Electronic risk assessment for venous thromboembolism: investigating physicians' rationale for bypassing clinical decision support recommendations.

Objective: The underutilisation of venous thromboembolism (VTE) prophylaxis is still a problem in the UK despite the emergence of national guidelines and incentives to increase the number of patients undergoing VTE risk assessments. Our objective was to examine the reasons doctors gave for not prescribing enoxaparin when recommended by an electronic VTE risk assessment alert. Design: We used a qualitative research design to conduct a thematic analysis of free text entered into an electronic prescribing system. Setting: The study took place in a large University teaching hospital, which has a locally developed electronic prescribing system known as PICS (Prescribing, Information and Communication System). Participants: We extracted prescription data from all inpatient admissions over a 7-month period in 2012 using the audit database of PICS. Intervention: The completion of the VTE risk assessment form introduced into the hospital-wide electronic prescribing and health records system is mandatory. Where doctors do not prescribe VTE prophylaxis when recommended, they are asked to provide a reason for this decision. The free-text field was introduced in May 2012. Primary and Secondary Outcome Measures: Free-text reasons for not prescribing enoxaparin when recommended were thematically coded. Results: A total of 1136 free-text responses from 259 doctors were collected in the time period and 1206 separate reasons were analysed and coded. 389 reasons (32.3%) for not prescribing enoxaparin were coded as being due to 'clinical judgment'; in 288 (23.9%) of the responses, doctors were going to reassess the patient or prescribe enoxaparin; and in 245 responses (20.3%), the system was seen to have produced an inappropriate alert. Conclusions: In order to increase specificity of warnings and avoid users developing alert fatigue, it is essential that an evaluation of user responses and/or end user feedback as to the appropriateness and timing of alerts is obtained

Evaluating the effectiveness of self-administration of medication (SAM) schemes in the hospital setting: a systematic review of the literature

BackgroundSelf-administration of medicines is believed to increase patients' understanding about their medication and to promote their independence and autonomy in the hospital setting. The effect of inpatient self-administration of medication (SAM) schemes on patients, staff and institutions is currently unclear.ObjectiveTo systematically review the literature relating to the effect of SAM schemes on the following outcomes: patient knowledge, patient compliance/medication errors, success in self-administration, patient satisfaction, staff satisfaction, staff workload, and costs.DesignKeyword and text word searches of online databases were performed between January and March 2013. Included articles described and evaluated inpatient SAM schemes. Case studies and anecdotal studies were excluded.Results43 papers were included for final analysis. Due to the heterogeneity of results and unclear findings it was not possible to perform a quantitative synthesis of results. Participation in SAM schemes often led to increased knowledge about drugs and drug regimens, but not side effects. However, the effect of SAM schemes on patient compliance/medication errors was inconclusive. Patients and staff were highly satisfied with their involvement in SAM schemes.ConclusionsSAM schemes appear to provide some benefits (e.g. increased patient knowledge), but their effect on other outcomes (e.g. compliance) is unclear. Few studies of high methodological quality using validated outcome measures exist. Inconsistencies in both measuring and reporting outcomes across studies make it challenging to compare results and draw substantive conclusions about the effectiveness of SAM schemes

Mortality in children with complicated severe acute malnutrition is related to intestinal and systemic inflammation:an observational cohort study

Background: Diarrhea affects a large proportion of children with severe acute malnutrition (SAM). However, its etiology and clinical consequences remain unclear.Objective: We investigated diarrhea, enteropathogens, and systemic and intestinal inflammation for their interrelation and their associations with mortality in children with SAM.Design: Intestinal pathogens (n = 15), cytokines (n= 29), fecal calprotectin, and the short-chain fatty acids (SCFAs) butyrate and propionate were determined in children aged 6-59 mo (n = 79) hospitalized in Malawi for complicated SAM. The relation between variables, diarrhea, and death was assessed with partial least squares (PLS) path modeling.Results: Fatal subjects (n = 14; 18%) were younger (mean +/- SD age: 17 +/- 11 compared with 25 +/- 11 mo; P = 0.01) with higher prevalence of diarrhea (46% compared with 18%, P = 0.03). Intestinal pathogens Shigella (36%), Giardia (33%), and Campylobacter (30%) predominated, but their presence was not associated with death or diarrhea. Calprotectin was significantly higher in children who died [median (IQR): 1360 mg/kg feces (2443-535 mg/kg feces) compared with 698 mg/kg feces (1438-244 mg/kg feces), P = 0.03]. Butyrate [median (IQR): 31 ng/mL (112-22 ng/mL) compared with 2036 ng/mL (5800 [49 ng/mL), P = 0.02] and propionate [median (IQR): 167 ng/mL (831-131 ng/mL) compared with 3174 ng/mL (5819-357 ng/mL), P = 0.04] were lower in those who died. Mortality was directly related to high systemic inflammation (path coefficient = 0.49), whereas diarrhea, high calprotectin, and low SCFA production related to death indirectly via their more direct association with systemic inflammation.Conclusions: Diarrhea, high intestinal inflammation, low concentrations of fecal SCFAs, and high systemic inflammation are significantly related to mortality in SAM. However, these relations were not mediated by the presence of intestinal pathogens. These findings offer an important understanding of inflammatory changes in SAM, which may lead to improved therapies.</p

Towards BioDBcore: a community-defined information specification for biological databases

The present article proposes the adoption of a community-defined, uniform, generic description of the core attributes of biological databases, BioDBCore. The goals of these attributes are to provide a general overview of the database landscape, to encourage consistency and interoperability between resources and to promote the use of semantic and syntactic standards. BioDBCore will make it easier for users to evaluate the scope and relevance of available resources. This new resource will increase the collective impact of the information present in biological database

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

The experience of white British fathers providing care to a son or daughter with a diagnosis of psychosis : an exploration of fathers’ accounts of coping.

Aim: Given the move towards community-based care and potential changes in attitudes towards men and caring, it was the aim of this study to explore the experiences of fathers caring for and coping with having a son or daughter with psychosis and begin to identify ‘how’ they cope or ‘what helps’ them to cope in this challenging role. Methods: A qualitative exploratory design was employed using semi-structured interviews. Interviews were transcribed and analysed using Interpretative Phenomenological Analysis (IPA). Participants were six white British fathers who self-identified as providing care to their son/daughter who had experienced a first-episode of psychosis, and were under the care of an early intervention team. All fathers were of working age, with a mean age of 56 years and the identified child was living with them at the time of interview. Results: Results suggest that gender identity and masculinity play some role in these fathers’ understanding of their caring role. Strategies that helped them to cope were identified and themes around men and talking emerged as prominent in interviews. Conclusions: With the literature lacking in focused research around coping in relation to parents caring for children with psychosis, and even less focused on fathers, the current research adds valuable research into this important population. Themes suggest that providing opportunities for fathers to talk about their emotions and encouragement to make use of strategies they find effective will enable these fathers to continue providing care to their son or daughter. Implications for clinical practice are discussed

The experience of white British fathers providing care to a son or daughter with a diagnosis of psychosis : an exploration of fathers’ accounts of coping.

Aim: Given the move towards community-based care and potential changes in attitudes towards men and caring, it was the aim of this study to explore the experiences of fathers caring for and coping with having a son or daughter with psychosis and begin to identify ‘how’ they cope or ‘what helps’ them to cope in this challenging role. Methods: A qualitative exploratory design was employed using semi-structured interviews. Interviews were transcribed and analysed using Interpretative Phenomenological Analysis (IPA). Participants were six white British fathers who self-identified as providing care to their son/daughter who had experienced a first-episode of psychosis, and were under the care of an early intervention team. All fathers were of working age, with a mean age of 56 years and the identified child was living with them at the time of interview. Results: Results suggest that gender identity and masculinity play some role in these fathers’ understanding of their caring role. Strategies that helped them to cope were identified and themes around men and talking emerged as prominent in interviews. Conclusions: With the literature lacking in focused research around coping in relation to parents caring for children with psychosis, and even less focused on fathers, the current research adds valuable research into this important population. Themes suggest that providing opportunities for fathers to talk about their emotions and encouragement to make use of strategies they find effective will enable these fathers to continue providing care to their son or daughter. Implications for clinical practice are discussed

PRISMA flow diagram of study selection.

<p>PRISMA flow diagram of study selection.</p

Intestinal pathogen clearance in children with severe acute malnutrition is unrelated to inpatient morbidity

Background & aims: Children with Severe Acute Malnutrition (SAM) often suffer from diarrhea, which is associated with increased mortality. The contribution of intestinal bacteria, parasites and viruses to morbidity such as diarrhea in SAM remains poorly understood. To evaluate their association with clinical outcomes, we detected stool pathogens in children with SAM at hospital admission and after clinical stabilization prior to discharge. Methods: 15 intestinal pathogens, fecal calprotectin and C-reactive protein (CRP) were determined at admission and after clinical stabilization in children aged 8-59 months (n = 47) hospitalized in Malawi for complicated SAM. Differences in fecal pathogens, intestinal and systemic inflammation, and clinical outcomes between time points were evaluated using the Wilcoxon Signed-Rank test or Wilcoxon rank-sum test. Results: On admission pathogens were present in nearly all children and after clinical stabilization many were cleared with only 55% of children still harboring a pathogen (89% vs. 55%, p = 0.001). Nosocomial infections were infrequent. The pathogens Giardia lamblia and Shigella spp. were most likely to persist. After clinical stabilization, fecal calprotectin was higher in children harboring a pathogen (median (IQR): 383 mg/kg (903-149 mg/kg) vs 140 mg/kg (300-71 mg/kg), p = 0.03). CRP did not correlate with fecal calprotectin levels nor was it associated with pathogen detection. Presence of stool pathogens was not associated with clinical outcomes such as diarrhea. Conclusions: Fecal pathogens were very common and cleared in most children with complicated SAM treated with antibiotics. The presence of stool pathogens after stabilization was associated with increased intestinal inflammation but not with clinical outcomes. (http://www.isrctn.com/ISRCTN13916953). (c) 2018 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved

Facilitators and Barriers to Supplemental Nutrition Assistance Program Incentive Usee: Findings From a Clinic Intervention for Low-Income Patients

Healthy food incentives matching Supplemental Nutrition Assistance Program (SNAP) benefits spent on fruits and vegetables subsidize increased produce consumption among low-income individuals at risk for food insecurity and diet-related disease. Yet many eligible participants do not use these incentives, in part because of limited awareness. This study examined the acceptability and impact of a primary care?based informational intervention on facilitators andbarriers to use of the statewide SNAP incentive program Double Up Food Bucks