Clinician's Perceptions of a CME Activity to Increase Knowledge of Vaccination in Adults with Chronic Inflammatory Conditions.

OBJECTIVE: Annual influenza and pneumococcal vaccination rates remain suboptimal in patients with systemic lupus erythematosus despite their higher risk of infections and related complications. The CDC identified lack of knowledge about vaccine guidelines among adult patients and their providers as the most substantial barrier to vaccination coverage. As specialists working with particularly affected populations, rheumatologists, allergists, and immunologists can advise patients regarding gaps in recommended vaccinations.The aim of this study was to describe prescribers' perceptions of an educational activity that was developed to increase rates of appropriate pneumococcal and influenza vaccination in adults with chronic inflammatory conditions. We were interested in the impact of the educational activity on the knowledge and practice of providers. METHODS: We evaluated a multimodal educational activity aimed at increasing vaccination rates in high-risk adults. We assessed provider knowledge, perceptions of the activity, and impact on their practice. The activity was conducted at a single site "in house" education event in the live format and was disseminated nationally in print and online format. RESULTS: In the "in house" interactive education session, mean scores on the pre- and post-tests were 75% (SD 11.6%, 95% CI 70-80%) and 89% (SD 11.1%, 95% CI 85-95%; p=.0001 vs. pre-test score), respectively, demonstrating that knowledge was significantly increased after completing the activity. In the nationally available activity 93% (n=240) of respondents indicated that the activity significantly increased their awareness about the importance of vaccinations in these high-risk patients and recognition of when these vaccines were indicated or contraindicated, while 55% (n=142) planned to consequently change their practice. CONCLUSION: Provider education is a valuable strategy for practice-based improvements in vaccination coverage since provider failure to recommend vaccinations is a primary barrier in high-risk patients. Most patients received vaccinations based on physician recommendations and vaccination rates were markedly higher among patients receiving vaccine information from their providers. This educational activity increased clinicians' knowledge of and confidence in vaccinations for adults with chronic inflammatory conditions.

Using college internship programs to promote the healthcare security profession.

This article describes a college internship program conducted by a health system's security department from two points of view--the trainer's and the trainee's.

Overuse of antihypertensives in patients with acute ischemic stroke.

BACKGROUND: The Stroke Council of the American Heart Association/American Stroke Association (AHA/ASA) recommends conservative management of hypertension (HTN) during acute ischemic stroke (AIS), although clinicians often manage blood pressure more aggressively. Our hypothesis was that aggressive management of HTN in patients with AIS is associated with hypotensive events and worsened neurologic outcomes. METHODS: The study was a retrospective, observational cohort of patients who were admitted to the hospital with AIS. Classification of neurologic outcomes was based on nurses' neurologic assessments and were categorized as "worsened," "stayed the same," or "improved." The accuracy of these assessments was verified by review of physician's progress notes. Management of arterial HTN was recorded in all patients. RESULTS: Fifty medical records of patients with AIS who met inclusion criteria were reviewed. While only 22% of patients met the AHA/ASA criteria for hypertension treatment, 98% of the cohort were given antihypertensive therapy. Relative hypotension occurred in 64% of treated patients. Absolute hypotension associated with antihypertensive medications was uncommon but did occur in 2 of 15 patients who experienced neurologic worsening (13%), in 1 of 28 (3%) of patients who stayed the same, and in none of those who improved. Blood pressure was reduced excessively in all 11 of the patients who met AHA/ASA guidelines for treatment. CONCLUSIONS: Adherence to AHA/ASA guidelines for HTN management during AIS was poor. Initiation or intensification of antihypertensive drugs was not associated with worsened neurologic outcomes. Furthermore, relative hypotension, absolute hypotension and excessive reductions in blood pressure were not associated with worsened neurologic outcomes.

Thermodynamic linkage between the S1 site, the Na+ site, and the Ca2+ site in the protease domain of human activated protein C (APC). Sodium ion in the APC crystal structure is coordinated to four carbonyl groups from two separate loops.

The serine protease domain of activated protein C (APC) contains a Na+ and a Ca2+ site. However, the number and identity of the APC residues that coordinate to Na+ is not precisely known. Further, the functional link between the Na+ and the Ca2+ site is insufficiently defined, and their linkage to the substrate S1 site has not been studied. Here, we systematically investigate the functional significance of these two cation sites and their thermodynamic links to the S1 site. Kinetic data reveal that Na+ binds to the substrate-occupied APC with K(d) values of approximately 24 mm in the absence and approximately 6 mm in the presence of Ca2+. Sodium-occupied APC has approximately 100-fold increased catalytic efficiency ( approximately 4-fold decrease in K(m) and approximately 25-fold increase in k(cat)) in hydrolyzing S-2288 (H-d-Ile-Pro-Arg-p-nitroanilide) and Ca2+ further increases this k(cat) slightly ( approximately 1.2-fold). Ca2+ binds to the protease domain of APC with K(d) values of approximately 438 microm in the absence and approximately 105 microm in the presence of Na+. Ca2+ binding to the protease domain of APC does not affect K(m) but increases the k(cat) approximately 10-fold, and Na+ further increases this k(cat) approximately 3-fold and decreases the K(m) value approximately 3.7-fold. In agreement with the K(m) data, sodium-occupied APC has approximately 4-fold increased affinity in binding to p-aminobenzamidine (S1 probe). Crystallographically, the Ca2+ site in APC is similar to that in trypsin, and the Na+ site is similar to that in factor Xa but not thrombin. Collectively, the Na+ site is thermodynamically linked to the S1 site as well as to the protease domain Ca2+ site, whereas the Ca2+ site is only linked to the Na+ site. The significance of these findings is that under physiologic conditions, most of the APC will exist in Na2+-APC-Ca2+ form, which has 110-fold increased proteolytic activity.