Electronic health record-embedded individualized pain plans for emergency department treatment of vaso-occlusive episodes in adults with sickle cell disease: Protocol for a preimplementation and postimplementation study

BACKGROUND: Individuals living with sickle cell disease often require aggressive treatment of pain associated with vaso-occlusive episodes in the emergency department. Frequently, pain relief is poor. The 2014 National Heart, Lung, and Blood Institute evidence-based guidelines recommended an individualized treatment and monitoring protocol to improve pain management of vaso-occlusive episodes. OBJECTIVE: This study will implement an electronic health record-embedded individualized pain plan with provider and patient access in the emergency departments of 8 US academic centers to improve pain treatment for adult patients with sickle cell disease. This study will assess the overall effects of electronic health record-embedded individualized pain plans on improving patient and provider outcomes associated with pain treatment in the emergency department setting and explore barriers and facilitators to the implementation process. METHODS: A preimplementation and postimplementation study is being conducted by all 8 sites that are members of the National Heart, Lung, and Blood Institute-funded Sickle Cell Disease Implementation Consortium. Adults with sickle cell disease aged 18 to 45 years who had a visit to a participating emergency department for vaso-occlusive episodes within 90 days prior to enrollment will be eligible for inclusion. Patients will be enrolled in the clinic or remotely. The target analytical sample size of this study is 160 patient participants (20 per site) who have had an emergency department visit for vaso-occlusive episode treatment at participating emergency departments during the study period. Each site is expected to enroll approximately 40 participants to reach the analytical sample size. The electronic health record-embedded individualized pain plans will be written by the patient\u27s sickle cell disease provider, and sites will work with the local informatics team to identify the best method to build the electronic health record-embedded individualized pain plan with patient and provider access. Each site will adopt required patient and provider implementation strategies and can choose to adopt optional strategies to improve the uptake and sustainability of the intervention. The study is informed by the Technology Acceptance Model 2 and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Provider and patient baseline survey, follow-up survey within 96 hours of an emergency department vaso-occlusive episode visit, and selected qualitative interviews within 2 weeks of an emergency department visit will be performed to assess the primary outcome, patient-perceived quality of emergency department pain treatment, and additional implementation and intervention outcomes. Electronic health record data will be used to analyze individualized pain plan adherence and additional secondary outcomes, such as hospital admission and readmission rates. RESULTS: The study is currently enrolling study participants. The active implementation period is 18 months. CONCLUSIONS: This study proposes a structured, framework-informed approach to implement electronic health record-embedded individualized pain plans with both patient and provider access in routine emergency department practice. The results of the study will inform the implementation of electronic health record-embedded individualized pain plans at a larger scale outside of Sickle Cell Disease Implementation Consortium centers. TRIAL REGISTRATION: ClinicalTrials.gov NCT04584528; https://clinicaltrials.gov/ct2/show/NCT04584528. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24818

Evaluation and implications of natural product use in preoperative patients: a retrospective review

Background: Medication Reconciliation and Medication Safety are two themes emphasized in a variety of healthcare organizations. As a result, health care facilities have established methods for obtaining a patient's medication history. However, these methods may vary among institutions or even among the health care professionals in a single institution, and studies have shown that patients are reluctant to disclose their complementary and alternative medicine use to any health care professional. This lack of disclosure is important in surgical patients because of potential herbal interactions with medications and drugs used during the surgical procedure; and the potential for adverse reactions including effects on coagulation, blood pressure, sedation, electrolytes or diuresis. Therefore, the objectives of this study are to identify patterns of natural product use, to identify potential complications among patients scheduled for surgery, to improve existing medication reconciliation efforts, and to develop discontinuation guidelines for the use of these products prior to surgery. Methods: A retrospective review of surgery patients presenting to the Anesthesia Preoperative Evaluation Clinic (APEC) at the University of Kansas Hospital was conducted to identify the prevalence of natural product use. The following data was collected: patient age; gender; allergy information; date of medication history; number of days prior to surgery; source of medication history; credentials of person obtaining the history; number and name of prescription medications, over-the-counter medications and natural products; and natural product dosage. Following the collection of data and analysis of the most common natural products used, possible complications and interactions were identified, and a protocol regarding the pre-operative use of natural products was developed and implemented. Results: Approximately one-fourth of patients seen in the APEC indicated the use of natural products. Patients taking natural products were significantly older, were more likely to undergo cardiac or chest surgery, and were more likely to be taking more prescription and non-prescription medications (all p < 0.001). Conclusion: Based on the results of this study, it is concluded that there is a need for established guidelines regarding discontinuation of selected natural products prior to surgery and further education is needed concerning the perioperative implications of natural products

The high-energy spectrum of the nearby planet-hosting inactive mid-M dwarf LHS 3844

To fully characterize the atmospheres, or lack thereof, of terrestrial exoplanets we must include the high-energy environments provided by their host stars. The nearby mid-M dwarf LHS 3844 hosts a terrestrial world which lacks a substantial atmosphere. We present a time series UV spectrum of LHS 3844 from 1131-3215A captured by HST/COS. We detect one flare in the FUV, which has an absolute energy of 8.96+/-0.79e28 erg and an equivalent duration of 355+/-31 s. We extract the flare and quiescent UV spectra separately. For each spectrum we estimate the Ly-alpha flux using correlations between UV line strengths. We use Swift-XRT to place an upper limit on the soft X-ray flux and construct a differential emission model (DEM) to estimate flux that is obscured by the interstellar medium. We compare the DEM flux estimates in the XUV to other methods that rely on scaling from the Ly-alpha, Si IV, and N V lines in the UV. The XUV, FUV, and NUV flux of LHS 3844 relative to its bolometric luminosity is log10(Lband/LBol) = -3.65, -4.16, and -4.56, respectively, for the quiescent state. These values agree with trends in high-energy flux as a function of stellar effective temperature found by the MUSCLES survey for a sample of early-M dwarfs. Many of the most spectroscopically accessible terrestrial exoplanets orbit inactive mid- to late-M dwarfs like LHS 3844. Measurements of M dwarf high-energy spectra are preferable for exoplanet characterization, but are not always possible. The spectrum of LHS 3844 is a useful proxy for the current radiation environment for these worlds.Comment: Published in AJ; HLSPs now availabl

Testing the universality of star formation - I. Multiplicity in nearby star-forming regions

We have collated multiplicity data for five clusters (Taurus, Chamaeleon I, Ophiuchus, IC348, and the Orion Nebula Cluster). We have applied the same mass ratio (flux ratios of delta K <= 2.5) and primary mass cuts (~0.1-3.0 Msun) to each cluster and therefore have directly comparable binary statistics for all five clusters in the separation range 62-620 au, and for Taurus, Chamaeleon I, and Ophiuchus in the range 18-830 au. We find that the trend of decreasing binary fraction with cluster density is solely due to the high binary fraction of Taurus, the other clusters show no obvious trend over a factor of nearly 20 in density. With N-body simulations we attempt to find a set of initial conditions that are able to reproduce the density, morphology and binary fractions of all five clusters. Only an initially clumpy (fractal) distribution with an initial total binary fraction of 73 per cent (17 per cent in the range 62-620 au) is able to reproduce all of the observations (albeit not very satisfactorily). Therefore, if star formation is universal the initial conditions must be clumpy and with a high (but not 100 per cent) binary fraction. This could suggest that most stars, including M-dwarfs, form in binaries.Comment: Accepted for publication in MNRAS, 19 pages, 22 figure

Leptogenesis in a Realistic Supersymmetric Model of Inflation with a Low Reheat Temperature

We discuss leptogenesis in a realistic supersymmetric model of inflation with a low reheat temperature 1-10 GeV. The lepton asymmetry is generated by a decaying right handed sneutrino, which is produced after inflation during preheating. The inflationary model is based on a simple variant of the Next-to-Minimal Supersymmetric Standard model (NMSSM) which solves the \mu problem, called \phiNMSSM, where the additional singlet \phi plays the role of the inflaton in hybrid (or inverted hybrid) type models. The model is invariant under an approximate Peccei-Quinn symmetry which also solves the strong CP problem, and leads to an invisible axion with interesting cosmological consequences. We show how the baryon number of the universe and the nature of cold dark matter are determined by the same parameters controlling the strong CP problem, the \mu problem and the neutrino masses and mixing angles.Comment: 17 page, latex, 1 eps fi

Intentional and unintentional nonadherence to hydroxyurea among people with sickle cell disease: A qualitative study

Hydroxyurea is an efficacious treatment for sickle cell disease (SCD), but adoption is low among individuals with SCD. The objective of this study was to examine barriers to patients' adherence to hydroxyurea use regimens by using the intentional and unintentional medication nonadherence framework. We interviewed individuals with SCD age 15 to 49.9 years who were participants in the Sickle Cell Disease Implementation Consortium (SCDIC) Needs Assessment. The intentional and unintentional medication nonadherence framework explains barriers to using hydroxyurea and adds granularity to the understanding of medication adherence barriers unique to the SCD population. In total, 90 semi-structured interviews were completed across 5 of the 8 SCDIC sites. Among interviewed participants, 57.8% (n = 52) were currently taking hydroxyurea, 28.9% (n = 26) were former hydroxyurea users at the time of the interview, and 13.3% (n = 12) had never used hydroxyurea but were familiar with the medication. Using a constructivist grounded theory approach, we discovered important themes that contributed to nonadherence to hydroxyurea, which were categorized under unintentional (eg, Forgetfulness, External Influencers) and intentional (Negative Perceptions of Hydroxyurea, Aversion to Taking Any Medications) nonadherence types. Participants more frequently endorsed adherence barriers that fell into the unintentional nonadherence type (70%) vs intentional nonadherence type (30%). Results from this study will help SCD health care providers understand patient choices and decisions as being either unintentional or intentional, guide tailored clinical discussions regarding hydroxyurea therapy, and develop specific, more nuanced interventions to address nonadherence factors

The K2-3 system revisited: testing photoevaporation and core-powered mass loss with three small planets spanning the radius valley

Multi-planet systems orbiting M dwarfs provide valuable tests of theories of small planet formation and evolution. K2-3 is an early M dwarf hosting three small exoplanets (1.5-2.0 Earth radii) at distances of 0.07-0.20 AU. We measure the high-energy spectrum of K2-3 with HST/COS and XMM-Newton, and use empirically-driven estimates of Ly-alpha and extreme ultraviolet flux. We use EXOFASTv2 to jointly fit radial velocity, transit, and SED data. This constrains the K2-3 planet radii to 4% uncertainty and the masses of K2-3b and c to 13% and 30%, respectively; K2-3d is not detected in RV measurements. K2-3b and c are consistent with rocky cores surrounded by solar composition envelopes (mass fractions of 0.36% and 0.07%), H2O envelopes (55% and 16%), or a mixture of both. However, based on the high-energy output and estimated age of K2-3, it is unlikely that K2-3b and c retain solar composition atmospheres. We pass the planet parameters and high-energy stellar spectrum to atmospheric models. Dialing the high-energy spectrum up and down by a factor of 10 produces significant changes in trace molecule abundances, but not at a level detectable with transmission spectroscopy. Though the K2-3 planets span the small planet radius valley, the observed system architecture cannot be readily explained by photoevaporation or core-powered mass loss. We instead propose 1) the K2-3 planets are all volatile-rich, with K2-3d having a lower density than typical of super-Earths, and/or 2) the K2-3 planet architecture results from more stochastic processes such as planet formation, planet migration, and impact erosion.Comment: 15 pages, 7 figure, published in AJ, HLSPs at https://archive.stsci.edu/hlsp/mstarpanspe

Publication of data collection forms from NHLBI funded sickle cell disease implementation consortium (SCDIC) registry

Background: Sickle cell disease (SCD) is an autosomal recessive blood disorder affecting approximately 100,000 Americans and 3.1 million people globally. The scarcity of relevant knowledge and experience with rare diseases creates a unique need for cooperation and infrastructure to overcome challenges in translating basic research advances into clinical advances. Despite registry initiatives in SCD, the unavailability of descriptions of the selection process and copies of final data collection tools, coupled with incomplete representation of the SCD population hampers further research progress. This manuscript describes the SCDIC (Sickle Cell Disease Implementation Consortium) Registry development and makes the SCDIC Registry baseline and first follow-up data collection forms available for other SCD research efforts. Results: Study data on 2400 enrolled patients across eight sites was stored and managed using Research Electronic Data Capture (REDCap). Standardized data collection instruments, recruitment and enrollment were refined through consensus of consortium sites. Data points included measures taken from a variety of validated sources (PHENX, PROMIS and others). Surveys were directly administered by research staff and longitudinal follow-up was coordinated through the DCC. Appended registry forms track medical records, event-related patient invalidation, pregnancy, lab reporting, cardiopulmonary and renal functions. Conclusions: The SCDIC Registry strives to provide an accurate, updated characterization of the adult and adolescent SCD population as well as standardized, validated data collecting tools to guide evidence-based research and practice

Dynamical evolution of star-forming regions

We model the dynamical evolution of star-forming regions with a wide range of initial properties. We follow the evolution of the regions’ substructure using the Q-parameter, we search for dynamical mass segregation using the !MSR technique, and we also quantify the evolution of local density around stars as a function of mass using the "LDR method. The amount of dynamical mass segregation measured by !MSR is generally only significant for subvirial and virialized, substructured regions – which usually evolve to form bound clusters. The "LDR method shows that massive stars attain higher local densities than the median value in all regions, even those that are supervirial and evolve to form (unbound) associations. We also introduce the Q − "LDR plot, which describes the evolution of spatial structure as a function of mass-weighted local density in a star-forming region. Initially dense (>1000 stars pc−2), bound regions always have Q > 1, "LDR > 2 after 5 Myr, whereas dense unbound regions always have Q 2 after 5 Myr. Less dense regions (<100 stars pc−2) do not usually exhibit "LDR > 2 values, and if relatively high local density around massive stars arises purely from dynamics, then the Q − "LDR plot can be used to estimate the initial density of a star-forming region