Poterack KA, Miksch T, Helmers RA. Multi-Method Study of Electronic Health Records Workflows. AMIA Annu Symp Proc 2018; 2018:498-507. [PMID: 30815090 PMCID: PMC6371265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
EHRs transform work practices in ways that enhance or impede the quality of care. There is a need for in-depth analysis of EHR workflows, particularly in complex clinical environments. We investigated EHR-basedpre-operative workflows by combining findings from 18 interviews, 7 days of observations, and process mining of EHR interactions from 31 personnel caring for 375 patients at one tertiary referral center. We provided high-definition descriptions of workflows and personnel roles. One third (32.2%) of the time with each patient was spent interacting with the EHR and 4.2% using paper-based artifacts. We also mined personnel social networks validating observed personnel's EHR-interactions. When comparing workflows between two similar pre-operative settings at different hospitals, we found significant differences in physical organization, patient workflow, roles, use of EHR, social networks and time efficiency. This study informs Mayo Clinic's enterprise-wide conversion to a single EHR and will guide before and after workflow comparisons.
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Affiliation(s)
- Adela Grando
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Areti Manataki
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Stephanie K Furniss
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Benjamin Duncan
- Department of Biomedical Informatics, Arizona State University, AZ, US
| | - Andrew Solomon
- Department of Biomedical Informatics, Arizona State University, AZ, US
| | - David Kaufman
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Sarah Hirn
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Robert Sunday
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Joanne Bouchereau
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Brad Doebbeling
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
- School for the Science of Healthcare Delivery, Arizona State University, AZ, US
| | - Matthew M Burton
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | | | - Tim Miksch
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Richard A Helmers
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
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Duncan BJ, Zheng L, Furniss SK, Solomon AJ, Doebbeling BN, Grando G, Burton MM, Poterack KA, Miksch TA, Helmers RA, Kaufman DR. In Search of Vital Signs: A Comparative Study of EHR Documentation. AMIA Annu Symp Proc 2018; 2018:1233-1242. [PMID: 30815165 PMCID: PMC6371263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Vital sign documentation is an essential part of perioperative workflow. Health information technology can introduce complexity into all facets of documentation and burden clinicians with high cognitive load3-4. The Mayo Clinic enterprise is in the process of documenting current EHR-mediated workflow prior to a system-wide EHR conversion. We compared and evaluated three different vital sign documentation interfaces in pre-operative nursing assessments at three different Mayo Clinic sites. The interfaces differed in their modes of interaction, organization of patient information and cognitive support. Analyses revealed that accessing displays and the organization of interface elements are often unintuitive and inefficient, creating unnecessary complexities when interacting with the system. These differences surface through interface workflow models and interactive behavior measures for accessing, logging and reviewing patient information. Different designs differentially mediate task performance, which can ultimately mitigate errors for complex cognitive tasks, risking patient safety. Identifying barriers to interface usability and bottlenecks in EHR-mediated workflow can lead to system redesigns that minimize cognitive load while improving patient safety and efficiency.
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Affiliation(s)
- Benjamin J Duncan
- Department of Biomedical Informatics, Arizona State University, AZ, US
| | - Lu Zheng
- Department of Biomedical Informatics, Arizona State University, AZ, US
| | - Stephanie K Furniss
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Center for Translational Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Andrew J Solomon
- Department of Biomedical Informatics, Arizona State University, AZ, US
| | - Brad N Doebbeling
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Center for Translational Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
- School for the Science of Healthcare Delivery, Arizona State University, AZ, US
| | - Grando Grando
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Center for Translational Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Matthew M Burton
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Center for Translational Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | | | - Timothy A Miksch
- Center for Translational Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Richard A Helmers
- Center for Translational Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - David R Kaufman
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Center for Translational Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
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Duncan BJ, Zheng L, Furniss SK, Doebbeling BN, Grando A, Solomon AJ, Burton MM, Poterack KA, Miksch TA, Helmers RA, Kaufman DR. Perioperative Medication Management: Reconciling Differences across Clinical Sites. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/2327857918071010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medication reconciliation (MedRec) is a mission-critical process which can serve to reduce adverse drug events (ADEs) in surgical settings. However, providing quality care is limited by current health information technology (IT), which is often inefficient and unintuitive due to poor usability, resulting in high cognitive burden. We have been characterizing EHR mediated workflow in the Mayo Clinic enterprise prior to a system-wide electronic health records (EHR) conversion in order to harmonize workflows. We compared and evaluated MedRec processes in pre-operative nursing assessments across two different EHRs in place in different locales at baseline. The interfaces differed both in their modes of interaction and cognitive support. Analyses surfaced interface elements that were unintuitive and inefficient, creating unnecessary complexities in clinicians’ interactive behavior. Keystroke level models (KLM), a modeling tool for predicting task completion time, showed that to access medication lists required a different series of operations across the two systems. Different designs can differentially mediate task performance, which can aid in the mitigation of errors for complex cognitive tasks. Identification of barriers in EHR-mediated workflow and barriers to interface usability could lead to system redesigns that minimize cognitive load while improving patient safety and efficiency.
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Affiliation(s)
| | - Lu Zheng
- Department of Biomedical Informatics, Arizona State University, AZ, US
| | - Stephanie K. Furniss
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Bradley N. Doebbeling
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
- School for the Science of Healthcare Delivery, Arizona State University, AZ, US
| | - Adela Grando
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Andrew J. Solomon
- Department of Biomedical Informatics, Arizona State University, AZ, US
| | - Matthew M. Burton
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | | | - Timothy A. Miksch
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Richard A. Helmers
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - David R. Kaufman
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
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Grando A, Groat D, Furniss SK, Nowak J, Gaines R, Kaufman DR, Poterack KA, Miksch T, Helmers RA. Using Process Mining Techniques to Study Workflows in a Pre-operative Setting. AMIA Annu Symp Proc 2018; 2017:790-799. [PMID: 29854145 PMCID: PMC5977611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Information technologies have transformed healthcare delivery and promise to improve efficiency and quality of care. However, in-depth analysis of EHR-mediated workflows is challenging. Our goal was to apply process mining, in combination with observational techniques, to understand EHR-based workflows. We reviewed nearly 76,000 event logs from 15 providers and supporting staff, and 142 patients in a pre-operative setting and we inspected 3 weeks of interviews and video observations. We found that on average 44 minutes were spent per patient interacting with the EHR, 55% of the time of the patient visit was spent by personnel interacting with the EHR and for over 5% of the time personnel used or reviewed paper-based artifacts. We also discovered the handover-of-care network and compared frequency of interactions between personnel. This study suggests that applying process mining in combination with observational techniques has vast potential for informing Mayo Clinic in the forthcoming EHR conversion.
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Affiliation(s)
- Adela Grando
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
| | - Danielle Groat
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
| | - Stephanie K Furniss
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
- Mayo Clinic, Rochester, MN
| | - Joshua Nowak
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
- Department of Biomedical Engineering, Arizona State University, Phoenix, AZ
| | - Regina Gaines
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
| | - David R Kaufman
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
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Helmers RA, Dilling JA, Chaffee CR, Larson MV, Narr BJ, Haas DA, Kaplan RS. Overall Cost Comparison of Gastrointestinal Endoscopic Procedures With Endoscopist- or Anesthesia-Supported Sedation by Activity-Based Costing Techniques. Mayo Clin Proc Innov Qual Outcomes 2017; 1:234-241. [PMID: 30225422 PMCID: PMC6132202 DOI: 10.1016/j.mayocpiqo.2017.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
OBJECTIVE Endoscopic/colonoscopic procedures are either done with gastroenterologist-administered conscious sedation or with anesthesia-administered sedation with propofol. There are potential benefits to anesthesia-administered sedation, but the concern has been the associated increased cost. METHODS To perform this study, we used the time-derived activity-based costing (TDABC) technique to accurately assess the true cost of gastrointestinal procedures done with gastroenterologist-administered conscious sedation vs anesthesia-administered sedation in 2 areas of our practice that use predominantly conscious sedation or anesthesia-administered sedation. This type of study has never been reported using such an integrated approach. This study was performed on 2 different days in June 2015. RESULTS The true cost associated with anesthesia-administered sedation in our practice was associated with only 9% to 24% greater cost when the TDABC technique was applied. CONCLUSION Gastrointestinal procedures with anesthesia-administered sedation are not as costly when all factors are considered. Using novel approaches to cost measurement, such as the TDABC, allows a total cost measurement approach across an episode of care that existing cost measurements in health care are incapable of.
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Affiliation(s)
- Richard A. Helmers
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Scottsdale, AZ
- Correspondence: Address to Richard A. Helmers, MD, Mayo Clinic Health System, Administration Building, 1400 Bellinger St, Eau Claire, WI 54703.
| | | | | | - Mark V. Larson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Bradly J. Narr
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Derek A. Haas
- Institute for Strategy & Competitiveness, Harvard Business School, Boston, MA
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Helmers RA, Kaplan RS. TDABC in primary care: Results of a Harvard/Mayo Clinic collaboration. Healthc Financ Manage 2016; 70:35-41. [PMID: 29893527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Helmers RA, Gabrielson SR, Harper MM. DEVELOPING A NEW GOVERNANCE STRUCTURE: THE MAYO CLINIC EXPERIENCE. Physician Leadersh J 2016; 3:40-45. [PMID: 27295745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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19
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Rank MA, Ochkur SI, Lewis JC, Teaford HG, Wesselius LJ, Helmers RA, Lee NA, Nair PK, Lee JJ. Nasal and Pharyngeal Eosinophil Peroxidase Levels Represent Surrogate Biomarkers for the Presence of Lower Airway Eosinophils in Adults with Poorly Controlled Asthma. J Allergy Clin Immunol 2016. [DOI: 10.1016/j.jaci.2015.12.480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Helmers RA, Byrne TJ, Wesselius LJ, Leslie KO. Serious Pulmonary Toxicity Secondary to Novel Hepatitis C Antiviral Therapy in a Liver Transplant Recipient. Mayo Clin Proc 2015; 90:1294-7. [PMID: 26231293 DOI: 10.1016/j.mayocp.2015.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 05/25/2015] [Accepted: 06/17/2015] [Indexed: 11/30/2022]
Abstract
Historically, the treatment of hepatitis C virus infection has been difficult, but therapeutic options have improved markedly recently because of the development of novel antiviral therapies. These therapies have been well tolerated. We describe a patient who was receiving such therapy and had development of temporally related and histologically confirmed severe pulmonary toxicity. Pulmonary toxicity should be considered a potential serious complication of novel antiviral therapy for hepatitis C virus infection.
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Affiliation(s)
| | - Thomas J Byrne
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ
| | | | - Kevin O Leslie
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, AZ
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Abstract
Nitrofurantoin-induced lung toxicity is relatively common, but rare histologic patterns sometimes occur that may make diagnosis difficult. We present the case of a 69-year-old woman taking prophylactic nitrofurantoin for urinary tract infections, who developed granulomatous interstitial pneumonia. She improved with cessation of nitrofurantoin, without other therapy. To our knowledge, this is the fourth reported case of granulomatous interstitial pneumonia associated with nitrofurantoin, and the first to show complete resolution with cessation of the drug alone, without steroids. It is important to recognize that idiosyncratic reactions to nitrofurantoin can produce a wide spectrum of histologic patterns. Of these patterns, granulomatous interstitial pneumonia is a rarely evidenced manifestation (possibly because few cases undergo a confirmatory lung biopsy). Recognition of granulomatous interstitial pneumonia as a manifestation of nitrofurantoin toxicity can aid in early identification of the reaction and prompt withdrawal of the drug, both of which are essential to prevent long-term complications.
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Lee JJ, Jacobsen EA, Ochkur SI, McGarry MP, Condjella RM, Doyle AD, Luo H, Zellner KR, Protheroe CA, Willetts L, Lesuer WE, Colbert DC, Helmers RA, Lacy P, Moqbel R, Lee NA. Human versus mouse eosinophils: "that which we call an eosinophil, by any other name would stain as red". J Allergy Clin Immunol 2012; 130:572-84. [PMID: 22935586 DOI: 10.1016/j.jaci.2012.07.025] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 07/25/2012] [Accepted: 07/25/2012] [Indexed: 12/20/2022]
Abstract
The respective life histories of human subjects and mice are well defined and describe a unique story of evolutionary conservation extending from sequence identity within the genome to the underpinnings of biochemical, cellular, and physiologic pathways. As a consequence, the hematopoietic lineages of both species are invariantly maintained, each with identifiable eosinophils. This canonical presence nonetheless does not preclude disparities between human and mouse eosinophils, their effector functions, or both. Indeed, many books and reviews dogmatically highlight differences, providing a rationale to discount the use of mouse models of human eosinophilic diseases. We suggest that this perspective is parochial and ignores the wealth of available studies and the consensus of the literature that overwhelming similarities (and not differences) exist between human and mouse eosinophils. The goal of this review is to summarize this literature and in some cases provide experimental details comparing and contrasting eosinophils and eosinophil effector functions in human subjects versus mice. In particular, our review will provide a summation and an easy-to-use reference guide to important studies demonstrating that although differences exist, more often than not, their consequences are unknown and do not necessarily reflect inherent disparities in eosinophil function but instead species-specific variations. The conclusion from this overview is that despite nominal differences, the vast similarities between human and mouse eosinophils provide important insights as to their roles in health and disease and, in turn, demonstrate the unique utility of mouse-based studies with an expectation of valid extrapolation to the understanding and treatment of patients.
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Affiliation(s)
- James J Lee
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, USA.
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23
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Ochkur SI, Kim JD, Protheroe CA, Colbert D, Condjella RM, Bersoux S, Helmers RA, Moqbel R, Lacy P, Kelly EA, Jarjour NN, Kern R, Peters A, Schleimer RP, Furuta GT, Nair P, Lee JJ, Lee NA. A sensitive high throughput ELISA for human eosinophil peroxidase: a specific assay to quantify eosinophil degranulation from patient-derived sources. J Immunol Methods 2012; 384:10-20. [PMID: 22750539 PMCID: PMC3432656 DOI: 10.1016/j.jim.2012.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/20/2012] [Accepted: 06/20/2012] [Indexed: 11/19/2022]
Abstract
Quantitative high throughput assays of eosinophil-mediated activities in fluid samples from patients in a clinical setting have been limited to ELISA assessments for the presence of the prominent granule ribonucleases, ECP and EDN. However, the demonstration that these ribonucleases are expressed by leukocytes other than eosinophils, as well as cells of non-hematopoietic origin, limits the usefulness of these assays. Two novel monoclonal antibodies recognizing eosinophil peroxidase (EPX) were used to develop an eosinophil-specific and sensitive sandwich ELISA. The sensitivity of this EPX-based ELISA was shown to be similar to that of the commercially available ELISA kits for ECP and EDN. More importantly, evidence is also presented confirming that among these granule protein detection options, EPX-based ELISA is the only eosinophil-specific assay. The utility of this high throughput assay to detect released EPX was shown in ex vivo degranulation studies with isolated human eosinophils. In addition, EPX-based ELISA was used to detect and quantify eosinophil degranulation in several in vivo patient settings, including bronchoalveolar lavage fluid obtained following segmental allergen challenge of subjects with allergic asthma, induced sputum derived from respiratory subjects following hypotonic saline inhalation, and nasal lavage of chronic rhinosinusitis patients. This unique EPX-based ELISA thus provides an eosinophil-specific assay that is sensitive, reproducible, and quantitative. In addition, this assay is adaptable to high throughput formats (e.g., automated assays utilizing microtiter plates) using the diverse patient fluid samples typically available in research and clinical settings.
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Affiliation(s)
- Sergei I. Ochkur
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - John Dongil Kim
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
- Pulmonary Research Group, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Cheryl A. Protheroe
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Dana Colbert
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Rachel M. Condjella
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Sophie Bersoux
- Division of Primary Care, Department of Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Richard A. Helmers
- Division of Pulmonary Medicine, Department of Critical Care Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Redwan Moqbel
- Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Paige Lacy
- Pulmonary Research Group, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Elizabeth A. Kelly
- Division of Pulmonary Medicine, Department of Internal Medicine, University of Wisconsin Medical School, Madison, WI
| | - Nizar N. Jarjour
- Division of Pulmonary Medicine, Department of Internal Medicine, University of Wisconsin Medical School, Madison, WI
| | - Robert Kern
- Departments of Medicine and Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anju Peters
- Departments of Medicine and Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert P. Schleimer
- Departments of Medicine and Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Glenn T. Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology and Hepatology, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, National Jewish Health; Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora CO
| | - Parameswaran Nair
- Division of Respiratory, Department of Internal Medicine, McMaster University, Hamilton, Ontario Canada
| | - James J. Lee
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Nancy A. Lee
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
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24
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Nassar AA, Jaroszewski DE, Helmers RA, Colby TV, Patel BM, Mookadam F. Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia. Am J Respir Crit Care Med 2011; 184:8-16. [DOI: 10.1164/rccm.201010-1685pp] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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25
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Rady MY, Johnson DJ, Patel BM, Larson JS, Helmers RA. Influence of individual characteristics on outcome of glycemic control in intensive care unit patients with or without diabetes mellitus. Mayo Clin Proc 2005; 80:1558-67. [PMID: 16342648 DOI: 10.4065/80.12.1558] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To clarify the relationship of patient and critical illness characteristics (including any history of diabetes mellitus) to glycemic control with insulin and hospital mortality. PATIENTS AND METHODS A case-control descriptive study was performed of patients admitted to a tertiary-care center multidisciplinary closed intensive care unit (ICU) at Mayo Clinic Hospital in Phoenix, Ariz, between January 1, 1999, and December 31, 2003, after implementation of a glycemic management protocol. Hospital mortality, the primary outcome, was examined in nondiabetic and diabetic ICU patients receiving insulin and in patients not requiring insulin (control group). RESULTS Of 7285 patients, 2826 (39%) required insulin, 1083 of whom (15% of total) had a history of diabetes mellitus. The control group had a median (10th-90th percentile) glucose level of 118 mg/dL (range, 97-153 mg/dL) and a 5% mortality rate. The median glucose level was 134 mg/dL (range, 110-181 mg/dL) in nondiabetic patients and 170 mg/dL (121-238 mg/dL) in diabetic patients (P<.001), whereas mortality rates were 10% and 6%, respectively (P<.001). Compared with nondiabetic survivors, nondiabetic nonsurvivors had longer periods with glucose levels greater than 144 mg/dL. Diabetic nonsurvivors vs diabetic survivors had longer periods with glucose levels greater than 200 mg/dL. Poor glycemic control in nondiabetic patients was associated with increased insulin requirement and increased mortality. Critical illness characteristics that predicted poor glycemic control were advanced age, history of diabetes, cardiac surgery, postoperative complications, severity of illness, nosocomial infections, prolonged mechanical ventilation, or concurrent medications. CONCLUSIONS Critical illness characteristics determined glycemic control and clinical outcome in ICU patients. Acute insulin resistance was associated with worse outcomes in nondiabetic patients. Although critical illness characteristics influenced glycemic control, future evaluation of the effect of insulin administration and optimal glycemic control in ICU patients is necessary.
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Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care, Mayo Clinic Hospital, Phoenix, AZ 85054, USA
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26
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Cheung OY, Muhm JR, Helmers RA, Aubry MC, Tazelaar HD, Khoor A, Leslie KO, Colby TV. Surgical pathology of granulomatous interstitial pneumonia. Ann Diagn Pathol 2003; 7:127-38. [PMID: 12715340 DOI: 10.1053/adpa.2003.50018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Agranulomatous interstitial pneumonia is a form of diffuse lung disease in which granulomas are a component of the histologic findings. The differential diagnosis is quite broad, but most cases represent examples of either sarcoidosis, diffuse granulomatous infections, or hypersensitivity pneumonitis. "Hot tub lung" is a recently described form of granulomatous interstitial pneumonia that appears to have some features of diffuse infections and some features of hypersensitivity pneumonitis. The pathologist's approach to these conditions can be facilitated by giving careful attention to the anatomic distribution of the granulomas, the qualitative features of the granulomas, and the histologic changes in the lung tissue around and away from the granulomas. These features, along with the results of cultures and special stains for micro-organisms and clinical and radiologic correlation allow for a diagnosis in the vast majority of cases.
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Affiliation(s)
- Oi Yee Cheung
- Department of Pathology and Laboratory Medicine, Mayo Clinic, Scottsdale, AZ 85259, USA
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Abstract
Graves disease is an autoimmune thyroid condition characterized by the production of autoantibodies against the thyrotropin receptor. The autoantibodies mimic the effect of the hormone on thyroid cells, which stimulates autonomous production of thyroxine and triiodothyronine. It has been hypothesized that cross-reactivity of autoantibodies may result in Graves ophthalmopathy and dermopathy. A seldom-recognized feature of Graves disease is thymic hyperplasia. We report 2 patients with Graves disease and incidentally discovered anterior mediastinal masses presumed to be thymic hyperplasia. In both cases, these masses regressed spontaneously after treatment of hyperthyroidism.
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Affiliation(s)
- Adriane I Budavari
- Division of Community Internal Medicine, Mayo Clinic, Scottsdale, AZ 85259, USA
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28
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Khoor A, Leslie KO, Tazelaar HD, Helmers RA, Colby TV. Diffuse pulmonary disease caused by nontuberculous mycobacteria in immunocompetent people (hot tub lung). Am J Clin Pathol 2001; 115:755-62. [PMID: 11345841 DOI: 10.1309/jrdc-0mjv-aca3-2u9l] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
The clinicopathologic spectrum of infections due to nontuberculous mycobacteria (NTM) includes cavitary disease, opportunistic infection, and nodular disease associated with bronchiectasis. We report a less well-described manifestation of NTM infection: 10 immunocompetent patients without preexisting bronchiectasis had radiographic evidence of diffuse infiltrative lung disease. The most common symptoms were dyspnea, cough, hypoxia, and fever. All 10 patients had used a hot tub. Histologic examination revealed exuberant nonnecrotizing, frequently bronchiolocentric, granulomatous inflammation in all cases. In 1 case, necrotizing granulomas were also noted. The inflammation often was associated with patchy chronic interstitial pneumonia and organization. Cultures revealed NTM in all cases (Mycobacterium avium complex in all but 1 case), but staining for acid-fast bacilli was positive in only 1 case. Four patients received corticosteroids alone for presumed hypersensitivity pneumonia, 4 were treated with antimycobacterial therapy, and 2 received both. All patients demonstrated significant improvement at the time of follow-up. These findings suggest that disease due to NTM may manifest as diffuse infiltrates in immunocompetent adults and that hot tub use may be an important risk factor for this disease pattern.
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Affiliation(s)
- A Khoor
- Department of Pathology, Mayo Clinic, Jacksonville, FL, USA
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29
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Abstract
Pneumonitis is a serious and unpredictable side-effect of treatment with methotrexate (MTX) that may become life-threatening. The clinical and histological features of nine cases of MTX pneumonitis are reported and the literature reviewed. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxaemia and tachypnoea are always present and crackles are frequently audible. Chest radiography reveals a diffuse interstitial or mixed interstitial and alveolar infiltrate, with a predilection for the lower lung fields. Pulmonary function tests show a restrictive pattern with diminished diffusion capacity. Lung biopsy reveals cellular interstitial infiltrates, granulomas or a diffuse alveolar damage pattern accompanied by perivascular inflammation. These clinical and pathological findings are not specific to MTX pneumonitis and can be seen with other drug-induced lung toxicities. It is important that all patients receiving methotrexate be educated concerning this potential adverse reaction and instructed to contact their physicians should significant new pulmonary symptoms develop while undergoing therapy. If methotrexate pneumonitis is suspected, methotrexate should be discontinued, supportive measures instituted and careful examination for different causes of respiratory distress conducted.
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Affiliation(s)
- S Imokawa
- Dept of Laboratory Medicine and Pathology, Mayo Clinic Scottsdale, Arizona 85259, USA
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30
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Wechsler ME, Garpestad E, Flier SR, Kocher O, Weiland DA, Polito AJ, Klinek MM, Bigby TD, Wong GA, Helmers RA, Drazen JM. Pulmonary infiltrates, eosinophilia, and cardiomyopathy following corticosteroid withdrawal in patients with asthma receiving zafirlukast. JAMA 1998; 279:455-7. [PMID: 9466639 DOI: 10.1001/jama.279.6.455] [Citation(s) in RCA: 227] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
CONTEXT Zafirlukast is a potent leukotriene antagonist that recently was approved for the treatment of asthma. As use of this drug increases, adverse events that occur at low frequency or in populations not studied in premarketing clinical trials may become evident. OBJECTIVE To describe a clinical syndrome associated with zafirlukast therapy. DESIGN Case series. PATIENTS Eight adults (7 women and 1 man) with steroid-dependent asthma who received zafirlukast. MAIN OUTCOME MEASURES Development of a clinical syndrome characterized by pulmonary infiltrates, cardiomyopathy, and eosinophilia following the withdrawal of corticosteroid treatment. RESULTS The clinical syndrome developed while patients were receiving zafirlukast from 3 days to 4 months and from 3 days to 3 months after corticosteroid withdrawal. All 8 patients developed leukocytosis (range, 14.5-27.6 x 10(9)/L) with eosinophilia (range, 0.19-0.71). Six patients had fever (temperature >38.5 degrees C), 7 had muscle pain, 6 had sinusitis, and 6 had biopsy evidence of eosinophilic tissue infiltration. The clinical syndrome improved with discontinuation of zafirlukast treatment and reinitiation of corticosteroid treatment or addition of cyclophosphamide treatment. COMMENT Development of pulmonary infiltrates, cardiomyopathy, and eosinophilia may have occurred independent of zafirlukast use or may have resulted from an allergic response to this medication. We suspect that these patients may have had a primary eosinophilic infiltrative disorder that had been clinically recognized as asthma, was quelled by steroid treatment, and was unmasked following corticosteroid withdrawal facilitated by zafirlukast.
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Affiliation(s)
- M E Wechsler
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Gharagozloo F, Dausmann MJ, McReynolds SD, Sanderson DR, Helmers RA. Recurrent bronchogenic pseudocyst 24 years after incomplete excision. Report of a case. Chest 1995; 108:880-3. [PMID: 7656652 DOI: 10.1378/chest.108.3.880] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Bronchogenic cysts (BCs) are uncommon congenital anomalies. Due to the inherent complications, the mere presence of a BC should warrant surgical therapy. Partial excision of these structures leads to recurrence. Complete surgical excision using a thoracotomy or video-assisted thoracic surgery is the goal. We report a case of recurrent bronchogenic pseudocyst 24 years after initial excision. This case supports the argument for complete surgical excision of BCs at the time of diagnosis.
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Affiliation(s)
- F Gharagozloo
- Division of Cardiothoracic Surgery, Georgetown University School of Medicine, Washington, DC 20007, USA
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Mathur PN, Beamis JF, Helmers RA. PREFACE. Clin Chest Med 1995. [DOI: 10.1016/s0272-5231(21)00994-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Helmers RA, Sanderson DR. Rigid bronchoscopy. The forgotten art. Clin Chest Med 1995; 16:393-9. [PMID: 8521695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Rigid bronchoscopy is superior to flexible fiberoptic bronchoscopy in several clinical situations. General anesthesia is usually used with side port ventilation. In children, removal of foreign bodies is an important indication. Tracheal stricture dilatation and cryotherapy are indications in adults, but laser bronchoscopy has become the major indication for rigid bronchoscopy in adult medicine.
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Affiliation(s)
- R A Helmers
- Division of Thoracic Diseases and Critical Care, Mayo Clinic Scottsdale, Arizona, USA
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Schwartz DA, Helmers RA, Galvin JR, Van Fossen DS, Frees KL, Dayton CS, Burmeister LF, Hunninghake GW. Determinants of survival in idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 1994; 149:450-4. [PMID: 8306044 DOI: 10.1164/ajrccm.149.2.8306044] [Citation(s) in RCA: 228] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
To identify the determinants of survival in patients with idiopathic pulmonary fibrosis (IPF), we performed a survival analysis on 74 subjects with IPF. The study subjects were on average 64 yr of age (range, 25 to 83 yr), 62% were male, and 29% were never smokers. A tissue diagnosis was made in 67 (91%) of our study subjects. These subjects were followed for a mean period of 4 yr (range, 1.4 to 118.8 months) after the onset of pulmonary symptoms. During the period of observation, 41 subjects died (median survival = 28.2 months) and 33 continue to survive (median follow-up period = 60.9 months). A univariate analysis demonstrated that diminished survival was significantly associated with male gender (hazard ratio = 1.98; 95% confidence interval [CI] = 1.01-3.85), a higher FEV1/FVC ratio (hazard ratio = 1.82 [per 10% increase in the FEV1/FVC ratio]; 95% CI = 1.21-2.73), a lower percent predicted FVC (hazard ratio = 0.74; 95% CI = 0.60-0.91), a lower percent predicted total lung capacity (TLC) (hazard ratio = 0.75; 95% CI = 0.60-0.94), a lower percent predicted diffusing capacity of carbon monoxide (DLCO) (hazard ratio = 0.69; 95% CI = 0.53-0.89), a higher ILO profusion category on chest radiograph (hazard ratio = 3.52; 95% CI = 1.58-7.87), and an enhanced release of prostaglandin E2 (PGE2) by cultured alveolar macrophages (hazard ratio = 1.32 [per 10 pm/ml of PGE2]; 95% CI = 1.07-1.62).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D A Schwartz
- Department of Internal Medicine, Department of Veterans Administration Medical Center, Iowa City, Iowa
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Schwartz DA, Van Fossen DS, Davis CS, Helmers RA, Dayton CS, Burmeister LF, Hunninghake GW. Determinants of progression in idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 1994; 149:444-9. [PMID: 8306043 DOI: 10.1164/ajrccm.149.2.8306043] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive form of lung disease with a median survival of less than 5 yr. To address the progressive nature of this disease process, we investigated the determinants of decrements in lung function in patients with IPF. We prospectively evaluated 39 subjects with IPF. Our study subjects were followed for an average of 2 yr (range, 49 to 1,883 days) and lung function was measured on at least two separate occasions (mean = 9.1 separate tests) during the follow-up period. Since IPF is characterized by reduced lung volume and abnormal gas exchange, our analysis focused on the determinants of total lung capacity (TLC) and diffusing capacity of carbon monoxide (DLCO) during the period of observation. Although, on average, there was a 5.3% increase in the TLC and a 9.8% increase in DLCO between the first and last measure of lung function, 25% of the study population experienced a decline in the TLC and 28% of the study population experienced a decline in the DLCO. Decrements in TLC were independently associated with severe dyspnea (p = 0.01) and treatment with cyclophosphamide (p = 0.03). Decrements in DLCO were significantly and independently associated with more pack-years of cigarette smoking (p = 0.02), moderate (p = 0.03) or severe (p = 0.02) dyspnea, and treatment with cyclophosphamide (p = 0.0002). These findings indicate that several clinical characteristics are independently associated with subsequent declines in TLC and DLCO in patients with IPF.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D A Schwartz
- Department of Internal Medicine, Department of Veterans Administration Medical Center, Iowa City, Iowa
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Dayton CS, Schwartz DA, Helmers RA, Pueringer RJ, Gilbert SR, Merchant RK, Hunninghake GW. Outcome of subjects with idiopathic pulmonary fibrosis who fail corticosteroid therapy. Implications for further studies. Chest 1993; 103:69-73. [PMID: 8417939 DOI: 10.1378/chest.103.1.69] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
To evaluate the outcome of subjects with idiopathic pulmonary fibrosis (IPF) whose conditions clinically deteriorate while receiving corticosteroid therapy, we studied 12 of these subjects (7 male, 5 female) who received subsequent therapy with intravenous (IV) pulse cyclophosphamide (CPX). Seven of the 12 study subjects died during the course of therapy. Six of these subjects died of respiratory failure, and one died of cholecystitis. Among those who died, the mean age at diagnosis was 63 years compared with 57 years in those who have continued to survive (p = 0.29). Smoking status and pack-years of cigarette smoking were similar between those subjects who died and those who continue to survive. However, subjects who died received CPX for a mean of 6 months, while subjects still living have received CPX for a mean of 16 months (p = 0.01). Subjects who died were given a CPX a mean of 64 months after the onset of symptoms, compared with a mean of 50 months for subjects who are still alive (p = 0.57). Interestingly, there were no significant differences in measures of pulmonary function between living and dead subjects. In fact, measures of lung function and gas exchange remained stable in both groups throughout the period of observation. These data suggest that (1) measures of lung function may not be a reliable indicator of patient mortality in end-stage IPF, and (2) while not statistically significant, these data raise the possibility that duration of symptomatic disease may play a role in the outcome of IPF patients receiving alternative therapeutic agents after failure of corticosteroid therapy. In future intervention trails, controlling entry criteria for duration of disease may prove helpful in determining the effects of these agents on the disease process. These data do not permit a determination of the effect of CPX in patients with IPF.
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Affiliation(s)
- C S Dayton
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City 52242
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Merchant RK, Schwartz DA, Helmers RA, Dayton CS, Hunninghake GW. Bronchoalveolar lavage cellularity. The distribution in normal volunteers. Am Rev Respir Dis 1992; 146:448-53. [PMID: 1489138 DOI: 10.1164/ajrccm/146.2.448] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Bronchoalveolar lavage (BAL) is used to obtain inflammatory cells from the lung. For clinical research, parametric statistics are frequently used to compare cells present in BAL of patients with lung disease with cells present in BAL of normal subjects. To determine if these populations can be compared in this manner we performed BAL on 111 never-smoking, normal volunteers and determined: (1) the mean, median, standard deviation, and range of the cells in BAL; (2) whether the data are normally distributed and satisfy the criteria for use of parametric statistical analysis. The BAL cellularity was expressed as a percentage of total cells, cells per milliliter return, and total cells per lavage. Regardless of the means of expression, no measure of BAL cellularity (total cells, macrophages, lymphocytes, neutrophils, or eosinophils) conformed to the normal (bell-shaped) distribution when tested for goodness of fit with the G statistic (all p < 0.001). The lack of fit to the normal distribution was not substantially altered by either the method of expressing the data (i.e., cells per milliliter, total cells, or percent of cells) or log transformation of the data. The poor fit in all cases resulted from clumping of the data about the mean and large tails. The percent of cells were, therefore, tested for goodness of fit to the Poisson distribution, a distribution of discrete variables. The neutrophil and eosinophil percentages resulted in an excellent fit to the Poisson distribution, but macrophage and lymphocyte percentages did not.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R K Merchant
- Department of Internal Medicine, Department of Veterans Affairs Medicinal Center, Iowa City, Iowa
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Schwartz DA, Helmers RA, Dayton CS, Merchant RK, Hunninghake GW. Determinants of bronchoalveolar lavage cellularity in idiopathic pulmonary fibrosis. J Appl Physiol (1985) 1991; 71:1688-93. [PMID: 1761464 DOI: 10.1152/jappl.1991.71.5.1688] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
To investigate factors that determine bronchoalveolar lavage (BAL) cellularity in patients with idiopathic pulmonary fibrosis (IPF), we compared BAL cells in patients with IPF (n = 83) to both nonsmoking (n = 111) and smoking (n = 19) normal volunteers. Patients with IPF had higher concentrations of BAL total cells and alveolar macrophages than nonsmoking volunteers and more BAL neutrophils and eosinophils than normal volunteers regardless of smoking status. Among patients with IPF, the numbers of alveolar macrophages, neutrophils, or eosinophils were strongly associated with either smoking status or pack-years of cigarette smoking. In fact, after accounting for cigarette smoking, using multivariate analysis, the only additional factors that were found to be associated with BAL cellularity were age (macrophages and eosinophils) and the percent predicted forced expired volume in 1 s (neutrophils). Additional multivariate models failed to identify a significant relationship between BAL cellularity and either the type of immunosuppressive therapy or other physiological measures of lung function. We conclude that cigarette smoking strongly influences BAL cellularity in patients with IPF. These findings suggest that cigarette smoking may have a role in the pathogenesis of IPF or may adversely affect the prognosis in patients with IPF.
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Affiliation(s)
- D A Schwartz
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City 52242
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Schwartz DA, Merchant RK, Helmers RA, Gilbert SR, Dayton CS, Hunninghake GW. The influence of cigarette smoking on lung function in patients with idiopathic pulmonary fibrosis. Am Rev Respir Dis 1991; 144:504-6. [PMID: 1892287 DOI: 10.1164/ajrccm/144.3_pt_1.504] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The purpose of this investigation was to quantify the effect of cigarette smoking on standard measures of lung function in patients with idiopathic pulmonary fibrosis (IPF). Our study population consisted of 73 patients in whom IPF had been clinically diagnosed; in 67% the diagnosis was confirmed by open lung biopsy. The average age was 63 yr; 62% were men, and 70% were either former or current cigarette smokers. Current cigarette smokers were found to have a greater percent predicted residual volume. Interestingly, in a univariate analysis, pack-years of cigarette smoking was found to be directly associated with increased measures of lung volumes (TLC, FRC, and RV) and diminished gas exchange (DLCO). Linear multivariate regression models demonstrated that current cigarette smokers have greater measures of RV and FRC and that increasing pack-years of cigarette smoking is associated with diminished gas exchange. Importantly, the FEV/FVC ratio was not significantly related to either smoking status or pack-years of cigarette smoking. Results from our study indicated that among patients with IPF, current cigarette smokers will tend to trap air (higher RV and FRC), and that cigarette smoking appears to adversely alter gas exchange. Moreover, IPF appears to reduce the likelihood of developing physiologic correlates of airflow obstruction among cigarette smokers. However, this does not imply that IPF prevents the development of cigarette-induced lung disease. In fact, the association between cigarette smoking and both increased lung volumes and diminished gas exchange suggests the presence of both emphysema and interstitial fibrosis.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D A Schwartz
- Department of Internal Medicine, University of Iowa, Iowa City
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Minor RL, Helmers RA. Sarcoidosis and giant splenomegaly. Sarcoidosis 1990; 7:119-22. [PMID: 2255787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Splenomegaly is often a manifestation of sarcoidosis, but giant splenomegaly is rare. Only 25 cases of sarcoidosis presenting as massive splenomegaly have been reported. Splenectomy was performed before the diagnosis of sarcoidosis was made in more than half of these patients. Serious complications of giant splenomegaly including rupture, severe thrombocytopenia and hemolytic anemia were not consistently present preoperatively. A case of disseminated sarcoidosis presenting with giant splenomegaly and normal chest roentgenograms is described. Prednisone therapy improved the patient's pulmonary function testing while constitutional symptoms, splenomegaly and elevated angiotensin-converting enzyme levels completely resolved. Sarcoidosis should be considered in the differential diagnosis of massive splenomegaly. A trial of steroids is warranted as initial treatment, and in selected cases may prevent unnecessary splenectomy, thereby precluding a compromise in host defenses against encapsulated bacteria.
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Affiliation(s)
- R L Minor
- Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City
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Affiliation(s)
- R A Helmers
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City
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Helmers RA, Dayton CS, Floerchinger C, Hunninghake GW. Bronchoalveolar lavage in interstitial lung disease: effect of volume of fluid infused. J Appl Physiol (1985) 1989; 67:1443-6. [PMID: 2793747 DOI: 10.1152/jappl.1989.67.4.1443] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
To evaluate the effect of varying infusate volume on the results of bronchoalveolar lavage (BAL) in patients with interstitial lung disease, 55 patients underwent 58 BAL during which both a 100- and 250-ml lavage was performed in the same lobe of the lung. Although the percent of the fluid that was returned and the total numbers of cells were greater in the 250- vs. the 100-ml lavage, there were no significant differences in cell differentials or numbers of cells per milliliter between the 100- and 250-ml BAL. We conclude that infusate volume does not affect cell differentials or numbers of cells per milliliter of bronchoalveolar lavage fluid in patients with interstitial lung disease.
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Affiliation(s)
- R A Helmers
- Department of Medicine, Veterans Administration, Iowa City, Iowa
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Abstract
A patient underwent exercise testing during evaluation for unexplained dyspnea. Evidence of ventilation-perfusion mismatch was noted and subsequent testing revealed multiple pulmonary emboli. Ventilation perfusion parameters by serial exercise testing progressively improved during the course of the patient's illness but did not totally normalize. A discussion of the utility of exercise testing in the evaluation of the patient with unexplained dyspnea is provided and the potential value of serial exercise testing in the management of patients with pulmonary emboli is discussed.
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Affiliation(s)
- R A Helmers
- Division of Pulmonary Medicine, University of Iowa College of Medicine, Iowa City
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