Primer Part 1 - Preparing a laboratory quality improvement project.

Quality in laboratory medicine encompasses multiple components related to total quality management, including quality control (QC), quality assurance (QA), quality indicators, and quality improvement (QI). Together, they contribute to minimizing errors (pre-analytical, analytical, or post-analytical) in clinical service delivery and improving process appropriateness and efficiency. In contrast to static quality benchmarks (QC, QA, quality indicators), the QI paradigm is a continuous approach to systemic process improvement for optimizing patient safety, timeliness, effectiveness, and efficiency. Healthcare institutions have placed emphasis on applying the QI framework to identify and improve healthcare delivery. Despite QI's increasing importance, there is a lack of guidance on preparing, executing, and sustaining QI initiatives in the field of laboratory medicine. This has presented a significant barrier for clinical laboratorians to participate in and lead QI initiatives. This three-part primer series will bridge this knowledge gap by providing a guide for clinical laboratories to implement a QI project that issuccessful and sustainable. In the first article, we introduce the steps needed to prepare a QI project with focus on relevant methodology and tools related to problem identification, stakeholder engagement, root cause analysis (e.g., fishbone diagrams, Pareto charts and process mapping), and SMART aim establishment. Throughout, we describe a clinical vignette of a real QI project completed at our institution focused on serum protein electrophoresis (SPEP) utilization. This primer series is the first of its kind in laboratory medicine and will serve as a useful resource for future engagement of clinical laboratory leaders in QI initiatives.

COVID-19 vaccine reactogenicity among participants enrolled in the GENCOV study.

BACKGROUND: GENCOV is a prospective, observational cohort study of COVID-19-positive adults. Here, we characterize and compare side effects between COVID-19 vaccines and determine whether reactogenicity is exacerbated by prior SARS-CoV-2 infection. METHODS: Participants were recruited across Ontario, Canada. Participant-reported demographic and COVID-19 vaccination data were collected using a questionnaire. Multivariable logistic regression was performed to assess whether vaccine manufacturer, type, and previous SARS-CoV-2 infection are associated with reactogenicity. RESULTS: Responses were obtained from n = 554 participants. Tiredness and localized side effects were the most common reactions across vaccine doses. For most participants, side effects occurred and subsided within 1-2 days. Recipients of Moderna mRNA and AstraZeneca vector vaccines reported reactions more frequently compared to recipients of a Pfizer-BioNTech mRNA vaccine. Previous SARS-CoV-2 infection was independently associated with developing side effects. CONCLUSIONS: We provide evidence of relatively mild and short-lived reactions reported by participants who have received approved COVID-19 vaccines.

The inseparability of context and clinical reasoning.

Early descriptions of clinical reasoning have described a dual process model that relies on analytical or nonanalytical approaches to develop a working diagnosis. In this classic research, clinical reasoning is portrayed as an individual-driven cognitive process based on gathering information from the patient encounter, forming mental representations that rely on previous experience and engaging developed patterns to drive working diagnoses and management plans. Indeed, approaches to patient safety, as well as teaching and assessing clinical reasoning focus on the individual clinician, often ignoring the complexity of the system surrounding the diagnostic process. More recent theories and evidence portray clinical reasoning as a dynamic collection of processes that takes place among and between persons across clinical settings. Yet, clinical reasoning, taken as both an individual and a system process, is insufficiently supported by theories of cognition based on individual clinicals and lacks the specificity needed to describe the phenomenology of clinical reasoning. In this review, we reinforce that the modern healthcare ecosystem - with its people, processes and technology - is the context in which health care encounters and clinical reasoning take place.

Tumor microenvironment and immune system preservation in early-stage breast cancer: routes for early recurrence after mastectomy and treatment for lobular and ductal forms of disease.

BACKGROUND: Intra-ductal cancer (IDC) is the most common type of breast cancer, with intra-lobular cancer (ILC) coming in second. Surgery is the primary treatment for early stage breast cancer. There are now irrefutable data demonstrating that the immune context of breast tumors can influence growth and metastasis. Adjuvant chemotherapy may be administered in patients who are at a high risk of recurrence. Our goal was to identify the processes underlying both types of early local recurrences. METHODS: This was a case-control observational study. Within 2 years of receiving adjuvant taxan and anthracycline-based chemotherapy, as well as modified radical mastectomy (MRM), early stage IDC and ILC recurred. Vimentin, α-smooth muscle actin (SMA), platelet-derived growth factor (PDGF), matrix metalloproteinase (MMP1), and clustered differentiation (CD95) were investigated. RESULTS: Of the samples in the ductal type group, 25 showed local recurrence, and 25 did not. Six individuals in the lobular-type group did not experience recurrence, whereas seven did. Vimentin (p = 0.000 and 0.021), PDGF (p = 0.000 and 0.002), and CD95 (p = 0.000 and 0.045) expressions were significantly different in ductal and lobular carcinoma types, respectively. Measurement of ductal type was the sole significant difference found in MMP1 (p = 0.000) and α-SMA (p = 0.000). α-SMA and CD95 were two variables that helped the recurrence mechanism in the ductal type according to the pathway analysis. In contrast, the CD95 route is a recurrent mechanism for the lobular form. CONCLUSIONS: While the immune system plays a larger role in ILC, the tumor microenvironment and immune system both influence the recurrence of IDC. According to this study, improving the immune system may be a viable cancer treatment option.

Predictors of time-to-nadir serum creatinine after drainage of bilaterally obstructed kidneys due to bladder cancer.

Background: There are persistent controversies about the outcomes and benefits of drainage of malignant ureteral obstruction by percutaneous nephrostomy (PCN). This study aimed to assess the predictors of the time-to-nadir (TTN) of serum creatinine (SCr) levels after drainage of bilaterally obstructed kidneys (BOKs) due to bladder cancer (BC) by PCN. Materials and methods: This prospective nonrandomized study included patients with BOKs due to BC treated by PCN between April 2019 and March 2022. The primary outcome measure was TTN. Results: Of the 55 patients with a median age (range) of 66 years (47-86 years), 32 (58.2%) had a normal nadir SCr and 23 (41.8%) had a high nadir SCr within 21 days after drainage of BOKs due to BC. High nadir SCr was associated with a higher mean age (p = 0.011) and lower body mass index (BMI, p = 0.043). However, patients with normal nadir SCr had a significantly shorter TTN (p = 0.023) and an increased mean SCr trajectory (p < 0.001) during TTN. In multivariate analysis, low urine output at presentation (p = 0.021) and high BMI (p = 0.006) were associated with longer TTN. However, the mean parenchymal thickness (p = 0.428) and laterality of drainage (p = 0.466) were not associated with the mean TTN and SCr normalization rates. According to the modified Clavien-Dindo classification, 8 cases of hematuria were managed conservatively (grade 2), and 2 cases of PCN slippage were repositioned using local anesthesia (grade 3). Conclusions: Despite the safety of PCN for drainage of BOKs due to BC, more than 41% of the patients failed to have a normal nadir SCr. Predrainage low urine output and high BMI were associated with longer TTN. Laterality of drainage had no significant effects on the TTN and SCr trajectory.

Characterizing Risk Factors for Hospitalization and Clinical Characteristics in a Cohort of COVID-19 Patients Enrolled in the GENCOV Study.

The GENCOV study aims to identify patient factors which affect COVID-19 severity and outcomes. Here, we aimed to evaluate patient characteristics, acute symptoms and their persistence, and associations with hospitalization. Participants were recruited at hospital sites across the Greater Toronto Area in Ontario, Canada. Patient-reported demographics, medical history, and COVID-19 symptoms and complications were collected through an intake survey. Regression analyses were performed to identify associations with outcomes including hospitalization and COVID-19 symptoms. In total, 966 responses were obtained from 1106 eligible participants (87% response rate) between November 2020 and May 2022. Increasing continuous age (aOR: 1.05 [95%CI: 1.01-1.08]) and BMI (aOR: 1.17 [95%CI: 1.10-1.24]), non-White/European ethnicity (aOR: 2.72 [95%CI: 1.22-6.05]), hypertension (aOR: 2.78 [95%CI: 1.22-6.34]), and infection by viral variants (aOR: 5.43 [95%CI: 1.45-20.34]) were identified as risk factors for hospitalization. Several symptoms including shortness of breath and fever were found to be more common among inpatients and tended to persist for longer durations following acute illness. Sex, age, ethnicity, BMI, vaccination status, viral strain, and underlying health conditions were associated with developing and having persistent symptoms. By improving our understanding of risk factors for severe COVID-19, our findings may guide COVID-19 patient management strategies by enabling more efficient clinical decision making.

Revitalize splenic functions. Following a splenectomy for trauma, a small amount of splenic autotransplantation was performed.

INTRODUCTION: The spleen is a responsible significant part of the immune system; after Splenectomy following trauma, the immune system changes; splenic autotransplantation can preserve the immune system after trauma and Splenectomy. BACKGROUND: Patients can be protected from immune dysfunction by autotransplanting splenic tissues after splenectomy following trauma because their immune systems and spleens are changed. Patients can gain their immune function after splenic autotransplantation. METHODS: Patient classification methods are into three categories, Group A, 6 cases with auto-translation; Group B, 6 cases without transplantation; Group C, seven regular people serving as the control. AIM OF WORK: The aim of the work is not to compare outcome methods or compare types of autotransplantation; This work aims to document postoperative radiological, immunological, clinical, and hematological investigations. We concentrated on the results of investigations more than the types of operation or approach or types of autotransplantation. RESULTS: We showed that, after comparing each group with normal individuals subjects, patients who did not undergo autotransplantation had significantly higher platelet counts, a more significant percentage of micronucleated reticulocytes, increased levels of naive B lymphocytes, changes in class-switched memory and class-unswitched memory B cells, and higher levels of PD1 on CD8 + T lymphocytes. Nevertheless, neither splenic autotransplant patients nor the average general population showed any appreciable variations in any of the parameters. CONCLUSIONS: Spleen's activities with adequate hemocatheter activity and recovery of the immunological deficit after splenic autotransplantation.

Public knowledge of SARS-CoV-2 serological and viral lineage laboratory testing and result interpretation: A GENCOV study cross-sectional survey.

OBJECTIVES: Concepts related to SARS-CoV-2 laboratory testing and result interpretation can be challenging to understand. A cross-sectional survey of COVID-19 positive adults residing in Ontario, Canada was conducted to explore how well people understand SARS-CoV-2 laboratory tests and their associated results. DESIGN AND METHODS: Participants were recruited through fliers or by prospective recruitment of outpatients and hospitalized inpatients with COVID-19. Enrolled participants included consenting adults with a positive SARS-CoV-2 polymerase chain reaction test result. An 11-item questionnaire was developed by researchers, nurses, and physicians in the study team and was administered online between April 2021 to May 2022 upon enrolment into the study. RESULTS: Responses were obtained from 940 of 1106 eligible participants (85% participation rate). Most respondents understood 1) that antibody results should not influence adherence to social distancing measures (n = 602/888, 68%), 2) asymptomatic SARS-CoV-2 infection following test positivity (n = 698/888, 79%), 3) serological test sensitivity in relation to post-infection timeline (n = 540/891, 61%), and 4) limitations of experts' knowledge related to SARS-CoV-2 serology (n = 693/887, 78%). Conversely, respondents demonstrated challenges understanding 1) conflicting molecular and serological test results and their relationship with immune protection (n = 162/893, 18%) and 2) the impact of SARS-CoV-2 variants on vaccine effectiveness (n = 235/891, 26%). Analysis of responses stratified by sociodemographic variables identified that respondents who were either: 1) female, 2) more educated, 3) aged 18-44, 4) from a high-income household, or 5) healthcare workers responded expectedly more often. CONCLUSIONS: We have highlighted concepts related to SARS-CoV-2 laboratory tests and associated results which may be challenging to understand. The findings of this study enable us to identify 1) misconceptions related to various SARS-CoV-2 test results, 2) groups of individuals at risk, and 3) strategies to improve people's understanding of their test results.

The lateral forearm flap versus traditional upper extremity flaps: A comparison of donor site morbidity and flap thickness.

INTRODUCTION: The lateral forearm flap (LFF) is a thin fasciocutaneous flap with a donor site that can be closed primarily. METHODS: A retrospective analysis of donor site morbidity and hand function was performed in patients who underwent a radial forearm flap (RFF), ulnar artery perforator flap (UAPF), or LFF. Flap thickness was evaluated radiographically in 50 control patients. RESULTS: Of 134 patients (lateral forearm flap: n = 49, RFF: n = 47, UAPF: n = 38), the LFF demonstrated significantly faster return to baseline hand grip strength (3 months vs. 12 months in RFF and UAPF; p < 0.001), had significantly fewer donor site complications (6.1% compared to 6.4% in RFF and 28.9% in UAPF; p = 0.003) and fewer sensory deficits (2.0% compared to 6.4% in RFF and 15.8% in UAPF sites; p = 0.013). The radiographic study confirmed the LFF to be the thinnest of all upper extremity flap options. CONCLUSIONS: The LFF is an excellent forearm-based flap option with thin, pliable tissue and low donor site morbidity.

Isolated ventral congenital penile curvature treated by incisionless plication of tunica albuginea in adults: A prospective case series.

Background: Numerous surgical techniques are available for the correction of isolated ventral congenital penile curvature (IVCPC). This study aimed to assess the outcomes and predictors of IVCPC treatment in adults using an incisionless plication technique. Materials and methods: This prospective case series examined patients with IVCPC who were treated in our hospital between October 2017 and February 2020 using incisionless plication of the tunica albuginea (Essed-Schroeder technique) with a covering pair of absorbable sutures. The primary outcomes were successful correction (defined as a residual curvature ≤15 degrees) and patient satisfaction. Postoperative follow-ups were performed at 3, 6, and 12 months. Results: A total of 23 patients were treated for IVCPC with a mean (range) age of 25.3 (18-31) years. Eighteen patients (78.3%) were single with cosmetic complaints, whereas the other 5 patients (21.7%) were married and presented with a difficult vaginal intromission. The mean (range) curvature, length, and operative time were 40 (30-50) degrees, 15 (10-19) cm, and 82 (65-100) minutes, respectively. Postoperative penile pain and numbness occurred in 13 patients (56.5 %) and 7 patients (30.4%) only within the first month, respectively. Palpable suture knots were reported in 15 patients (65.5%) without being bothersome up to 12 months. The postoperative means (ranges) of penile curvature and length were significantly different from that of the preoperative values at 3 (5 [0-20] degrees and 14.5 [9-18.5] cm), 6 (5 [0-20] degrees and 14.5 [9-18.5] cm), and 12 months (5 [0-30] degrees and 14.5 [9-18.5] cm; all p < 0.001). Age, preoperative penile curvature, penile length, postoperative pain, wound infections, and knot palpation insignificantly affected curvature recurrence. Seventeen patients (73.9%) were very satisfied with their surgical outcomes. Conclusions: Incisionless plication of the tunica albuginea is effective and safe for the correction of IVCPC in adults with high success and patient satisfaction rates.

Distinguishing features of Lycium L. species (family Solanaceae) distributed in Egypt based on their anatomical, metabolic, molecular, and ecological characteristics.

Among the 70-80 species of the genus Lycium (family Solanaceae) disjunctly distributed around the world, only three are frequently distributed in different locations in Egypt. Due to the morphological similarities between these three species, there is a need for alternative tools to distinguish them. Thus, the objective of this study was to revise the taxonomic features of Lycium europaeum L., Lycium shawii Roem. & Schult., and Lycium schweinfurthii var. aschersonii (Dammer) Feinbrun in consideration of their anatomical, metabolic, molecular, and ecological characteristics. In addition to analysis of their anatomical and ecological features, DNA barcoding was performed for molecular characterization through internal transcribed spacer (ITS) sequencing and start codon targeted (SCoT) markers. Furthermore, metabolic profiling of the studied species was conducted based on gas chromatography-mass spectrometry (GC-MS). The observed anatomical features of the adaxial and abaxial epidermal layers, type of mesophyll, crystals, number of palisade and spongy layers, and the vascular system showed variations between the studied species. Beyond this, the anatomy of the leaves showed an isobilateral structure in the studied species, without distinct differences. Species were molecularly identified in terms of ITS sequences and SCoT markers. The ITS sequences were deposited in GenBank with accession numbers ON149839.1, OP597546.1, and ON521125.1 for L. europaeum L., L. shawii, and L. schweinfurthii var. aschersonii, respectively. The sequences showed variations in GC content between the studied species; this was 63.6% in L. europaeum, 61.53% in L. shawii, and 63.55% in L. schweinfurthii var. aschersonii. A total of 62 amplified fragments, including 44 polymorphic fragments with a ratio of 70.97%, were obtained in the SCoT analysis, as well as unique amplicons in L. europaeum L., shawii, and L. schweinfurthii var. aschersonii of 5, 11, and 4 fragments, respectively. Through GC-MS profiling, 38 compounds were identified with clear fluctuations in the extracts of each species. Of these, 23 were distinguishing chemicals that could help in chemical identification of the extracts of the studied species. The present study succeeds in identifying alternative clear and diverse characteristics that can be used to distinguish between L. europaeum, L. shawii, and L. schweinfurthii var. aschersonii.

Physiological and Anatomical Responses of Faba Bean Plants Infected with Chocolate Spot Disease to Chemical Inducers.

Plant diseases are biotic stresses that restrict crop plants' ability to develop and produce. Numerous foliar diseases, such as chocolate spots, can cause significant production losses in Vicia faba plants. Certain chemical inducers, including salicylic acid (SA), oxalic acid (OA), nicotinic acid (NA), and benzoic acid (BA), were used in this study to assess efficacy in controlling these diseases. A foliar spray of these phenolic acids was used to manage the impacts of the biotic stress resulting from disease incidence. All tested chemical inducers resulted in a significant decrease in disease severity. They also enhanced the defense system of treated plants through increasing antioxidant enzyme activity (Peroxidase, polyphenol oxidase, ß-1, 3-glucanase, and chitinase) compared to the corresponding control. Healthy leaves of faba plants recorded the lowest (p < 0.05) values of all antioxidant activities compared to those plants infected by Botrytis fabae. Moreover, the separation of proteins using SDS-PAGE showed slight differences among treatments. Furthermore, foliar spray with natural organic acids reduced the adverse effects of fungal infection by expediting recovery. The SA (5 mM) treatment produced a pronounced increase in the upper, lower epidermis, palisade thickness, spongy tissues, midrib zone, length, and width of vascular bundle. The foliar application with other treatments resulted in a slight increase in the thickness of the examined layers, especially by benzoic acid. In general, all tested chemical inducers could alleviate the adverse effects of the biotic stress on faba bean plants infected by Botrytis fabae.

A Quality Improvement Initiative to Decrease Central Line-Associated Bloodstream Infections During the COVID-19 Pandemic: A "Zero Harm" Approach.

INTRODUCTION: Central line-associated bloodstream infections (CLABSIs) are associated with significant patient harm and health care costs. Central line-associated bloodstream infections are preventable through quality improvement initiatives. The COVID-19 pandemic has caused many challenges to these initiatives. Our community health system in Ontario, Canada, had a baseline rate of 4.62 per 1000 line days during the baseline period. OBJECTIVES: Our aim was to reduce CLABSIs by 25% by 2023. METHODS: An interprofessional quality aim committee performed a root cause analysis to identify areas for improvement. Change ideas included improving governance and accountability, education and training, standardizing insertion and maintenance processes, updating equipment, improving data and reporting, and creating a culture of safety. Interventions occurred over 4 Plan-Do-Study-Act cycles. The outcome was CLABSI rate per 1000 central lines: process measures were rate of central line insertion checklists used and central line capped lumens used, and balancing measure was the number of CLABSI readmissions to the critical care unit within 30 days. RESULTS: Central line-associated bloodstream infections decreased over 4 Plan-Do-Study-Act cycles from a baseline rate of 4.62 (July 2019-February 2020) to 2.34 (December 2021-May 2022) per 1000 line days (51%). The rate of central line insertion checklists used increased from 22.8% to 56.9%, and central line capped lumens used increased from 72% to 94.3%. Mean CLABSI readmissions within 30 days decreased from 1.49 to 0.1798. CONCLUSIONS: Our multidisciplinary quality improvement interventions reduced CLABSIs by 51% across a health system during the COVID-19 pandemic.

Serum creatinine trajectory after drainage of kidneys with bilateral malignant ureteral obstruction: a prospective non-randomized comparative study.

BACKGROUND: Serum creatinine trajectory (SCr-Tr) is a neglected prognostic tool for chronic and acute kidney injury. We aimed to assess the predictors of SCr-Tr during the time-to-nadir and serum creatinine (SCr) normalization rate after drainage, using percutaneous nephrostomy in patients with bilateral malignant ureteral obstruction. METHODS: A prospective non-randomized study was performed on SCr-Tr in patients with bilateral malignant ureteral obstruction from August 2019 to March 2022. The primary outcome was SCr-Tr during the time-to-nadir. RESULTS: This study included 102 patients with a mean age ± SD of 59.6 ± 14.7 years. SCr-Tr was non-linear with a mean ± SD (range) of 0.5 ± 0.4 (0.03-2.3) mg/dl/day. Multivariate analyses revealed that female gender (p = 0.016), body mass index (BMI; p = 0.005), and SCr at presentation (p < 0.001) were predictors of rapid SCr-Tr during the time-to-nadir. However, age (p = 0.008) and low urine output at presentation (p = 0.015) were associated with a lower SCr-Tr. In contrast, laterality of drainage (p = 0.544) and mean parenchymal thickness (p = 0.066) were not associated with mean SCr-Tr. Also, only the mean parenchymal thickness (p = 0.002) was a predictor of rapid SCr-Tr at ≥ 0.5 mg/dl/day. However, low BMI (p = 0.023) was associated with a high SCr normalization rate, while unilateral drainage (p = 0.045) was associated with a lower rate. CONCLUSIONS: Female gender, low BMI, and SCr at presentation were predictors of rapid SCr-Tr during the time-to-nadir. Bilateral drainage was an independent predictor of SCr normalization rate, but not of rapid SCr-Tr. The mean parenchymal thickness was the only independent predictor for rapid SCr-Tr at ≥ 0.5 mg/dl/day.

Characterization of Some Cichorium Taxa Grown under Mediterranean Climate Using Morphological Traits and Molecular Markers.

The verification of taxonomic identities is of the highest significance in the field of biological study and categorization. Morpho-molecular characterization can clarify uncertainties in distinguishing between taxonomic groups. In this study, we characterized five local taxa of the genus Cichorium using morphological and molecular markers for taxonomic authentication and probably future genetic improvement. The five Cichorium taxa grown under the Mediterranean climate using morphological traits and molecular markers showed variations. The examined taxa showed a widespread range of variations in leaf characteristics, i.e., shape, type, texture, margin, and apex and cypsela characteristics i.e., shape, color, and surface pattern. The phylogenetic tree categorized the Cichorium intybus var. intybus and C. intybus var. foliosum in a single group, whereas C. endivia var. endivia was grouped separately. However, C. endivia var. crispum and C. endivia subsp. pumilum were classified as a cluster. The recorded variance between classes using the molecular markers SCoT, ISSR, and RAPD was documented at 34.43%, 36.62%, and 40.34%, respectively. Authentication using molecular tools proved the usefulness of a dichotomous indented key, as revealed by morphological identification. The integrated methodology using morphological and molecular assessment could support improved verification and authentication of the various taxa of chicory. It seems likely that the Egyptian chicory belongs to C. endivia subsp. pumilum.

EFOMP's protocol quality controls in PET/CT and PET/MR.

This article presents the protocol on Quality Controls in PET/CT and PET/MRI published online in May 2022 by the European Federation of Organisations for Medical Physics (EFOMP), which was developed by the Working group for PET/CT and PET/MRI Quality Control (QC) protocol. The main objective of this protocol was to comprehensively provide simple and practical procedures that may be integrated into clinical practice to identify changes in the PET/CT/MRI system's performance and avoid short- and long-term quality deterioration. The protocol describes the quality control procedures on radionuclide calibrators, weighing scales, PET, CT and MRI systems using selected and measurable parameters that are directly linked to clinical images quality. It helps to detect problems before they can impact clinical studies in terms of safety, image quality, quantification accuracy and patient radiation dose. CT and MRI QCs are described only in the context of their use for PET (attenuation correction and anatomical localization) imaging. Detailed step-by-step instructions have been provided, limiting any misinterpretations or interpersonal variations as much as possible. This paper presents the main characteristics of the protocol illustrated together with a brief summary of the content of each chapter. A regular QC based on the proposed protocol would guarantee that PET/CT and PET/MRI systems operate under optimal conditions, resulting in the best performance for routine clinical tasks.

Genome screening, reporting, and genetic counseling for healthy populations.

Rapid advancements of genome sequencing (GS) technologies have enhanced our understanding of the relationship between genes and human disease. To incorporate genomic information into the practice of medicine, new processes for the analysis, reporting, and communication of GS data are needed. Blood samples were collected from adults with a PCR-confirmed SARS-CoV-2 (COVID-19) diagnosis (target N = 1500). GS was performed. Data were filtered and analyzed using custom pipelines and gene panels. We developed unique patient-facing materials, including an online intake survey, group counseling presentation, and consultation letters in addition to a comprehensive GS report. The final report includes results generated from GS data: (1) monogenic disease risks; (2) carrier status; (3) pharmacogenomic variants; (4) polygenic risk scores for common conditions; (5) HLA genotype; (6) genetic ancestry; (7) blood group; and, (8) COVID-19 viral lineage. Participants complete pre-test genetic counseling and confirm preferences for secondary findings before receiving results. Counseling and referrals are initiated for clinically significant findings. We developed a genetic counseling, reporting, and return of results framework that integrates GS information across multiple areas of human health, presenting possibilities for the clinical application of comprehensive GS data in healthy individuals.

Acute kidney injury due to bilateral malignant ureteral obstruction: Is there an optimal mode of drainage?

There is a well-known relationship between malignancy and impairment of kidney functions, either in the form of acute kidney injury or chronic kidney disease. In the former, however, bilateral malignant ureteral obstruction is a surgically correctable factor of this complex pathology. It warrants urgent drainage of the kidneys in emergency settings. However, there are multiple controversies and debates about the optimal mode of drainage of the bilaterally obstructed kidneys in these patients. This review addressed most of the concerns and provided a comprehensive presentation of this topic from the recent literature. Also, we provided different perspectives on the management of the bilateral obstructed kidneys due to malignancy. Despite the frequent trials for improving the success rates and functions of ureteral stents, placement of a percutaneous nephrostomy tube remains the most recommended tool of drainage due to bilateral ureteral obstruction, especially in patients with advanced malignancy. However, the disturbance of the quality of life of those patients remains a major unresolved concern. Beside the unfavorable prognostic potential of the underlying malignancy and the various risk stratification models that have been proposed, the response of the kidney to initial drainage can be anticipated and evaluated by multiple renal prognostic factors, including increased urine output, serum creatinine trajectory, and time-to-nadir serum creatinine after drainage.

Improving safety and communication for healthcare providers caring for SARS-COV-2 patients.

BACKGROUND: Decreasing healthcare provider (HCP) exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus in emergency departments (EDs) is crucial. Approaches include limiting the HCP presence and ensuring sealed isolation rooms, which can result in communication difficulties. This quality improvement (QI) initiative aimed to decrease by 50% duration of isolation room door opening and increasing HCP-perceived communication clarity by one point on a five-point Likert scale. METHODS: This was a prospective, multi-stage project with three Plan-Do-Study-Act (PDSA) cycles between May and July 2020: (1) an educational intervention, (2) the introduction of a novel transceiver communication device, and (3) utilizing a clinical champion. Statistical Process Control XbarR charts were used to assess for special cause variation, and two-tailed Mann-Whitney U tests were used for statistical significance between Likert survey means. Qualitative responses underwent thematic analysis. RESULTS: Observation of 174 patient encounters was completed over 33 days, with 95 meeting the inclusion criteria. Door opening decreased from baseline (n=40; mean 72.97%) to PDSA 3 (n=21; mean 1.58%; p<0.0001). HCP-perceived communication clarity improved from baseline (n=36; mean 3.36) to PDSA-3 (n=49; mean 4.21; p<0.001). Survey themes included positive effects on communication and workflow, with some challenges on the integration of the new device into the clinical workflow. HCP-perceived errors, workarounds, and workflow pauses showed significant improvements. CONCLUSION: This QI initiative with a novel transceiver showed significant decreases in isolation room door opening and increases in communication clarity. Future work will expand to operating rooms and intensive care units.