Reducing Unnecessary Phlebotomy Testing Using a Clinical Decision Support System

Background: Overuse of phlebotomy testing offers little to improve patient outcomes. Reducing unnecessary phlebotomy tests can cut costs without compromising quality. Purpose: To determine the effectiveness of a clinical decision support system (CDSS) on reducing unnecessary type and screen tests, estimate the cost saved by the CDSS implementation, and describe the unnecessary ordering practices by provider type. Methods: Our study used a separate-sample pretest posttest design at a mid-Atlantic academic medical center to examine the number of unnecessary type and screen tests three months before and after CDSS implementation. A CDSS was embedded in our electronic health record. The CDSS appears when a type and screen is ordered informing the provider of the date and time the current test expires. Cost savings was estimated using time-driven activity-based costing. Pre-intervention (801 tests) and post-intervention (801 tests) periods were used to describe ordering practices by provider type. Results: There were a total of 26,206 pre- and 25,053 post-intervention specimens. Significantly fewer unnecessary type and screen tests were ordered after the intervention (12.3%, n=3,073) than before (14.1%, n=3,691; p\u3c0.001). The results demonstrated an estimated yearly savings of $142,612 after CDSS implementation. The majority of the tests were ordered by physicians (85.3% before and 83.1% after the intervention) compared to advanced practice nurses and physician assistants. Conclusions: Our study demonstrated that a CDSS impacted a variety of provider types, reduced unnecessary phlebotomy tests, and decrease annual costs. Interventions such as education, audits, and feedback are recommended to further reduce unnecessary ordering practices

Reducing Unnecessary Phlebotomy Testing Using a Clinical Decision Support System

Overuse of phlebotomy testing offers little to improve patient outcomes but may subject patients to additional morbidity. Low-cost, high-frequency tests are ordered recurrently, unnecessarily, and contribute to the high cost of health care. Reducing unnecessary phlebotomy tests can cut costs without compromising quality. Type and screen tests are active for three days from the date the specimen is collected, yet our blood bank laboratory observed type and screen tests were often unnecessarily ordered in our organization. We set out to determine the effectiveness of a clinical decision support system (CDSS) on reducing unnecessary type and screen tests, estimate the cost saved by the CDSS implementation, and describe the unnecessary ordering practices by provider type. Adoption of CDSSs has been successful in reducing unnecessary radiologic imaging, overutilization of antibiotics, and Clostridium dificile testing. Our value improvement initiative was a separate-sample pretest posttest design at a mid-Atlantic academic health system. A CDSS was embedded in our computerized order entry (COPE) system to promote appropriate test ordering. The CDSS appears when a type and screen is ordered informing the provider of the date and time the current test expires. Our study demonstrated that CDSSs impacted a variety of provider types, reduced unnecessary phlebotomy tests, and achieved yearly cost savings. Unnecessary testing continues in health care and contributes to excessive health spending without adding value. Phlebotomy testing is one example of how providers can reduce waste and control healthcare costs for low-cost, high-frequency tests. To further improve test ordering practices of all provider types, we recommend additional interventions such as organizational support, education, audits, and feedback. In this era of precision medicine, ordering the right test, at the right time, for the right reason can reduce cost, reduce waste, and improve quality, outcomes, and satisfaction for patients. Until the establishment of national quality measures aimed to control the number of low-cost, high-frequency tests, health systems must find a way to reduce unnecessary health services. CPOE is widely used in a variety of health care settings and can incorporate CDSS to guide all provider types to make judicious decisions at the time of care

Real-Time Fluorescence PCR Assays for Detection and Characterization of Heat-Labile I and Heat-Stable I Enterotoxin Genes from Enterotoxigenic \u3ci\u3eEscherichia coli\u3c/i\u3e

To facilitate the diagnosis of enterotoxigenic Escherichia coli (ETEC) infections in humans, we developed and evaluated real-time fluorescence PCR assays for the Roche LightCycler (LC) against the enterotoxin genes commonly present in strains associated with human illness. Separate LC-PCR assays with identical cycling conditions were designed for the type I heat-labile enterotoxin (LT I) and the type I heat-stable enterotoxin (ST I) genes, using the LC hybridization probe format. A duplex assay for ST I with two sets of amplification primers and three hybridization probes was required to detect the major nucleotide sequence variants of ST I, ST Ia and ST Ib. LC-PCR findings from the testing of 161 E. coli isolates of human origin (138 ETEC and 23 non-ETEC) were compared with those obtained by block cycler PCR analysis. The sensitivities and specificities of the LC-PCR assays were each 100% for the LT I and ST I genes. The LC-PCR and block cycler PCR assays were also compared for their abilities to detect LT I and ST I genes in spiked stool specimens with different methods of sample preparation. Findings from these experiments revealed that the limits of detection for the LC-PCR assays were the same or substantially lower than those observed for the block cycler PCR assay. Melting curve analysis of the amplified LT I and ST I genes revealed sequence variation within each gene, which for the ST I genes correlated with the presence of ST Ia and ST Ib. The rapidity, sensitivity, and specificity of the LC-PCR assays make them attractive alternatives to block cycler PCR assays for the detection and characterization of ETEC

Shiga toxin 2 translocation across intestinal epithelium is linked to virulence of Shiga toxin-producing Escherichia coli in humans

Shiga toxin-producing Escherichia coli (STEC) are characterized by the release of potent Shiga toxins (Stx), which are associated with severe intestinal and renal disease. Although all STEC strains produce Stx, only a few serotypes cause infection in humans. To determine which virulence traits in vitro are linked to human disease in vivo, 13 Stx2a-producing STEC strains of seropathotype (SPT) A or B (associated with severe human intestinal disease and outbreaks) and 6 strains of SPT D or E (rarely or not linked to human disease) were evaluated in a microaerobic human colonic epithelial infection model. All SPT strains demonstrated similar growth, colonization of polarized T84 colon carcinoma cells and Stx release into the medium. In contrast, Stx translocation across the T84 cell monolayer was significantly lower in SPT group DE compared to SPT group AB strains. Further experiments showed that Stx penetration occurred via a transcellular pathway and was independent of bacterial type III secretion and attaching and effacing lesion formation. These results suggest that the extent of Stx transcytosis across the gut epithelium may represent an important indicator of STEC pathogenicity for humans

Univerity of Dallas History of Athletics, 1956-2006

The University of Dallas is an institution dedicated to the pursuit of excellence. Every facet of the institution is seen in that light. Regarding the relation of the sports program to the central pursuit of the University. Plato\u27s observation is pertinent. Gymnastic and music, in due proportions, he said, are the dispositional base for reason. A disciplined, coordinated body is itself a model of the rational system. This statement, opening the report of the 1984 ad hoc Committee on Sports and Recreation, demonstrates the approach toward athletics that has always existed at the University of Dallas. UD accepts athletic prowess as a good and encourages the pursuit of this good by its students. Throughout the history of athletics at UD there have been good times and bad, but the University has tried its best to support the athletics in its proper place.https://digitalcommons.udallas.edu/historybook/1001/thumbnail.jp

Identification of \u3ci\u3eVibrio\u3c/i\u3e Isolates by a Multiplex PCR Assay and \u3ci\u3erpoB\u3c/i\u3e Sequence Determination

Vibrio, a diverse genus of aquatic bacteria, currently includes 72 species, 12 of which occur in human clinical samples. Of these 12, three species—Vibrio cholerae, Vibrio parahaemolyticus, and Vibrio vulnificus—account for the majority of Vibrio infections in humans. Rapid and accurate identification of Vibrio species has been problematic because phenotypic characteristics are variable within species and biochemical identification requires 2 or more days to complete. To facilitate the identification of human-pathogenic species, we developed a multiplex PCR that uses species-specific primers to amplify gene regions in four species (V. cholerae, V. parahaemolyticus, V. vulnificus, and V. mimicus). The assay was tested on a sample of 309 Vibrio isolates representing 26 named species (including 12 human pathogens) that had been characterized by biochemical methods. A total of 190 isolates that had been identified as one of the four target species all yielded results consistent with the previous classification. The assay identified an additional four V. parahaemolyticus isolates among the other 119 isolates. Sequence analysis based on rpoB was used to validate the multiplex results for these four isolates, and all clustered with other V. parahaemolyticus sequences. The rpoB sequences for 12 of 15 previously unidentified isolates clustered with other Vibrio species in a phylogenetic analysis, and three isolates appeared to represent unnamed Vibrio species. The PCR assay provides a simple, rapid, and reliable tool for identification of the major Vibrio pathogens in clinical samples, and rpoB sequencing provides an additional identification tool for other species in the genus Vibrio

Patterns of Variations in \u3ci\u3eEscherichia coli\u3c/i\u3e Strains That Produce Cytolethal Distending Toxin

A collection of 20 Escherichia coli strains that produce cytolethal distending toxin (CDT) were analyzed for their virulence-associated genes. All of these strains were serotyped, and multiplex PCR analysis was used to ascertain the presence of genes encoding other virulence factors, including Shiga toxin, intimin, enterohemolysin, cytotoxic necrotizing factor type 1 (CNF1) and CNF2, heat-stable toxin, and heat-labile toxin. These CDT-producing strains possessed various combinations of known virulence genes, some of which have not been noted before. Partial cdtB sequences were obtained from 10 of these strains, and their predicted CdtB sequences were compared to known E. coli CdtB sequences; some of the sequences were identical to known CdtB sequences, but two were not. PCR primers based on sequence differences between the known cdt sequences were tested for their ability to detect CDT producers and to determine CDT type. Correlations between the type of CDT produced, the presence of other virulence properties, and overall strain relatedness revealed that the CDT producers studied here can be divided into three general groups, with distinct differences in CDT type and in their complement of virulence-associated genes

Non-O157 Shiga Toxin–Producing \u3ci\u3eEscherichia coli\u3c/i\u3e Infections in the United States, 1983–2002

Background. Shiga toxin–producing Escherichia coli (STEC) O157:H7 is a well-recognized cause of bloody diarrhea and hemolytic-uremic syndrome (HUS). Non-O157 STEC contribute to this burden of illness but have been underrecognized as a result of diagnostic limitations and inadequate surveillance. Methods. Between 1983 and 2002, 43 state public health laboratories submitted 940 human non-O157 STEC isolates from persons with sporadic illnesses to the Centers for Diseases Control and Prevention reference laboratory for confirmation and serotyping. Results. The most common serogroups were O26 (22%), O111 (16%), O103 (12%), O121 (8%), O45 (7%), and O145 (5%). Non-O157 STEC infections were most frequent during the summer and among young persons (median age, 12 years; interquartile range, 3–37 years). Virulence gene profiles were as follows: 61% stx1 but not stx2; 22% stx2 but not stx1; 17% both stx1 and stx2; 84% intimin (eae); and 86% enterohemolysin (E-hly). stx2 was strongly associated with an increased risk of HUS, and eae was strongly associated with an increased risk of bloody diarrhea. STEC O111 accounted for most cases of HUS and was also the cause of 3 of 7 non-O157 STEC outbreaks reported in the United States. Conclusions. Non-O157 STEC can cause severe illness that is comparable to the illness caused by STEC O157. Strains that produce Shiga toxin 2 are much more likely to cause HUS than are those that produce Shiga toxin 1 alone. Improving surveillance will more fully elucidate the incidence and pathological spectrum of these emerging agents. These efforts require increased clinical suspicion, improved clinical laboratory isolation, and continued serotyping of isolates in public health laboratories

Comparison of multiple amber force fields and development of improved protein backbone parameters,”

ABSTRACT The ff94 force field that is commonly associated with the Amber simulation package is one of the most widely used parameter sets for biomolecular simulation. After a decade of extensive use and testing, limitations in this force field, such as over-stabilization of a-helices, were reported by us and other researchers. This led to a number of attempts to improve these parameters, resulting in a variety of ''Amber'' force fields and significant difficulty in determining which should be used for a particular application. We show that several of these continue to suffer from inadequate balance between different secondary structure elements. In addition, the approach used in most of these studies neglected to account for the existence in Amber of two sets of backbone u/w dihedral terms. This led to parameter sets that provide unreasonable conformational preferences for glycine. We report here an effort to improve the u/w dihedral terms in the ff99 energy function. Dihedral term parameters are based on fitting the energies of multiple conformations of glycine and alanine tetrapeptides from high level ab initio quantum mechanical calculations. The new parameters for backbone dihedrals replace those in the existing ff99 force field. This parameter set, which we denote ff99SB, achieves a better balance of secondary structure elements as judged by improved distribution of backbone dihedrals for glycine and alanine with respect to PDB survey data. It also accomplishes improved agreement with published experimental data for conformational preferences of short alanine peptides and better accord with experimental NMR relaxation data of test protein systems

Epstein-Barr Virus-Encoded BARF1 Protein is a Decoy Receptor for Macrophage Colony Stimulating Factor and Interferes with Macrophage Differentiation and Activation

Epstein-Barr virus (EBV), like many other persistent herpes viruses, has acquired numerous mechanisms for subverting or evading immune surveillance. This study investigates the role of secreted EBV-encoded BARF1 protein (sBARF1) in creating an immune evasive microenvironment. Wild-type consensus BARF1 was expressed in the human 293 cell line and purified. This native hexameric sBARF1 had inhibitory capacity on macrophage colony stimulating factor (M-CSF)-stimulated, and not on granulocyte macrophage-colony stimulating factor (GM-CSF)-stimulated growth and differentiation of myeloid cells. Antibodies specific to hexameric sBARF1 were able to block this effect. M-CSF was shown to interact with sBARF1 via the protruding N-terminal loops involving Val38 and Ala84. Each BARF1 hexamer was capable of binding three M-CSF dimers. Mutations in the BARF1 loops greatly affected M-CSF interaction, and showed loss of growth inhibition. Analysis of the activation state of the M-CSF receptor c-fms and its downstream kinase pathways showed that sBARF1 prevented M-CSF-induced downstream phosphorylation. Since M-CSF is an important factor in macrophage differentiation, the effect of sBARF1 on the function of monocyte-derived macrophages was evaluated. sBARF1 affected overall survival and morphology and significantly reduced expression of macrophage differentiation surface markers such as CD14, CD11b, CD16, and CD169. Macrophages differentiating in the presence of sBARF1 showed impaired responses to lipopolysaccharide and decreased oxygen radical formation as well as reduced phagocytosis of apoptotic cells. In conclusion, EBV sBARF1 protein is a potent decoy receptor for M-CSF, hampering the function and differentiation of macrophages. These results suggest that sBARF1 contributes to the modulation of immune responses in the microenvironment of EBV-positive carcinoma