Quality Improvement at the Laboratory’s Specimen Reception Station

Introduction/Objective

In our 1000-bed acute care tertiary hospital, physicians order laboratory tests via the computerized-provider-order-entry (CPOE) system and print barcode labels (patient demographics/tests ordered) at the computer-on-wheel printer. When tubes with unsuitable barcodes (misaligned, poor quality) are received at the laboratory specimen reception area a fresh barcode is re-printed by our laboratory staff. An incident involving a re- printed barcode label pasted on the wrong blood tube prompted an investigation into the quality of barcodes.

Methods/Case Report

We initiated ‘an opportunity for improvement (OFI) project’ at the laboratory specimen reception station. The OFI team involved Nursing, Information Technology (IT) and Pathology departments aimed to eliminate re-printing of barcode labels by 75% within 6 months. We collated and analyzed reasons for re-printing of barcodes on 3 separate 48-hour periods (27-28 April 2020, 24-25 June 2020, and 13-14 June 2022). A series of interventions and initiatives were implemented.

Results (if a Case Study enter NA)

Re-printed barcodes were from the Emergency Department (56%), Out-patient clinics (7%) and Wards (57%). Root cause analysis(RCA) using the “5 whys” technique categorized re-print causes into staff-related (misaligned barcodes) and printer-related (faint barcodes lines/truncated un-verifiable patient demographics). The team mass-emailed clinicians an educational “Do-You-Know” guide on proper pasting of barcodes on blood tubes and instructions on how to obtain help for printer rectification. These guide documents were placed in the hospital-wide document-sharing portal - Docupedia. Immediate close follow-up with sites that had poor barcodes was done in real-time. Barcode reprints decreased 83% within 2 months - from 174 (27-28 Apr 2020) to 30 (24-25 Jun 2020). A recent audit showed sustained elimination of barcode re-printing: 25 cases (13-14 Jun 2022).

Conclusion

The OFI project has successfully raised the quality of CPOE labels on specimen tubes contributing to process efficiency and safer patient care. Close communication with all care sites and their representatives on the OFI team are critical success factors.

Pan-cancer pervasive upregulation of 3' UTR splicing drives tumourigenesis

Most mammalian genes generate messenger RNAs with variable untranslated regions (UTRs) that are important post-transcriptional regulators. In cancer, shortening at 3′ UTR ends via alternative polyadenylation can activate oncogenes. However, internal 3′ UTR splicing remains poorly understood as splicing studies have traditionally focused on protein-coding alterations. Here we systematically map the pan-cancer landscape of 3′ UTR splicing and present this in SpUR (http://www.cbrc.kaust.edu.sa/spur/home/). 3′ UTR splicing is widespread, upregulated in cancers, correlated with poor prognosis and more prevalent in oncogenes. We show that antisense oligonucleotide-mediated inhibition of 3′ UTR splicing efficiently reduces oncogene expression and impedes tumour progression. Notably, CTNNB1 3′ UTR splicing is the most consistently dysregulated event across cancers. We validate its upregulation in hepatocellular carcinoma and colon adenocarcinoma, and show that the spliced 3′ UTR variant is the predominant contributor to its oncogenic functions. Overall, our study highlights the importance of 3′ UTR splicing in cancer and may launch new avenues for RNA-based anti-cancer therapeutics.

Chan et al. report that 3′ UTR splicing is widespread and enhanced across different cancer types and is associated with more advanced tumour progression.

Study of Two-Photon Exchange via the Beam Transverse Single Spin Asymmetry in Electron-Proton Elastic Scattering at Forward Angles over a Wide Energy Range

We report on a new measurement of the beam transverse single spin asymmetry in electron-proton elastic scattering, A_{⊥}^{ep}, at five beam energies from 315.1 to 1508.4 MeV and at a scattering angle of 30°<θ<40°. The covered Q^{2} values are 0.032, 0.057, 0.082, 0.218, 0.613 (GeV/c)^{2}. The measurement clearly indicates significant inelastic contributions to the two-photon-exchange (TPE) amplitude in the low-Q^{2} kinematic region. No theoretical calculation is able to reproduce our result. Comparison with a calculation based on unitarity, which only takes into account elastic and πN inelastic intermediate states, suggests that there are other inelastic intermediate states such as ππN, KΛ, and ηN. Covering a wide energy range, our new high-precision data provide a benchmark to study those intermediate states.

A near-peer regional surgical teaching programme designed by medical students, delivered by junior doctors

BACKGROUND

Near-peer teaching initiatives has been shown to be a highly successful method of improving student learning. There has been little data on surgical teaching initiatives of this kind and little data to show if this improves student confidence in surgical topics. This study was designed to show whether a regional surgical teaching programme, delivered by junior doctors, improves confidence levels of students prior to their final examinations.

METHOD

Final year medical students were invited from four hospitals in the Northern deanery of England to participate in a voluntary surgical teaching day. Junior doctors were then recruited to present on various surgical topics based on their own knowledge and experience of finals examinations and working on the wards. A pre and post-course questionnaire was designed, validated and distributed to the students to assess their confidence on a five-point Likert scale of 1-5 (1- most confidence, 5- least confidence) levels in each of the 11 chosen topics. Other variables were also measured relating to the topics including visual material, enthusiasm, content relevance and communication.

RESULTS

53 students completed the questionnaire (n = 53). There were 31 females and 22 males with a mean age of 24.7. A mean level of confidence of 2.7 pre-course and 1.6 post-course showed an increase in confidence by 68.8%. All eleven topics covered showed improvement in confidence. General Surgical Principles showed the lowest improvement in confidence from 2.683 to 1.917 (p = <0.001) compared to endocrine which showed the maximum increased in confidence from 3.650 to 1.694 (p = <0.0001). Orthopedics showed an increased in confidence from 3.010 to 1.62 (p = <0.0001).

CONCLUSION

Near-peer education designed by medical students and delivered by junior doctors is an effective way for improving confidence levels and test results prior to finals examination and is also valuable for junior doctors.

Increasing Obesity Prevalence in the United States End-Stage Renal Disease Population

Background

Among ESRD patients, obesity may improve dialysis-survival but decreases likelihood of transplantation, and as such, obesity prevalence may directly affect growth of the dialysis population.

Objective

The objective of this study was to assess BMI trends in the ESRD population as compared to the general population.

Materials and Methods

Incident adult ESRD patients were identified from the United States Renal Data System from 01/01/1995-12/31/2010 (n=1,458,350). Data from the Behavioral Risk Factor Surveillance System (n=4,303,471) represented the US population. Trends in BMI, obesity classes I (BMI of 30-34.9), II (BMI of 35-39.9), and III (BMI ≥ 40), were examined by year of dialysis initiation. Trends in BMI slope were compared between the ESRD and US populations using linear regression.

Results

Mean BMI of ESRD patients in 1995 was 25.2 as compared to 29.4 in 2010, a 16.7% increase, while the US population's mean BMI increased from 25.3 to 27.2, a 7.5% increase. BMI increase among the ESRD population was significantly more rapid than among the US population (β: 0.16, 95% CI: 0.14-0.18, p<0.001).

Conclusions and Recommendations

Mean BMI among the ESRD population is increasing more rapidly than the US population. Given decreased access to kidney transplantation among ESRD patients with obesity, future research should be directed at controlling healthcare expenditures by identifying strategies to address the obesity epidemic among the US ESRD population.

New Measurements of the Beam Normal Spin Asymmetries at Large Backward Angles with Hydrogen and Deuterium Targets

New measurements of the beam normal single spin asymmetry in the electron elastic and quasielastic scattering on the proton and deuteron, respectively, at large backward angles and at ⟨Q^{2}⟩=0.22  (GeV/c)^{2} and ⟨Q^{2}⟩=0.35  ( GeV/c)^{2} are reported. The experimentally observed asymmetries are compared with the theoretical calculation of Pasquini and Vanderhaeghen [Phys. Rev. C 70, 045206 (2004).PRVCAN0556-281310.1103/PhysRevC.70.045206]. The agreement of the measurements with the theoretical calculations shows a dominance of the inelastic intermediate excited states of the nucleon, πN and the Δ resonance. The measurements explore a new, important parameter region of the exchanged virtual photon virtualities.

Alopecia areata incognita in Cronkhite-Canada syndrome

Cronkhite-Canada syndrome is an acquired inflammatory polyposis syndrome in which alopecia, onychomadesis and hyperpigmentation occur concurrently with gastrointestinal symptoms. The pathophysiology of alopecia in Cronkhite-Canada syndrome has not been definitively elucidated. We present evidence for alopecia areata incognita as a possible mechanism of hair loss.

A novel semi-automated method of tracking fetal movements

We have designed software that can "look" at recorded ultrasound sequences. We analyzed fifteen video sequences representing recorded ultrasound scans of nine fetuses. Our method requires a small amount of user labelled pixels for processing the first frame. These initialize GrowCut, a background removal algorithm, which was used for separating the fetus from its surrounding environment (segmentation). For each subsequent frame, user input is no longer necessary as some of the pixels will inherit labels from the previously processed frame. This results in our software's ability to track movement. Two sonographers rated the results of our computer's 'vision' on a scale from 1 (poor fit) to 10 (excellent fit). They assessed tracking accuracy for the entire video as well as segmentation accuracy (the ability to identify fetus from non-fetus) for every 100th processed frame. There was no appreciable deterioration in the software's ability to track the fetus over time.

Hepatic portal vein flow and three dimensional indices of hepatic perfusion in pre-eclampsia compared with normal pregnancy

It has been suggested that the origins of pre-eclampsia arise from the maternal venous system dysfunction. This study aimed to test this hypothesis by assessing hepatic perfusion in pre-eclampsia using three-dimensional (3D) ultrasound. The hepatic portal vein flow in 12 women with normal pregnancy and 11 women with pre-eclampsia was measured using standard Doppler ultrasound. The 3D indices of hepatic perfusion: flow index (FI), vascular index (VI) and vascularisation flow index (VFI), which are believed to reflect vascularity and flow intensity were also measured. Because of small numbers, a non-parametric test was used to test differences between groups. Hepatic portal vein flow was no different between women with normal pregnancy compared with women with pre-eclampsia (228.1 (215.5-270.6) vs. 283.0 (145.9-344.6); p = 0.90). The 3D indices of hepatic perfusion were as follows (FI: 36.3(30.7-42.5) vs. 39.7 (27.7-44.2), p = 1.00; VI: 11.7 (3.6-21.2) vs. 3.0 (0.5-7.6), p = 0.04; VFI: 4.7 (1.2-8.3) vs. 1.2 (0.1-3.2), p = 0.06, respectively). This study was not able to support or refute the suggestion that the genesis of pre-eclampsia arises from the maternal venous circulation. There may be biological differences in the 3D indices of hepatic perfusion in women with pre-eclampsia compared with normal pregnant women.

Does performing fetal ultrasound assessment once versus twice in the third trimester in low risk women alter the stillbirth rate?

The aim of this retrospective observational study was to evaluate if performing fetal growth scans once or twice in the third trimester impacts on stillbirth rates in low risk pregnancies. The study was performed in a tertiary centre with 6,000 deliveries per annum. Data on all deliveries was collected via the National Maternity System Database and high risk pregnancies were excluded to calculate the stillbirth rate before and after 2011 when ultrasound assessment was performed twice and once in the third trimester. Between 2009-2012 there were 18,856 low risk-pregnancy deliveries with 45 stillbirths, (average stillbirth rate 0.26%). The stillbirth rate in 2009/2010 was 54/9423 (0.25%). The stillbirth rate in 2012 was 13/5615 (0.27%). [p = 0.897; chi square = 0.017; df = 1]. There was no statistical difference in the stillbirth rate when low risk women were scanned once or twice in the third trimester.

Measurement of strange quark contributions to the vector form factors of the proton at Q2 = 0.22 (GeV / c)2

A new measurement of the parity violating asymmetry in elastic electron scattering on hydrogen at backward angles and at a four momentum transfer of Q;{2} = 0.22 (Ge V / c);{2} is reported here. The measured asymmetry is A_{LR} = (-17.23 +/- 0.82_{stat} +/- 0.89_{syst}) x 10;{-6}. The standard model prediction assuming no strangeness is A_{0} = (-15.87 +/- 1.22) x 10;{-6}. In combination with previous results from measurements at forward angles, it is possible to disentangle for the first time the strange form factors at this momentum transfer, G_{E};{s} = 0.050 +/- 0.038 +/- 0.019 and G_{M};{s} = -0.14 +/- 0.11 +/- 0.11.

Homology-free prediction of functional class of proteins and peptides by support vector machines

Protein and peptide sequences contain clues for functional prediction. A challenge is to predict sequences that show low or no homology to proteins or peptides of known function. A machine learning method, support vector machines (SVM), has recently been explored for predicting functional class of proteins and peptides from sequence-derived properties irrespective of sequence similarity, which has shown impressive performance for predicting a wide range of protein and peptide classes including certain low- and non- homologous sequences. This method serves as a new and valuable addition to complement the extensively-used alignment-based, clustering-based, and structure-based functional prediction methods. This article evaluates the strategies, current progresses, reported prediction performances, available software tools, and underlying difficulties in using SVM for predicting the functional class of proteins and peptides.

Transverse beam spin asymmetries in forward-angle elastic electron-proton scattering

We have measured the beam-normal single-spin asymmetry in elastic scattering of transversely polarized 3 GeV electrons from unpolarized protons at Q2=0.15, 0.25 (GeV/c)2. The results are inconsistent with calculations solely using the elastic nucleon intermediate state and generally agree with calculations with significant inelastic hadronic intermediate state contributions. A(n) provides a direct probe of the imaginary component of the 2gamma exchange amplitude, the complete description of which is important in the interpretation of data from precision electron-scattering experiments.

An epidemiological study of holoprosencephaly from a regional congenital anomaly register: 1995–2004

BACKGROUND

Adequate contemporary information to counsel patients with a prenatal diagnosis of holoprosencephaly is lacking. We addressed this using data from the West Midlands Congenital Anomaly Register (WMCAR), a population-based malformation register, during a time where technological improvements have been stable and anomaly screening is well established.

METHODS

Cases were defined using the ICD 10 code for holoprosencephaly. Cases of livebirths, stillbirths and termination at all gestations were included in the study. The diagnosis was verified by a pathology or definitive radiological report with cross validation from the regional pathology, clinical genetics, cytogenetics and fetal medicine databases.

RESULTS

There were 113 cases reported of holoprosencephaly for the years 1995-2004. This represents a prevalence of 1.7 per 10,000 births and terminations, with no change in prevalence over time. There was a decreased risk of holoprosencephaly in the white population [white vs. nonwhite; RR 0.53(0.36-0.79)]. Karyotypical abnormality was noted in 46% of cases where the karyotype was known. Trisomy 13 was the most common chromosomal abnormality. Correct allocation of a diagnosis of holoprosencephaly by ultrasound occurred in 77% of cases, with another 12% having a severe intracranial abnormality but was not reported as holoprosencephaly. In 4%, a prenatal diagnosis of holoprosencephaly was not made. Termination of pregnancy was performed in 80% of all cases.

CONCLUSION

Holoprosencephaly is a morbid condition associated with significant secondary etiologies.

PharmGED: Pharmacogenetic Effect Database

Prediction and elucidation of pharmacogenetic effects is important for facilitating the development of personalized medicines. Knowledge of polymorphism-induced and other types of drug-response variations is needed for facilitating such studies. Although databases of pharmacogenetic knowledge, polymorphism and toxicogenomic information have appeared, some of the relevant data are provided in separate web-pages and in terms of relatively long descriptions quoted from literatures. To facilitate easy and quick assessment of the relevant information, it is helpful to develop databases that provide all of the information related to a pharmacogenetic effect in the same web-page and in brief descriptions. We developed a database, Pharmacogenetic Effect Database (PharmGED), for providing sequence, function, polymorphism, affected drugs and pharmacogenetic effects. PharmGED can be accessed at free of charge for academic use. It currently contains 1825 entries covering 108 disease conditions, 266 distinct proteins, 693 polymorphisms, 414 drugs/ligands cited from 856 references.

Platelet inhibition beyond conventional antiplatelet agents: expanding role of angiotensin receptor blockers, statins and selective serotonin reuptake inhibitors

Aspirin, dipyridamole, cilostazol, thienopyridines and glycoprotein IIb/IIIa inhibitors represent the classical examples of the established antiplatelet agents commonly used for the secondary prevention in patients after vascular events. Obviously, the era of expanding antiplatelet regimens and indications may require new agents as the substitutes, or additions to the available strategies. However, recent results of the majority of antiplatelet trials strongly suggest boarder line advantages in clinical outcomes, and higher associated bleeding risks with the novel antiplatelet agents or/and regimens. Moreover, unexpected failures, such as lack of efficacy of clopidogrel and aspirin combination for ischaemic stroke prevention (MATCH), or use of the same antiplatelet regimen for the primary vascular prevention (CHARISMA) raise legitimate concerns that the concept 'the more the better' may not be valid. Broad use of statins, angiotensin receptor blockers and selective serotonin reuptake inhibitors may be in part responsible for the lack of impressive results with the antiplatelet therapy because each of these drug classes per se inhibits platelets. In this review, we discuss the available evidence and potential clinical significance of these findings.

A phase II study of fixed-dose capecitabine and assessment of predictors of toxicity in patients with advanced/metastatic colorectal cancer

The purpose of this study was to evaluate the safety and activity of fixed-dose capecitabine in patients with advanced colorectal cancer and to correlate pretreatment plasma concentrations of homocysteine and serum and red cell folate with toxicity. Patients received capecitabine 2000 mg (4 x 500 mg tablets) twice daily on days 1-14 every 3 weeks. They were reviewed weekly during the first cycle and then three weekly for safety assessment. Eligibility criteria were advanced/metastatic colorectal cancer, < or = 2 prior chemotherapy regimens, ECOG performance status 0-2 and life expectancy >12 weeks. A total of 60 patients were enrolled and 55 were evaluable for efficacy. The median age was 72 years and 63% of patients had a performance status of 1 or 2. Confirmed tumour responses were reported in 15 patients (28%; 95% confidence interval (CI), 15.7-40.3%). The median time to disease progression was 4.9 months and median overall survival was 11.2 months. The median ratio of fixed dose to body surface area (BSA)-calculated dose was 88% (range 65-108%). Significant myelosuppression was not observed. Grade 2/3 treatment-related adverse events were diarrhoea (34%), fatigue (27%), stomatitis (15%) and hand-foot syndrome (22%). Dose reduction due to adverse events was required in 16 patients (29%) and multiple reductions in five patients (9%). There was no grade 3/4 haematological toxicity, any grade 4 adverse events or treatment-related deaths. Patients with higher pretreatment levels of serum folate experienced significantly greater toxicity (P = 0.02, CI: 1.0-1.2) during cycle 1 and over the entire treatment period (P = 0.04, CI: 1.0-1.3). Pretreatment homocysteine concentrations did not predict for toxicity. In conclusion, fixed-dose capecitabine appears to have similar efficacy and safety compared to the currently recommended dose schedule based on body surface area and simplifies drug administration. A high pretreatment folate may be predictive of increased toxicity from capecitabine.

Strange-quark contributions to parity-violating asymmetries in the forward g0 electron-proton scattering experiment

We have measured parity-violating asymmetries in elastic electron-proton scattering over the range of momentum transfers 0.12 < or =Q2 < or =1.0 GeV2. These asymmetries, arising from interference of the electromagnetic and neutral weak interactions, are sensitive to strange-quark contributions to the currents of the proton. The measurements were made at Jefferson Laboratory using a toroidal spectrometer to detect the recoiling protons from a liquid hydrogen target. The results indicate nonzero, Q2 dependent, strange-quark contributions and provide new information beyond that obtained in previous experiments.

Evidence for strange-quark contributions to the nucleon's form factors at Q2=0.108 (GeV/c)2

We report on a measurement of the parity violating asymmetry in the elastic scattering of polarized electrons off unpolarized protons with the A4 apparatus at MAMI in Mainz at a four momentum transfer value of Q(2)=0.108 (GeV/c)(2) and at a forward electron scattering angle of 30 degrees <theta(e)<40 degrees . The measured asymmetry is A(LR)(e-->p)=[-1.36+/-0.29(stat)+/-0.13(syst)]x10(-6). The expectation from the standard model assuming no strangeness contribution to the vector current is A(0)=(-2.06+/-0.14)x10(-6). We have improved the statistical accuracy by a factor of 3 as compared to our previous measurements at a higher Q2. We have extracted the strangeness contribution to the electromagnetic form factors from our data to be G(s)(E)+0.106G(s)(M)=0.071+/-0.036 at Q(2)=0.108 (GeV/c)(2). We again find the value for G(s)(E)+0.106G(s)(M) to be positive, this time at an improved significance level of two sigma.