Hospital discharge documentation and risk of rehospitalisation

BACKGROUND Avoidable hospital readmission is a focus of quality improvement efforts. The effectiveness of individual elements of the standard discharge process in reducing rehospitalisation is unknown. METHODS The authors conducted a case-control study of 1039 patients experiencing rehospitalisation within 30 days of discharge and 981 non-rehospitalised patients matched on admission diagnosis, discharge disposition, and severity of illness. In separate models for each discharge process component, the authors measured the relationship between readmission and discharge summary completion, contents of discharge summary, completion of discharge instructions, contents of discharge instructions, presence of caregiver for discharge instruction, completion of medication reconciliation, and arrangement of ambulatory follow-up prior to discharge. RESULTS Adjusting for patient and hospital characteristics, including severity of illness and discharge disposition, the study failed to find an association between readmission and most components of the discharge process. There was no association between readmission and medication reconciliation, transmission of discharge summary to an outpatient physician, or documentation of any specific aspect of discharge instruction. Associations were found between readmission and discharge with followup arranged (adjusted odds ratio (OR) 1.21; 95% CI 1.05 to 1.37) and increasing number of medicines (adjusted OR 1.02; 95% CI 1.01 to 1.04). CONCLUSIONS Documentation of discharge process components in the medical record may not reflect actual discharge process activities. Alternatively, mandated discharge processes are ineffective in preventing readmission. The observed absence of an association between discharge documentation and readmission indicates that discharge quality improvement initiatives should target metrics of discharge process quality beyond improving rates of documentation.     

Cross-validation of an instrument for measuring professionalism behaviors

Objective. To cross-validate an instrument to measure behavioral aspects of professionalism in pharmacy students using a rating scale that minimizes ceiling effects.Methods. Seven institutions collaborated to create a 33-item assessment tool that included 5 domains of professionalism: (1) Reliability, Responsibility and Accountability; (2) Lifelong Learning and Adaptability; (3) Relationships with Others; (4) Upholding Principles of Integrity and Respect; and (5) Citizenship and Professional Engagement. Each item was rated based on 5 levels of competency which were aligned with a modified Miller''s Taxonomy (Knows, Knows How, Shows, Shows How and Does, and Teaches).Results. Factor analyses confirmed the presence of 5 domains for professionalism. The factor analyses from the 7-school pilot study demonstrated that professionalism items were good fits within each of the 5 domains.Conclusions. Based on a multi-institutional pilot study, data from the Professionalism Assessment Tool (PAT), provide evidence for internal validity and reliability. Use of the tool by external evaluators should be explored in future research.     

5-HT modulation by acute tryptophan depletion of human instrumental contingency judgements

Introduction

The concept of ??depressive realism??, that depression leads to more accurate perception of causal control, has been influential in the field of depression research, but remains controversial. Recent work testing contingency learning has suggested that contextual processing might determine realism-like effects. Serotonin (5-hydroxytryptamine, (5-HT)), which is implicated in the pathophysiology of depression, might also influence contextual processing. Using acute tryptophan depletion (ATD), we tested the hypothesis that dysfunctional serotoninergic neurotransmission influences contingency judgements in dysphoric subjects via an effect on contextual processing.

Materials and methods

We employed a novel contingency learning task to obtain separate measures (ratings) of the causal effect of partcipants?? responses and efficacy of the background context over an outcome. Participants, without a history of depression, completed this task on and off ATD in a double-blind, placebo-controlled, within-subjects design.

Results

As with other work on contingency learning, the effects of ATD were related to baseline mood levels. Although no overall effects of ATD were observed, the subgroup of participants with low Beck depression inventory (BDI) scores showed reduced ratings of contextual control and improved accuracy of contingency judgements under positive contingencies following ATD, compared to placebo. High BDI participants demonstrated low accuracy in contingency judgements, regardless of serotoninergic status.

Conclusions

No effect of ATD on contingency judgements was observed in the group as a whole, but effects were observed in a subgroup of participants with low BDI scores. We discuss these data in light of the context processing hypothesis, and prior research on 5-HT and depressive realism.     

Quantification of human skin barrier function and susceptibility to quantum dot skin penetration

Abstract In this study, we utilize in vivo human skin and a viable ex-vivo human skin model to investigate the effect of a commercial depilatory agent on barrier function. Tape stripping was used as a positive control. The magnitude of skin barrier was quantified by measuring transepidermal water loss values on in vivo human skin and transepithelial electrical resistance measurements and tissue histology on ex vivo skin. The susceptibility to carboxylated quantum dot penetration through ex vivo skin was investigated using fluorescent microcopy analysis of microtomed skin sections and flow cytometry to quantify quantum dot association with live epidermal cells. Results show that depilatory treatment modifies the outside-in barrier sufficiently to allow quantum dots to penetrate the stratum corneum but to a lesser extent than tape stripping. The implications of these finding are discussed.     

Drug-related problems identified in post-discharge medication reviews for patients taking warfarin

Objective To characterise the nature of the drug-related problems with warfarin therapy identified in pharmacist-conducted medication reviews during a collaborative post-discharge warfarin management service, with a focus on potentially serious drug interactions. Setting Australian community pharmacy practice. Method Medication review reports submitted by pharmacists to patients?? general practitioners as part of the service were reviewed and the type and clinical significance of the warfarin-associated drug-related problems, and the pharmacists?? recommendations were classified. The prevalence of prescribing of ??potentially hazardous?? warfarin drug interactions was investigated and compared with the frequency of documentation of these interactions in the medication review reports. Main outcome measure The number and nature of warfarin-associated drug-related problems identified and the rate of documentation of ??potentially hazardous?? warfarin drug interactions in the reports from pharmacist-conducted medication reviews. Results A total of 157 warfarin-associated drug-related problems were documented in 109 medication review reports (mean 1.4 per patient, 95% CI 1.3?C1.6, range 0?C5). Drug selection and Education or information were the most commonly identified warfarin-associated drug-related problems; most drug-related problems were of moderate clinical significance. Eight of 23 potentially serious warfarin drug interactions (34.8%) were identified in the medication review reports. Conclusion Pharmacists addressing drug selection and warfarin education drug-related problems during medication reviews may have contributed to the positive outcomes of the post-discharge service. Warfarin drug interactions were frequently identified; however, well-recognised potentially hazardous interactions were under-reported. Improved communication along the continuum of care would permit improved targeting of drug-related problem reporting, especially in relation to preventable drug interactions.     

6-oxopurine phosphoribosyltransferase: a target for the development of antimalarial drugs

Malaria remains the most serious parasitic diseases affecting humans in the world today, resulting in 1-2 million fatalities each year. Plasmodium falciparum (Pf) and Plasmodium vivax (Pv) are the predominant causative agents. Both are responsible for widespread mortality and morbidity and are a serious socio-economic burden, especially for countries in the developing world. One of the most important defences against malaria has been the use of chemotherapeutic drugs (e.g. chloroquine, artemisinins, pyrimethamine) but these have mainly been found by serendipity. Their mechanisms was not understood at the time of their discovery and, even today, are still not unequivocal. For many of these compounds, the parasite is now resistant and, hence, there is an urgent need to develop new therapeutic drugs directed to validated targets. One metabolic pathway crucial for the survival and replication and survival of the parasite is the synthesis of the purine nucleoside monophosphates essential for the production of DNA/RNA molecules. A key enzyme in this pathway is the 6-oxopurine phosphoribosyltransferase (PRTase). The focus of this review is on the identification and characterization of inhibitors of the enzymes from both Pf and Pv as antimalarial drug leads. The acyclic nucleoside phosphonates (ANPs) appear to be excellent candidates because they are good inhibitors of the two Plasmodium enzymes, can be selective compared to the human enzyme, can arrest parasitemia in cell based assays, have low cytotoxicity to the human host cell and, because of their stable carbon-phosphorous bond, are stable within the cell.     

The promise of nanotechnology for solving clinical problems in breast cancer

Approaches for breast cancer treatment are invasive, disfiguring, have significant side-effects, and are not always curative. Nanotechnology is an emerging area which is focused on engineering of materials <100 × 10(-9) m. There is significant promise for advancing nanotechnology to improve breast cancer diagnosis and treatment including non-invasive therapy, monitoring response to therapy, advanced imaging, treatment of metastatic disease, and improved nodal staging. Current approaches and important future directions are discussed.