bluuebunny/crossref_metadata_2025_split huggingface dataset:
Performance Improvement Utilizing Multidisciplinary Collaborations and Analytics Are the Key Drivers in Paradigm Shift From Volume to Value in Improving Test Utilization, Patient Safety, and Quality of Care
Authors: Gupta Sachin , Bean Jo , Pieretti Maura , Bischof Larry , Hruszczyk Victor , Chandler Suzanne , King Rita 
Published: September 2019

Abstract

Objectives
The objective of this session is to understand the value of performance improvement, teamwork, and laboratory analytics to improve test utilization, quality, and patient safety. This presentation will highlight BayCare Health System’s journey to achieve clinical excellence.

Methods
Laboratory performance improvement team collaborated with the Enterprise Data Warehouse team to build in-house Laboratory Analytics dashboards. The dashboard reports were used to identify opportunities and to implement best practices in collaboration with multidisciplinary teams. The improvements were achieved by using performance improvement tools and were measured by various process and outcome metrics.

Results: (
1) Lab collaborated with the infection prevention team and standardized the admission screening policies for rapid PCR testing. This has resulted in 50% and 85% reduction in MRSA and VRE testing, respectively, which led to annual savings of over $1 million/year. (2) Collaborating with the antibiotic stewardship team and introducing new urinalysis reflex criteria resulted in an about 18,000 fewer urines reflexed to culture per year. This change led to about $190,000 per year reduction in expense of reagents and labor. (3) Collaborating with the team of nursing, as well as monitoring and implementing best practices to reduce the blood contamination rates, has resulted in <1.4% blood contamination rates. (4) Multidisciplinary teams were able to reduce transfusion rates for various blood products in our hospitals to less than 7%, which brings us to top-decile performers in Premier database. (5) Collaboration with nursing and lab, by using lab analytics, was able to reduce emergency department lab orders result time by 21% and improve patient throughput. (6) The analytics reports also improved staff planning and efficiencies in specimen collection.

Conclusion
Performance improvement utilizing multidisciplinary collaborations and Lab Analytics are the key players in shifting the paradigm from volume to value, which eventually helps in appropriate test utilization and better patient care.
Rapid Identification of Bloodstream Pathogens and Timely Reporting Resulting in Effective Antibiotic Interventions Optimizing Patient Care
Authors: Lin Bo , Christian Manan , Kogan Margarita , Zuretti Alejandro 
Published: September 2019

Abstract

Objectives
Bloodstream infection is a major cause of morbidity and mortality in the United States. Rapid identification of bloodstream pathogens is a critical laboratory practice that allows rapid transition to direct targeted therapy, providing timely and effective patient care. Here, we examined the utilization impact of Biofire blood culture identification panel in identifying bloodstream pathogens and subsequent implementation of treatment on patient care at our medical center.

Methods
Results of patients’ blood culture results and the subsequent medical interventions were reviewed. A policy of reviewing and reporting positive blood culture results every 2 hours was implemented and the results before and after the policy implementation were compared.

Results
We reviewed blood culture results from 288 patients during 1/20/2018 to 4/30/2018. In total, 96.5% of patients had antibiotic interventions. Based on the blood culture results, the interventions were adjusted: 32% changed in dosing, 32% escalated, 25% deescalated, and 11% added sensitivity. After the every 2-hour blood culture result reporting policy was implemented, the median time for physicians to order escalation dropped from 3 hours to 1 hour and median time to deescalate also dropped from 2 hours to 1 hour.

Conclusion
We were able to improve the timeliness of identifying bloodstream pathogens and support effective patient care by using the Biofire blood culture identification panel with timely result reports. Rapid identification of bloodstream pathogens had impacted patient outcomes in multiple ways, including reductions in mortality, morbidity, hospital length of stay, antibiotic use, and patient care cost.
Laboratory Medicine Impact on Population Health in Arizona: Sonora Quest Implementation of the Kidney Profile
Authors: Montgomery Elizabeth , Ivie James , Zeigler Kim , Cohen Robert , Clark Jennifer 
Published: September 2019

Abstract

Introduction
Thirty million American adults are estimated to be living with chronic kidney disease (CKD), with over 80% unaware of the condition that puts them at increased risk for cardiovascular events and progression to kidney failure and death. In primary care populations, almost 90% of adults with type 2 diabetes and CKD are not currently diagnosed, and as many as 50% of patients with advanced CKD remain undiagnosed. There is underutilization of urinary albumin-creatinine ratio (uACR) testing in people at risk for CKD. Less than 10% of those with hypertension and less than 40% of those with diabetes are assessed for albuminuria.
Sonora Quest Laboratories (SQL) extracted data regarding CKD testing in Arizona. Of 604,328 people with laboratory evidence of diabetes, 79% were overdue for albuminuria testing. Significant gaps in diagnosis of individuals with laboratory evidence of CKD were identified as well.

Methods
The National Kidney Foundation (NKF) and the American Society for Clinical Pathology (ASCP) have implemented a national strategy to promote utilization of the Kidney Profile and improve CKD outcomes. NKF and ASCP are working in concert with SQL and NKF of Arizona to engage Arizona’s primary care providers in this effort. The goal is to enhance CKD-related data accuracy in the laboratory information system and to improve CKD recognition, diagnosis, and risk stratification in primary care population health throughout Arizona.

Conclusion
Widespread implementation of the Kidney Profile will improve recognition and risk stratification for CKD. This campaign will positively impact primary care utilization of the NKF/ASCP Choosing Wisely recommendation for CKD assessment: do not request just a serum creatinine to test adult patients with diabetes and/or hypertension for CKD; use the Kidney Profile (serum Creatinine with eGFR and urinary albumin-creatinine ratio).
Review of Inpatient Thrombophilia Testing at a Tertiary Care Center
Authors: Hall Andrew , Lopez Ortega , Powers Amy 
Published: September 2019

Abstract

Introduction
Testing for thrombophilic risk factors is common in patients with thrombosis. However, inpatient hereditary thrombophilia work-ups are prone to false-positive and false-negative results due to concurrent acute phase changes, protein consumption, anticoagulation therapy, and liver disease. A recent ASCP Choosing Wisely guideline recommends against measuring protein C (PC), protein S (PS), or antithrombin III (AT3) to diagnose a hereditary deficiency during an active clotting event.
We aimed to review inpatient PC, PS, and AT3 activity assay ordering practices at a tertiary care center. The goal of this study was to determine appropriateness and identify areas for improvement in inpatient thrombophilia ordering practices.

Methods
A retrospective review of inpatients who underwent thrombophilia testing was performed. Inclusion criteria consisted of adult inpatients with PC, PS, and/or AT3 activity results. Patients for whom AT3 was ordered alone were excluded. The timeframe of testing relative to an acute thrombotic event, anticoagulation therapy, and liver disease was determined via electronic medical record review. Other conditions that can affect PC, PS, or AT3 levels were recorded if noted.

Results
Over 5 months, 50 inpatients underwent testing for PC, PS, and/or AT3. Testing was performed within 2 weeks of an acute thrombotic event in 92% of patients; 32% received anticoagulation therapy prior to testing and 16% had liver disease. Test results below the reference range were found in the following percentage of patients: 16% PC, 34% PS, and 16% AT3. In total, 23 of 50 (46%) patients had one or more abnormal results; all 23 had potential confounding conditions/drug.

Conclusions
Inpatient PC, PS, and AT3 testing was frequently performed in clinical settings, which may cause false-positive or false-negative results. This demonstrates the need for increased education and dialogue between the laboratory and clinicians to improve test utilization practices. Potential interventions are currently being analyzed.
Routine Use of Flow Cytometry in the Initial Diagnosis of Myelodysplastic and Myeloproliferative Neoplasms Is Not Justified
Authors: Lynch David , Williams Grant , Eden Rina 
Published: September 2019

Abstract

Objectives
To retrospectively assess the utility of flow cytometry on bone marrow aspirates with respect to the initial diagnosis of myelodysplastic and myeloproliferative neoplasms.

Methods
Flow cytometry results at Brooke Army Medical Center from January 1, 2016, to January 1, 2019, were reviewed on all bone marrow biopsies performed for the initial diagnosis of myelodysplastic (MDS) or myeloproliferative neoplasms (MPN). Results were categorized as normal, abnormal myeloid population, or abnormal lymphoid population.

Results
A total of 197 cases were identified (134 for MDS and 76 for MPN). Of the biopsies for MDS, 27% showed an abnormal myeloid population, and 1% showed an abnormal lymphoid population. Three cases were diagnosed as acute myeloid leukemia. Of the biopsies for MPN, 8% showed an abnormal myeloid population, and 1% showed an abnormal lymphoid population. Cases with incidental abnormal lymphoid populations were small (<5% of events).

Conclusion
In all cases except those diagnosed as acute myeloid leukemia (1.4% of cases), flow cytometry findings did not affect the diagnosis. Based on these findings and the diagnostic criteria in the updated WHO 2016 revision, flow cytometry does not need to be routinely performed on the bone marrow specimens for the diagnosis of MDS or MPN. However, identification of possible cases of acute myeloid leukemia is critical since flow cytometry is required in those cases. Screening of a bone marrow aspirate slide by a pathologist would allow for canceling of unnecessary flow cytometry in these cases and allow for better test utilization.
Evidence-Based Duplicate Order Alerts Promote Effective Test Utilization and Reduce Unnecessary Laboratory Testing
Authors: Coberly Jared , Coberly Emily , Dettenwanger Katie , Ross Brandi , Pierce Robert 
Published: September 2019

Abstract

Introduction
Unnecessary and inappropriate laboratory testing contributes to increased health care costs, increases length of stay, and increases odds for blood product transfusion. The Choosing Wisely campaign recommends a judicious use of laboratory blood testing to combat iatrogenic anemia. Reducing the number of duplicate test orders may help address these issues. We evaluated duplicate order alert thresholds in our electronic health record for 10 common laboratory tests at an academic medical center.

Methods
In January 2019, alert intervals for 10 common inpatient laboratory tests (thyroid stimulating hormone, complete blood count, hemoglobin A1c, troponin, lactic acid, hemoglobin and hematocrit, urinalysis, vitamin D, urine beta HCG, and triglycerides) were adjusted to evidence-based, disease-specific thresholds. If a test was ordered within a timeframe shorter than this threshold, an alert interrupted the provider’s workflow. The provider was allowed to override the alert based on clinical judgment. This is a change from the previous settings, which alerted any test if ordered more frequently than 8 hours. Postintervention duplicate order alerts were compared to baseline rates and adjusted for number of inpatient discharges.

Results
In total, 914 orders were cancelled in 1 month as a result of tailored duplicate order alerts versus the baseline mean of 710 (95% CI, 633-786) and a predicted 552 (95% CI, 475-628) when adjusted for number of inpatient discharges, with the majority of cancelled orders being for CBC (530 accepted alerts). Overall, this reduction in unnecessary duplicate tests is equivalent to 3,092 mL of blood not collected from patients per month.

Conclusion
Tailoring duplicate order alert interval thresholds to evidence-based criteria helps reduce unnecessary testing, reduces costs, and may play an important role in reducing hospital-acquired anemia.
A Rare Case of Congenital Factor X Mild Deficiency Presenting as Life-Threatening Hemorrhagic Shock in a Neonate
Authors: Mendoza Rachelle , Haidary Tahmineh , Kang Steven 
Published: September 2019

Abstract

Introduction
Congenital factor X deficiency is one of rarest bleeding disorders, occurring in 1 out of 1 million births. Its rarity limits its consideration in newborns presenting with hemodynamic instability. It is autosomal recessive and seen frequently in the consanguineous population. Patients with factor X deficiency are classified into three groups, based on factor X activity level: severe (<1%), moderate (1%-4%), and mild (6%-10%). Severe deficiency presents with bleeding diathesis early in life.

Methods
A 3-day-old male newborn, delivered at term via spontaneous vaginal delivery, presented in a well-baby clinic for a routine bilirubin check. Family history was negative for bleeding disorder or consanguinity. Nurse noted persistent blood oozing at heel stick site and oral, nasal, and umbilical stump bleeding. The patient immediately developed respiratory distress and shock. Sepsis, vitamin K deficiency, and congenital metabolic syndrome were considered. Liver function, WBC count, and other chemistry were normal, and cultures were negative. Hemoglobin was low and platelet count was elevated. PT (30.3 seconds) and aPTT (53.3 seconds) were both prolonged. Mixing patient’s sample with normal plasma corrected PT (13.1 seconds) and aPTT (25.7 seconds), indicating a factor deficiency.

Results
Coagulation factor assays revealed normal levels of factors VII, VIII, IX, and II. Factor X activity (12.9%) was low. The patient’s condition improved after multiple pRBC and plasma transfusions. He was placed on a daily 25-mL/kg dose of fresh-frozen plasma, which maintained his PT at 17.6 to 19.1 seconds and aPTT at 34.1 to 48.0 seconds. Factor X level increased to 20% after plasma transfusion.

Conclusion
Congenital bleeding disorder should be considered for neonates presenting with bleeding and shock. Factor X deficiency is suspected when both PT and aPTT are prolonged and corrected with mixing studies. Although factor levels of 10% to 40% are considered adequate for hemostasis, our patient with 12% factor X activity presented with a life-threatening bleeding event.
Eucalyptol Masks the Olfactory But Not the Trigeminal Sensation of Ammonia
Authors: Müschenich Franziska S , Sijben Rik , Gallenmüller Felix , Singer Marco , Rodriguez-Raecke Rea , Di Francesco Maria Elisa , Wiesmann Martin , Freiherr Jessica 
Published: September 2019

Abstract
Eucalyptol is a substance with rather pleasant olfactory and trigeminal characteristics and is thus suggested as an efficient tool for malodor coverage. In this study ammonia would be the malodor substance such as is found in cat litter or hair coloration. We investigated the potential of eucalyptol to inhibit both the olfactory as well as the trigeminal sensation of ammonia. For this purpose, we mixed eucalyptol and ammonia and compared odor component intensities. After being presented with either the pure odors or a binary mixture thereof, 21 young and healthy participants had to lateralize the odors and rate component (eucalyptol and ammonia) and total intensity. Analysis of intensity ratings revealed hypoadditivity (total mixture intensity was less than the sum of the total intensity of the single components). Significant interaction effects verified that mixing eucalyptol and ammonia only affected the perceived intensity of ammonia. Comparing the odor components within the pure and mixed stimuli, the ammonia component was rated as significantly less intense in the mixture compared to pure ammonia whereas the eucalyptol component was rated equal in the pure and mixed condition. On the basis of lateralization scores, we observed trigeminal mixture enhancement. We conclude that eucalyptol is a suitable masking agent to cover the unpleasant smell of ammonia; however, it fails to serve as an ammonia counterirritant because it lacks the ability to mask the trigeminal sensation of ammonia.
Baloxavir Marboxil in Japanese Pediatric Patients With Influenza: Safety and Clinical and Virologic Outcomes
Authors: Hirotsu Nobuo , Sakaguchi Hiroki , Sato Chisako , Ishibashi Toru , Baba Keiko , Omoto Shinya , Shishido Takao , Tsuchiya Kenji , Hayden Frederick G , Uehara Takeki , Watanabe Akira 
Published: September 2019

Abstract

Background
We assessed the safety and effectiveness of baloxavir marboxil administration in Japanese children with influenza.

Methods
This open-label study administered 1 weight-adjusted dose of baloxavir to 107 children aged 1–11 years with laboratory-confirmed, febrile influenza virus infection of ≤48 hours duration.

Results
Adverse events (AEs) were reported in 34.6% of patients, most commonly vomiting (7.5%); no serious AEs or AEs causing discontinuation occurred. The median time to alleviation of influenza illness was 44.6 hours (95% confidence interval, 38.9–62.5 hours), to resolution of fever was 21.4 hours, and to sustained cessation of infectious viral shedding was 24.0 hours. However, viruses with amino acid substitutions in the viral polymerase acidic protein at position I38 (PA/I38T/M) emerged in 18 of 77 (23.4%) patients. Emergence was associated with longer infectious virus detectability (median time, 180.0 hours) and time to illness alleviation (median, 79.6 vs 42.8 hours in patients without PA/I38T/M-substituted viruses). Among patients with PA/I38T/M-substituted virus emergence, those with baseline hemagglutinin inhibition (HAI) antibody titer &lt;40 experienced delay in time to illness alleviation (median, 85.4 vs 56.0 hours in patients with higher baseline HAI antibody titer).

Conclusions
A single, oral dose of baloxavir marboxil was well tolerated and rapidly reduced viral titers, but the common emergence of PA/I38T/M-substituted viruses warrants consideration of alternative dosing regimens in young children.

Clinical Trials Registration
Japan Pharmaceutical Information Center Clinical Trials Information (Japic CTI-163417).
Usefulness of Procalcitonin in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis
Authors: Cheung Donna Ann , Tamariz Leonardo , Nemeth Zsuzsanna , Langshaw Amber Hamid 
Published: September 2019

Abstract

Background
Mixed results are reported for procalcitonin (PCT) as biomarkers of infection and disease activity in inflammatory bowel disease (IBD).

Method
We systematically evaluated and performed a meta-analysis on the usefulness of PCT in assessing infection and disease activity in IBD.

Results
The pooled standardized mean difference of PCT for those with infection compared with those without was 1.59 (95% CI, 0.72–2.46, P &lt; 0.01) and those with active disease compared with those without was 1.22 (95% CI, 0.66–1.78, P &lt; 0.01), respectively.

Conclusion
PCT may potentially be useful in differentiating an infectious process from IBD and active from inactive IBD.
A novel secreted-cAMP pathway inhibits pulmonary hypertension via a feed-forward mechanism
Authors: Jones Carly , Bisserier Malik , Bueno-Beti Carlos , Bonnet Guillaume , Neves-Zaph Susana , Lee Sang-Yong , Milara Javier , Dorfmüller Peter , Humbert Marc , Leopold Jane A , Hadri Lahouaria , Hajjar Roger J , Sassi Yassine 
Published: September 2019

AbstractAimsCyclic adenosine monophosphate (cAMP) is the predominant intracellular second messenger that transduces signals from Gs-coupled receptors. Intriguingly, there is evidence from various cell types that an extracellular cAMP pathway is active in the extracellular space. Herein, we investigated the role of extracellular cAMP in the lung and examined whether it may act on pulmonary vascular cell proliferation and pulmonary vasculature remodelling in the pathogenesis of pulmonary hypertension (PH).Methods and resultsThe expression of cyclic AMP-metabolizing enzymes was increased in lungs from patients with PH as well as in rats treated with monocrotaline and mice exposed to Sugen/hypoxia. We report that inhibition of the endogenous extracellular cAMP pathway exacerbated Sugen/hypoxia-induced lung remodelling. We found that application of extracellular cAMP induced an increase in intracellular cAMP levels and inhibited proliferation and migration of pulmonary vascular cells in vitro. Extracellular cAMP infusion in two in vivo PH models prevented and reversed pulmonary and cardiac remodelling associated with PH. Using protein expression analysis along with luciferase assays, we found that extracellular cAMP acts via the A2R/PKA/CREB/p53/Cyclin D1 pathway.ConclusionsTaken together, our data reveal the presence of an extracellular cAMP pathway in pulmonary arteries that attempts to protect the lung during PH, and suggest targeting of the extracellular cAMP signalling pathway to limit pulmonary vascular remodelling and PH.
Small Bowel Adenocarcinoma: Is There a Difference in Survival for Crohn's Versus Sporadic Cases?
Authors: Fields Adam C , Hu Frances Y , Lu Pamela , Irani Jennifer , Bleday Ronald , Goldberg Joel E , Melnitchouk Nelya 
Published: September 2019

AbstractBackground and AimsIt is well known that Crohn's disease is a risk factor for the development of small bowel adenocarcinoma. However, the association between Crohn's disease-associated small bowel adenocarcinoma and survival is less understood. The goal of this study was to determine the impact of Crohn's disease on survival in small bowel adenocarcinoma.MethodsPatients with small bowel adenocarcinoma, either associated with Crohn's disease or diagnosed sporadic, were identified in the National Cancer Database from 2004–2016. The primary outcome was overall survival.ResultsOf 2668 patients, 493 had Crohn's disease-associated small bowel adenocarcinoma and 2175 had sporadic small bowel adenocarcinoma. Crohn's disease patients were more likely to present at a younger age [62 vs 65, p &lt; 0.001], have tumours located in the ileum [62.7% vs 25.0%, p &lt; 0.001], and have poorly differentiated tumours [47.0% vs 31.7%, p &lt; 0.001] compared with sporadic small bowel adenocarcinoma. Factors associated with significantly decreased survival included older age (hazard ratio [HR]: 1.02, 95% confidence interval [CI]: 1.02–1.03, p &lt; 0.00)], higher Charlson score [HR: 1.39, 95% CI: 1.13–1.72, p = 0.002], higher tumour grade [HR: 1.09, 95% CI: 1.04–1.14, p &lt; 0.001], positive surgical margins [HR: 1.60, 95% CI: 1.39–1.84, p &lt; 0.001], and higher stage of disease [HR: 1.90, 3.75, 8.13, 95% CI: 1.37–2.64, 2.68–5.24, 5.77–11.47, for II, III, IV, respectively, compared with I, all p &lt; 0.001]. Receipt of chemotherapy was associated with significantly improved survival [HR: 0.61, 95% CI: 0.53–0.70, p &lt; 0.001]. Crohn's disease [HR: 1.01, 95% CI: 0.99–1.02, p = 0.39], was not significantly associated with survival.ConclusionCompared with sporadic patients, Crohn's disease patients have similar overall survival, and Crohn's disease is not an independent risk factor for mortality.