Technological viewpoints (frames) about electronic prescribing in physician practices

Objective

Physician practices may adopt and use electronic prescribing (eRx) in response to mandates, incentives, and perceived value of the technology. Yet, for the most part, diffusion has been limited and geographically confined, and even when adopted, use of eRx in many practices has been low. One explanation for this phenomenon is that decision-makers in the practices possess different technological viewpoints (frames) related to eRx and these frames have formed the basis for the adoption decision, expectations about the technology, and patterns of use. In this study eRx technological frames were examined.

Design

Focus groups, direct observation, and semi-structured interviews were conducted with physicians, practice managers, nurses, and other medical staff.

Measurements

Focus groups were observed, taped, transcribed, and analyzed to reveal themes. These themes guided the observational visits and subsequent interviews. A triangulation process was used to confirm the findings.

Results

Seven frames emerged from the qualitative analysis ranging from positive to neutral to negative: (1) eRx as an efficiency and effectiveness enhancing tool; (2) eRx as the harbinger of new practices; (3) eRx as core to the clinical workflow; (4) eRx as an administrative tool; (5) eRx: the artifact; (6) eRx as a necessary evil; and (7) eRx as an unwelcome disruption.

Conclusion

Frames provide a unique perspective within which to explore the adoption and use of eRx and may explain why perceptions of value vary greatly. Some frames facilitate effective use of eRx while others impose barriers. Electronic prescribing can be viewed as a transitional technology on the path to greater digitization at the physician practice level. Understanding the impact of technological frames on the effectiveness of eRx use may provide lessons for the implementation of future health information technology innovations.     

Seizure-related injury and death

Epilepsy is associated with significantly increased morbidity and mortality from a variety of causes. Patients with epilepsy have approximately two to three times the risk of death from any cause compared with persons without epilepsy. Seizures may cause significant trauma, drowning, and accidental injury. Many of the deaths in persons with epilepsy are directly related to seizures, accidents and injuries arising from seizures, and the underlying condition resulting in seizures. This review focuses on recent data regarding seizure-related injury and mortality.     

Possible underlying influence of p38MAPK and NF-κB in the diminished anti-anxiety effect of diazepam in stressed mice

The present study was designed to explore the possible nitriergic influence and role of p38MAPK and NF-κB in the diminished anti-anxiety effect of diazepam in stressed mice, using the elevated plus maze and light/dark box to assess anxiety. Immobilization stress for 6 h enhanced an anxiety-like behavior and increased plasma nitrite levels in mice. Diazepam (2 mg/kg, i.p.) produced an anti-anxiety effect in unstressed mice, but could not produce any change in anxiety levels of stressed mice. SB-203580 (2 mg/kg, i.p.), a specific inhibitor of p38MAPK, per se produced a significant antianxiety-like activity in stressed mice. Administration of a combination of SB-203580 (2 mg/kg, i.p.) and diazepam (2 mg/kg) in stressed mice produced a significantly higher antianxiety-like activity than that produced by SB-203580 alone. Pyrrolidine dithiocarbamate (PDTC), an inhibitor of the activation of NF-κB, per se produced a significant antianxiety-like activity in stressed mice. Combination of PDTC and diazepam also served to produce a higher significant antianxiety-like activity in stressed mice than that produced by PDTC alone. Diazepam could not produce any change in plasma nitrite levels in both unstressed and stressed mice. Both SB-203580 (2 mg/kg, i.p.) and PDTC (100 mg/kg, i.p.) significantly decreased plasma nitrite levels in stressed mice. The observations indicate that the diminished anti-anxiety effect of diazepam in stressed mice may involve strong nitriergic influence and may further be p38MAPK- and NF-κB-dependent.     

GAPDH regulates cellular heme insertion into inducible nitric oxide synthase

Heme proteins play essential roles in biology, but little is known about heme transport inside mammalian cells or how heme is inserted into soluble proteins. We recently found that nitric oxide (NO) blocks cells from inserting heme into several proteins, including cytochrome P450s, hemoglobin, NO synthases, and catalase. This finding led us to explore the basis for NO inhibition and to identify cytosolic proteins that may be involved, using inducible NO synthase (iNOS) as a model target. Surprisingly, we found that GAPDH plays a key role. GAPDH was associated with iNOS in cells. Pure GAPDH bound tightly to heme or to iNOS in an NO-sensitive manner. GAPDH knockdown inhibited heme insertion into iNOS and a GAPDH mutant with defective heme binding acted as a dominant negative inhibitor of iNOS heme insertion. Exposing cells to NO either from a chemical donor or by iNOS induction caused GAPDH to become S-nitrosylated at Cys152. Expressing a GAPDH C152S mutant in cells or providing a drug to selectively block GAPDH S-nitrosylation both made heme insertion into iNOS resistant to the NO inhibition. We propose that GAPDH delivers heme to iNOS through a process that is regulated by its S-nitrosylation. Our findings may uncover a fundamental step in intracellular heme trafficking, and reveal a mechanism whereby NO can govern the process.     

Multidrug transporters CaCdr1p and CaMdr1p of Candida albicans display different lipid specificities: both ergosterol and sphingolipids are essential for targeting of CaCdr1p to membrane rafts

In this study, we compared the effects of altered membrane lipid composition on the localization of two membrane drug transporters from different superfamilies of the pathogenic yeast Candida albicans. We demonstrated that in comparison to the major facilitator superfamily multidrug transporter CaMdr1p, ATP-binding cassette transporter CaCdr1p of C. albicans is preferentially localized within detergent-resistant membrane (DRM) microdomains called 'rafts.' Both CaCdr1p and CaMdr1p were overexpressed as green fluorescent protein (GFP)-tagged proteins in a heterologous host Saccharomyces cerevisiae, wherein either sphingolipid (Deltasur4 or Deltafen1 or Deltaipt1) or ergosterol (Deltaerg24 or Deltaerg6 or Deltaerg4) biosynthesis was compromised. CaCdr1p-GFP, when expressed in the above mutant backgrounds, was not correctly targeted to plasma membranes (PM), which also resulted in severely impaired drug resistance. In contrast, CaMdr1p-GFP displayed no sorting defect in the mutant background and remained properly surface localized and displayed no change in drug resistance. Our data clearly show that CaCdr1p is selectively recruited, over CaMdr1p, to the DRM microdomains of the yeast PM and that any imbalance in the raft lipid constituents results in missorting of CaCdr1p.     

Effects of school-based interventions on mental health stigmatization: a systematic review

Stigmatizing, or discriminatory, perspectives and behaviour, which target individuals on the basis of their mental health, are observed in even the youngest school children. We conducted a systematic review of the published and unpublished, scientific literature concerning the benefits and harms of school-based interventions, which were directed at students 18 years of age or younger to prevent or eliminate such stigmatization. Forty relevant studies were identified, yet only a qualitative synthesis was deemed appropriate. Five limitations within the evidence base constituted barriers to drawing conclusive inferences about the effectiveness and harms of school-based interventions: poor reporting quality, a dearth of randomized controlled trial evidence, poor methods quality for all research designs, considerable clinical heterogeneity, and inconsistent or null results. Nevertheless, certain suggestive evidence derived both from within and beyond our evidence base has allowed us to recommend the development, implementation and evaluation of a curriculum, which fosters the development of empathy and, in turn, an orientation toward social inclusion and inclusiveness. These effects may be achieved largely by bringing especially but not exclusively the youngest children into direct, structured contact with an infant, and likely only the oldest children and youth into direct contact with individuals experiencing mental health difficulties. The possible value of using educational activities, materials and contents to enhance hypothesized benefits accruing to direct contact also requires investigation. Overall, the curriculum might serve as primary prevention for some students and as secondary prevention for others.     

Functional MR imaging of the lung

Recent development of MR techniques has overcome many problems, such as susceptibility artifacts or motion artifact, allowing both static and dynamic MR lung imaging and providing quantitative information of pulmonary function, including perfusion, ventilation, and respiratory motion. Dynamic contrast-enhanced MR perfusion imaging is suitable for the evaluation of angiogenesis of pulmonary solitary nodules. (129)Xe MR imaging is potentially a robust technique for the evaluation of various pulmonary function and may replace (3)He. The information provided by these new MR imaging methods is proving useful in research and in clinical applications in various lung diseases.     

Can the UK guidelines for stroke be effective? Attitudes to the symptoms of a transient ischaemic attack among the general public and doctors

This questionnaire-based study assessed the attitudes of the general public to the symptoms of a transient ischaemic attack (TIA) and determined the current level of knowledge about the management of TIA among doctors. The public chose to wait for symptom recurrence before seeking medical advice for amaurosis (41%) and upper limb (UL) monoparesis (51%), sensory loss (68%), or paraesthesia (95%). However, medical advice would be sought most often for slurred speech alone (89%) or combined with UL monoparesis (99%). Most physicians confirmed that these symptoms could represent a 'carotid TIA' but many considered diverse symptoms as relevant. While most general practitioners would prescribe anti-platelet therapy, 22-40% would not refer first-time TIA patients, depending upon the presenting symptom. In conclusion, the general public does not recognise the importance of TIA symptoms and the need for rapid assessment. This is compounded by deficiencies in the medical management of TIA. Stroke guidelines will remain ineffective without public awareness campaigns and physician education.