Indication alerts to improve problem list documentation.

BACKGROUND: Problem lists represent an integral component of high-quality care. However, they are often inaccurate and incomplete. We studied the effects of alerts integrated into the inpatient and outpatient computerized provider order entry systems to assist in adding problems to the problem list when ordering medications that lacked a corresponding indication. METHODS: We analyzed medication orders from 2 healthcare systems that used an innovative indication alert. We collected data at site 1 between December 2018 and January 2020, and at site 2 between May and June 2021. We reviewed random samples of 100 charts from each site that had problems added in response to the alert. Outcomes were: (1) alert yield, the proportion of triggered alerts that led to a problem added and (2) problem accuracy, the proportion of problems placed that were accurate by chart review. RESULTS: Alerts were triggered 131 134, and 6178 times at sites 1 and 2, respectively, resulting in a yield of 109 055 (83.2%) and 2874 (46.5%), P< .001. Orders were abandoned, for example, not completed, in 11.1% and 9.6% of orders, respectively, P<.001. Of the 100 sample problems, reviewers deemed 88% ± 3% and 91% ± 3% to be accurate, respectively, P = .65, with a mean of 90% ± 2%. CONCLUSIONS: Indication alerts triggered by medication orders initiated in the absence of a justifying diagnosis were useful for populating problem lists, with yields of 83.2% and 46.5% at 2 healthcare systems. Problems were placed with a reasonable level of accuracy, with 90% ± 2% of problems deemed accurate based on chart review.

Complexed trace mineral supplementation alters antioxidant activities and expression in response to trailer stress in yearling horses in training.

To test the hypothesis that complexed trace mineral supplementation would increase antioxidant capacity and decrease muscle oxidative stress and damage in young horses entering an exercise training program, Quarter Horses (mean [Formula: see text] SD; 9.7 ± 0.7 mo) balanced by age, sex, and BW were assigned to receive complexed (CTM; n = 8) or inorganic (INORG; n = 8) trace minerals at -12 week relative to this study. Blood and muscle samples were collected before (week 0) and after 12 week of light exercise training surrounding a 1.5-h trailer stressor. Muscle glutathione peroxidase (GPx) activity was higher for CTM than INORG horses (P ≤ 0.0003) throughout the study. Following both trailer stressors, serum creatine kinase increased (P < 0.0001) and remained elevated through 24 h post-trailering (P < 0.0001). At week 0, muscle malondialdehyde, expression of superoxide dismutase 2, and whole blood GPx activity increased (P [Formula: see text] 0.003) following trailering but trailering did not affect these measures at week 12. Young horses supplemented with CTM had higher muscle GPx activity than horses receiving INORG, but CTM did not affect damage markers following a stressor. Dietary CTM may be useful for improving antioxidant capacity during exercise training in young equine athletes.

Effect of Default Order Standardization on Opioid Prescribing Patterns.

BACKGROUND: Opioid misuse, overprescribing, dependency, and overdose remains a significant concern in the United States. A quality improvement study was conducted at the University of Illinois Hospital & Health Sciences System to determine the effect of standardizing the default orders for hydrocodone-acetaminophen products implemented on June 22, 2016. METHODS: Prior to the intervention, default orders had variable dose tablet numbers (1 or 2) and dosing frequencies (every 4 or 6 hours), and no default dispense quantity. Defaults were modified to 1 tablet every 6 hours as needed for pain and dispense quantities of 3 and 5 days' supply were added. Number of tablets per order, dosing frequency, and days' supply prescribed between January 1, 2016, and June 21, 2016, were compared to those placed between June 22, 2016, and December 31, 2016. Opioid doses were converted into morphine milligram equivalents (MME). Analyses were performed to determine the effect of the intervention on daily opioid dose and number of days' supply prescribed. RESULTS: 22,052 orders were included in this study. Following the intervention, the number of tablets prescribed was reduced by an average of 19,832 tablets per month. Every 6 hours dosing (as opposed to every 4 hours) increased by 21.52 percentage points. Prescriptions with ≥ 50 MME/day dropped by 5.8 percentage points, and > 3 days' supply decreased by 2.54 percentage points. Linear regression demonstrated an increase in opioid prescriptions with daily < 50 MME (odds ratio [OR] = 1.72, p < 0.001) and ≤ 3 days' supply (OR = 1.27, p < 0.001). CONCLUSION: Default electronic health record settings strongly influence prescribing patterns.

Evaluation of dietary trace mineral supplementation in young horses challenged with intra-articular lipopolysaccharide.

Sixteen weanling Quarter Horses (255 ± 22 kg) were utilized in a 56-d trial to evaluate the effects of trace mineral (TM) source on intra-articular inflammation following a single acute inflammatory insult. Horses were stratified by age, sex, and BW and then randomly assigned to dietary treatment: concentrate formulated with Zn, Mn, Cu, and Co as inorganic sources (CON; n = 8) or complexed TMs (CTM; n = 8). Added TM were formulated at iso-levels across treatments and intakes met or exceeded NRC requirements. Horses were offered 1.75% BW (as-fed) of treatment concentrate and 0.75% BW (as-fed) coastal Bermudagrass hay. Growth measurements were collected on days 0, 28, and 56, and plasma was collected biweekly for determination of Mn, Cu, Zn, and Co concentrations. On day 42, carpal joints were randomly assigned to receive injections of 0.5 ng lipopolysaccharide (LPS) or sterile lactated Ringer's solution (LRS; contralateral control). Synovial fluid was collected at preinjection hours (PIH) 0, and 6, 12, 24, 168, and 336 h post-injection and analyzed for TM concentration, prostaglandin E2 (PGE2), carboxypeptide of type II collagen (CPII), collagenase cleavage neopeptide (C2C), and aggrecan chondroitin sulfate 846 epitope (CS846). Data were analyzed using the MIXED procedure of SAS. Results showed a TM source × LPS × h effect for synovial fluid Co, Cu, and Se (P < 0.05); concentrations of TM peaked at hour 6 and decreased to preinjection values by hour 168 in both CON and CTM-LPS knees. A delayed peak was observed at hour 12 for CTM-LRS. Peak synovial fluid Cu and Se concentrations were higher in LPS knees, and Co was highest in CTM-LPS. A TM source × h interaction was observed for Zn (P < 0.05); concentrations peaked at hour 6 in CON vs. hour 12 for CTM. An LPS × h interaction was observed for Mn (P < 0.01); synovial concentration peaked at hour 6 in LPS knees compared with hour 24 in LRS. Synovial PGE2, C2C, CPII, and CS846 concentrations were greater with LPS (P ≤ 0.01), and C2C was greater (P < 0.01) in CTM compared with CON. Concentrations of CPII and PGE2 were unaffected by diet. A TM source × h × LPS interaction was observed for CS846 (P = 0.02). Concentrations of CS846 in CTM peaked at 12 h, whereas CON peaked at a lower concentration at 24 h (P < 0.05). Data indicate sufficient intake of a complexed TM source may support cartilage metabolism through increased aggrecan synthesis and type II collagen breakdown following an intra-articular LPS challenge in growing horses.

Incidence of lameness and association of cause and severity of lameness on the outcome for cattle on six commercial beef feedlots.

OBJECTIVE To describe the incidence of specific causes of lameness and the associations of cause and severity of lameness on the outcome for cattle on commercial feedlots. DESIGN Dynamic population longitudinal study. ANIMALS Cattle on 6 commercial feedlots in Kansas and Nebraska during a 12-month period (mean daily population, 243,602 cattle; range, 223,544 to 252,825 cattle). PROCEDURES Feedlot personnel were trained to use a standardized diagnostic algorithm and locomotion score (LMS) system to identify and classify cattle by cause and severity of lameness. Information regarding lameness cause, severity, and treatments was recorded for individual cattle. Cattle were monitored until they left the feedlot (ie, outcome; shipped with pen mates [shipped], culled prematurely because of lameness [realized], or euthanized or died [died]). Incidence rates for various causes of lameness, LMSs, and outcomes were calculated. The respective associations of cause of lameness and LMS with outcome were evaluated. RESULTS Lameness was identified in 2,532 cattle, resulting in an overall lameness incidence rate of 1.04 cases/100 animal-years. Realized and mortality rates were 0.096 cattle/100 animal-years and 0.397 deaths/100 animal-years, respectively. Injury to the proximal portion of a limb was the most frequently identified cause of lameness followed by undefined lameness, septic joint or deep digital sepsis, and interdigital phlegmon (foot rot). As the LMS (lameness severity) at lameness detection increased, the percentage of cattle that died but not the percentage of cattle that were realized increased. CONCLUSIONS AND CLINICAL RELEVANCE Results provided clinically useful prognostic guidelines for management of lame feedlot cattle.

The histone-H3K4-specific demethylase KDM5B binds to its substrate and product through distinct PHD fingers.

The histone lysine demethylase KDM5B regulates gene transcription and cell differentiation and is implicated in carcinogenesis. It contains multiple conserved chromatin-associated domains, including three PHD fingers of unknown function. Here, we show that the first and third, but not the second, PHD fingers of KDM5B possess histone binding activities. The PHD1 finger is highly specific for unmodified histone H3 (H3K4me0), whereas the PHD3 finger shows preference for the trimethylated histone mark H3K4me3. RNA-seq analysis indicates that KDM5B functions as a transcriptional repressor for genes involved in inflammatory responses, cell proliferation, adhesion, and migration. Biochemical analysis reveals that KDM5B associates with components of the nucleosome remodeling and deacetylase (NuRD) complex and may cooperate with the histone deacetylase 1 (HDAC1) in gene repression. KDM5B is downregulated in triple-negative breast cancer relative to estrogen-receptor-positive breast cancer. Overexpression of KDM5B in the MDA-MB 231 breast cancer cells suppresses cell migration and invasion, and the PHD1-H3K4me0 interaction is essential for inhibiting migration. These findings highlight tumor-suppressive functions of KDM5B in triple-negative breast cancer cells and suggest a multivalent mechanism for KDM5B-mediated transcriptional regulation.