Quality Assurance Processes Ensuring Appropriate Follow-up of Test Results Pending at Discharge in Emergency Departments: A Systematic Review.

STUDY OBJECTIVE: In many cases, emergency department (ED) care leads to investigations for which there are not final results at patient disposition. The follow-up for these test results pending at discharge, most commonly final diagnostic imaging reports and microbiology cultures, is a significant safety concern for patients and a medicolegal risk for ED practitioners. Our objective is to perform a systematic review of the literature and report on the structure and outcomes of existing ED quality assurance processes to address these test results pending at discharge. METHODS: We searched for studies that reported processes to ensure follow-up of test results pending at discharge for patients discharged from ED settings in 6 relevant databases, from inception to June 11, 2019. We appraised the quality of each study and extracted characteristics of the quality assurance process being discussed, as well as its influence and outcomes, cost, and feasibility. RESULTS: We identified 17,862 studies, and 17 met our criteria for inclusion. Four major processes were identified to improve the follow-up of test results pending at discharge: only nurses or clerks involved, physician-driven process, direct patient contact, and pharmacist-led process. The 5 recommendations generated by our literature review included dedicating staff to the quality assurance process, protecting their quality assurance time from clinical duties, ensuring electronic medical record integration, encouraging collaboration among health care disciplines, and engaging patients. CONCLUSION: A variety of quality assurance processes have been described to follow up on ED test results pending at discharge, and we provided recommendations to improve patient care. All ED leaders should consider implementing these according to their local context.

Review of the Transitional Pain Service as a method of postoperative opioid weaning and a service aimed at minimizing the risk of chronic post-surgical pain.

Opioid use and prescribing have become a subject of increasing focus and scrutiny. The ongoing "opioid epidemic" in North America has further increased interest in this area. In patients presenting for surgery, the prescribing of opioids during and following admission to hospital is commonplace and has been identified as a potential contributor to the growing opioid problem in North America. This review aims to present the timeline of the "opioid epidemic" as well as to introduce the concept of a "Transitional Pain Service". The Transitional Pain Service is a multidisciplinary service originating at Toronto General Hospital that employs a multi-faceted approach to monitoring opioid use after discharge from surgery, and aims to safely wean patients from opioids while maintaining effective pain management. This approach and its results will be discussed in this review.

The opioid crisis in North America: facts and future lessons for Europe.

Over the past two decades, opioid-related hospitalizations and deaths in North America have reached the level of a public health emergency. Initially, the epidemic of opioid misuse was largely driven by pharmaceutical companies and initiated by their spread of misinformation, which led physicians to engage in overzealous prescribing behaviour. This was followed by significant harms as deaths related to overdoses on prescription and illicit opioids rose steadily throughout the 1990s and early 2000s. This review examines the historical context of the opioid crisis in the United States and Canada, the role of physicians, the contributions of the pharmaceutical industry and the evolution of the epidemic in response to the introduction of highly potent synthetic opioids now recognized as the main culprits in opioid overdose and death. This article further explores the evidence surrounding the effectiveness of various treatment strategies and harm-reduction interventions designed to curtail the morbidity and mortality associated with opioid use. Finally, the magnitude of the opioid epidemic in North America is compared to that in European countries. This paper describes the differences in North American and European experiences with opioid overdose and the evidence-based approaches that can be implemented to reduce the mortality and morbidity linked to opioids while simultaneously ensuring adequate pain control for patients.

Attend: A Two-Pronged Trial to Eliminate No Shows in Diagnostic Imaging at a Community-Based Hospital.

PURPOSE: Diagnostic imaging (DI) at Niagara Health, like other hospitals, experiences challenges with patients who do not attend their scheduled appointments, resulting in a "no show." Reducing no show percentages presents an opportunity to improve upon wait lists within specific modalities such as magnetic resonance imaging (MRI) and to reduce the loss of productivity for this high-demand resource. AIM: To reduce the MRI no-show percent in DI at two community hospitals from 6.5% to 5% through patient engagement via mailed reminder letters and education at the primary care level. METHODS: Our two-pronged approach included interventions at community hospitals and at the primary care level. Reminder letters were mailed to patients with their appointment time and other pertinent information to allow for an increased number of patients reminded about appointments and a second means of reminder. At the primary care level, an information package was sent to various independent physicians for distribution to patients requiring an MRI scan, outlining benefits of showing up to the scheduled appointment to educate patients and improve attendance at DI. RESULTS: The mailing letter resulted in a significant reduction from 7.1% to 6.3% in overall no shows across two community hospitals (P = .04). The true effect of the letter was likely masked by increased wait times during the study period, which correlates with increased no-show percentages. The first trial of the information pamphlet among five practices for 1 month resulted in a nonsignificant reduction of no shows from 19% to 3% (P = .125). The second trial among 19 practices for 3 months led to a significant reduction of no shows from 7.7% to 4.2% (P = .007). CONCLUSIONS: Both the methods, the mailing letter and patient-information pamphlet, provide promising results in regard to reducing the no-show percentage among patients seen in DI for MRI appointments.

Elevated whole muscle phosphatidylcholine: phosphatidylethanolamine ratio coincides with reduced SERCA activity in murine overloaded plantaris muscles.

BACKGROUND: An increase in phosphatidylcholine:phosphatidylethanolamine (PC:PE) and a decrease in fatty acyl chain length, monounsaturated:polyunsaturated (MUFA:PUFA) fatty acyl ratio reduces SERCA activity in liposomes and in mouse models of obesity and muscular dystrophy. We have previously shown that maximal SERCA activity is significantly reduced in mechanically overloaded (OVL) plantaris, however, whether changes in PC:PE ratio or fatty acyl composition may contribute to the alterations in maximal SERCA activity remain unknown. Here, we tested the hypotheses that in OVL plantaris 1) PC:PE ratio would negatively correlate with maximal SERCA activity and 2) PC fatty acyl chain length (ACL) and/or MUFA:PUFA ratio would positively correlate with maximal SERCA activity. METHODS: To overload plantaris in mice, we transected the soleus and gastrocnemius tendons from one leg, while the contralateral leg underwent a sham surgery. After two weeks, plantaris muscles were extracted, homogenized and processed for SERCA activity and lipid analyses. Specifically, we performed HPTLC densitometry to examine changes in PC, PE, and the ratio of PC:PE. We also performed gas chromatography to assess any potential changes to fatty acyl composition. RESULTS: SERCA activity was significantly reduced in OVL plantaris compared with sham. Coinciding with this, we found a significant increase in PC but not PE in OVL plantaris. In turn, there was an increase in PC:PE but did not reach significance (p = 0.09). However, we found a significant negative correlation between PC:PE and maximal SERCA activity. Fatty acyl composition of PE remained similar between OLV and sham and PC demonstrated higher percent mole fraction of 17:1, 18:1, and ACL compared to sham. In addition, PC ACL, % MUFA, % PUFA, or MUFA:PUFA did not significantly correlate with maximal SERCA activity. CONCLUSIONS: Our results indicate that the phospholipid headgroup PC:PE negatively correlated and could potentially contribute to reductions in SERCA activity seen in functionally overloaded plantaris. In contrast, fatty acyl chain (ACL, % MUFA, % PUFA, MUFA:PUFA) did not correlate with maximal SERCA activity. Future studies will determine whether altering PC:PE with genetic and dietary interventions can influence SERCA activity and ultimately change the physiological outcome in response to muscle overloading.

Dairy Attenuates Weight Gain to a Similar Extent as Exercise in Rats Fed a High-Fat, High-Sugar Diet.

OBJECTIVE: To compare the individual and combined effects of dairy and endurance exercise training in reducing weight gain and adiposity in a rodent model of diet-induced obesity. METHODS: An 8-week feeding intervention of a high-fat, high-sugar diet was used to induce obesity in male Sprague-Dawley rats. Rats were then assigned to one of four groups for 6 weeks: (1) casein sedentary (casein-S), (2) casein exercise (casein-E), (3) dairy sedentary (dairy-S), and (4) dairy exercise (dairy-E). Rats were exercise trained by treadmill running 5 d/wk. RESULTS: Dairy-E prevented weight gain to a greater extent than either dairy or exercise alone. Adipose tissue and liver mass were reduced to a similar extent in dairy-S, casein-E, and dairy-E groups. Differences in weight gain were not explained by food intake or total energy expenditure. The total amount of lipid excreted was greater in the dairy-S compared to casein-S and dairy-E groups. CONCLUSIONS: This study provides evidence that dairy limits weight gain to a similar extent as exercise training and the combined effects are greater than either intervention alone. While exercise training reduces weight gain through increases in energy expenditure, dairy appears to increase lipid excretion in the feces.

Influence of longitudinal radiation exposure from microcomputed tomography scanning on skeletal muscle function and metabolic activity in female CD-1 mice.

Microcomputed tomography (µCT) is an imaging technology to assess bone microarchitecture, a determinant of bone strength. When measured in vivo, µCT exposes the skeletal site of interest to a dose of radiation, in addition to nearby skeletal muscles as well. Therefore, the aim of this study was to determine the effects of repeated radiation exposure from in vivo µCT on muscle health - specifically, muscle morphometrics, contractile function, and enzyme activity. This study exposed the right hind limb of female mice to either a low (26 cGy) or moderate (46 cGy) dose, at 2, 4, and 6 months of age, while the left hind limb of the same animal was exposed to a single dose at 6 months to serve as a nonirradiated control. Muscle weight, cross-sectional area, isometric contractile function, and representative maximal enzyme activities of amino acid, fatty acid, glucose, and oxidative metabolism in extensor digitorum longus (EDL) and soleus were assessed. Low-dose radiation had no effect. In contrast, moderate-dose radiation resulted in a 5% increase in time-to-peak tension and 16% increase in half-relaxation time of isometric twitches in EDL, although these changes were not seen when normalized to force. Moderate-dose radiation also resulted in an ~33% decrease in citrate synthase activity in soleus but not EDL, with no changes to the other enzymes measured. Thus, three low doses of radiation over 6 months had no effect on contractile function or metabolic enzyme activity in soleus and EDL of female mice. In contrast, three moderate doses of radiation over 6 months induced some effects on metabolic enzyme activity in soleus but not EDL Future studies that wish to investigate muscle tissue that is adjacent to scanned bone should take radiation exposure dose into consideration.

Cardiolipin content, linoleic acid composition, and tafazzin expression in response to skeletal muscle overload and unload stimuli.

Cardiolipin (CL) is a unique mitochondrial phospholipid that, in skeletal muscle, is enriched with linoleic acid (18:2n6). Together, CL content and CL 18:2n6 composition are critical determinants of mitochondrial function. Skeletal muscle is comprised of slow and fast fibers that have high and low mitochondrial content, respectively. In response to overloading and unloading stimuli, these muscles undergo a fast-to-slow oxidative fiber type shift and a slow-to-fast glycolytic fiber type shift, respectively, with a concomitant change in mitochondrial content. Here, we examined changes in CL content and CL 18:2n6 composition under these conditions along with tafazzin (Taz) protein, which is a transacylase enzyme that generates CL lipids enriched with 18:2n6. Our results show that CL content, CL 18:2n6 composition, and Taz protein content increased with an overload stimulus in plantaris. Conversely, CL content and CL 18:2n6 composition was reduced with an unloaded stimulus in soleus. Interestingly, Taz protein was increased in the unloaded soleus, suggesting that Taz may provide some form of compensation for decreased CL content and CL 18:2n6 composition. Together, this study highlights the dynamic nature of CL and Taz in skeletal muscle, and future studies will examine the physiological significance behind the changes in CL content, CL 18:2n6 and Taz.