Randomized Comparison of Electronic Health Record Alert Types in Eliciting Responses about Prognosis in Gynecologic Oncology Patients.

OBJECTIVES: To compare the ability of different electronic health record alert types to elicit responses from users caring for cancer patients benefiting from goals of care (GOC) conversations. METHODS: A validated question asking if the user would be surprised by the patient's 6-month mortality was built as an Epic BestPractice Advisory (BPA) alert in three versions-(1) Required on Open chart (pop-up BPA), (2) Required on Close chart (navigator BPA), and (3) Optional Persistent (Storyboard BPA)-randomized using patient medical record number. Meaningful responses were defined as "Yes" or "No," rather than deferral. Data were extracted over 6 months. RESULTS: Alerts appeared for 685 patients during 1,786 outpatient encounters. Measuring encounters where a meaningful response was elicited, rates were highest for Required on Open (94.8% of encounters), compared with Required on Close (90.1%) and Optional Persistent (19.7%) (p < 0.001). Measuring individual alerts to which responses were given, they were most likely meaningful with Optional Persistent (98.3% of responses) and least likely with Required on Open (68.0%) (p < 0.001). Responses of "No," suggesting poor prognosis and prompting GOC, were more likely with Optional Persistent (13.6%) and Required on Open (10.3%) than with Required on Close (7.0%) (p = 0.028). CONCLUSION: Required alerts had response rates almost five times higher than optional alerts. Timing of alerts affects rates of meaningful responses and possibly the response itself. The alert with the most meaningful responses was also associated with the most interruptions and deferral responses. Considering tradeoffs in these metrics is important in designing clinical decision support to maximize success.

Effects of rumen-protected arginine supplementation and arginine-HCl injection on site and extent of digestion and small intestinal amino acid disappearance in forage-fed steers.

Four ruminally and intestinally cannulated steers were used in a 4 × 4 Latin square to evaluate effects of rumen-protected Arg supplementation or intravenous Arg injection on small intestinal delivery of AA, site and extent of digestion, and ruminal fermentation. Steers were fed grass hay (7.2% CP, 67.6% NDF, 0.29% Arg) for ad libitum intake with no additional Arg (CON), 54-mg L-Arg/kg BW injected intravenously (Arg-INJ), 180-mg rumen-protected L-Arg/kg BW daily (Arg-RP180), or 360-mg rumen-protected L-Arg/kg BW daily (Arg-RP360). Half of each treatment dose was administered twice daily. Each period had a 7-d washout of hay only followed by a 14-d treatment and collection period. Ruminal disappearance (%) of Arg was greater (P < 0.001) for both Arg-RP treatments than CON and Arg-INJ, although the amount of Arg disappearing was greatest in Arg-RP360, followed by Arg-RP180, and least in CON and Arg-INJ (P < 0.001). Duodenal flow and small intestinal disappearance (g/d) of Arg was greatest in Arg-RP360, followed by Arg-RP180, and least in CON and Arg-INJ (P < 0.004). Ileal flow of Arg was greatest in Arg-RP360, intermediate in Arg-RP180, and least in CON (P = 0.01) because the proportional small intestinal disappearance of Arg was not different (P = 0.96). Steers fed Arg-RP360 had greater (P = 0.01) ileal flow of Orn and tended to have greater (P = 0.09) ileal flow of Glu than all other treatments. There were no differences in hay or total DMI, microbial efficiency, or OM, NDF, or ADF digestibility (P ≥ 0.10). Total N intake and duodenal N flow were greater in Arg-RP360 than all other treatments (P ≤ 0.02). Total tract N digestibility was greatest in Arg-RP360, followed by Arg-RP180, and least in CON and Arg-INJ (P = 0.003). Ruminal ammonia was greater (P = 0.004) in Arg-RP360 compared with CON and Arg-INJ and greater (P = 0.06) in Arg-RP180 than CON. There was no effect of treatment (P ≥ 0.37) on total VFA, acetate, propionate, or butyrate concentrations. Results indicate that feeding rumen-protected Arg increases small intestinal Arg flow with minimal effects on ruminal fermentation and total tract digestibility of OM and fiber.

Impact of an Alcohol Withdrawal Treatment Pathway on Hospital Length of Stay: A Retrospective Observational Study Comparing Pre and Post Pathway Implementation.

OBJECTIVE: To determine if the implementation of a hospital-specific alcohol withdrawal treatment pathway used in a medical-surgical patient population decreased hospital length of stay (LOS) compared with the standard of care. METHODS: This retrospective observational study, conducted in a large academic tertiary care hospital, involved 582 subjects who met criteria for study inclusion, with 275 subjects in the 2010 cohort and 307 in the 2012 cohort. The Alcohol Withdrawal Project Team was formed with the goal of creating a standardized approach to the recognition and treatment of alcohol withdrawal at Duke University Hospital. The group created a computerized physician order entry alcohol withdrawal treatment pathway with 4 possible treatment paths chosen on the basis of current withdrawal symptoms, vital signs, and alcohol withdrawal history. The 4 treatment paths are 1 prophylaxis; 2 mild-to-moderate withdrawal; 3 moderate-to-severe withdrawal, and 4 severe withdrawal/alcohol withdrawal delirium. Each treatment path corresponds to a different lorazepam dose and dose schedule and symptom assessment. This pathway was implemented in the hospital at the end of 2011. RESULTS: Using a Cox proportional hazards model and adjusting for covariates, there was a 1 day [95% confidence interval (CI), 1-2 d] reduction in median hospital LOS between the 2010 and 2012 cohorts, 5 versus 4 days, respectively. The average ratio in hospital LOS between the 2 cohorts was 1.25 (95% CI, 1.25-1.67). The CI was estimated by bootstrapping and indicated a significantly longer LOS in the 2010 cohort compared with the 2012 cohort. Nonsignificant changes were found in the proportion of subjects admitted to the intensive care unit (24% in 2010 vs. 29.3% in 2012), LOS in the intensive care unit (7.1±8 d in 2010 vs. 5.6±6.9 d in 2012), and proportion of patients discharged with a diagnosis of delirium tremens (17.8% in 2010 vs. 15.3% in 2012). CONCLUSIONS: This study demonstrates the successful implementation of an alcohol withdrawal treatment pathway in a medical-surgical population hospitalized in a large tertiary care facility with significant impact on hospital LOS.

Survey of mycotoxins in corn distillers' dried grains with solubles from seventy-eight ethanol plants in twelve States in the U.S. In 2011.

Fuel ethanol co-products known as distillers' dried grains with solubles (DDGS) are a significant source of energy, protein, and phosphorous in animal feed. Fuel ethanol production may concentrate mycotoxins present in corn into DDGS. One hundred and forty one corn DDGS lots collected in 2011 from 78 ethanol plants located in 12 states were screened for the mycotoxins deoxynivalenol (DON), 15-acetyldeoxynivalenol (15-ADON), 3-acetyldeoxynivalenol (3-ADON), nivalenol (NIV), and zearalenone (ZON). DON ranged from <0.50 to 14.62 µg g-1, 15-ADON ranged from <0.10 to 7.55 µg g-1, and ZON ranged from <0.10 to 2.12 µg g-1. None of the DDGS lots contained 3-ADON or NIV. Plants in OH had the highest levels of DON overall (mean of 9.51 µg g-1), and plants in NY, MI, IN, NE, and WI had mean DON levels >1 and <4 µg g-1. Twenty six percent (36/141) of the DDGS lots contained 1.0 to 5.0 µg g-1 DON, 2% (3/141) contained >5.0 and <10.0 µg g-1 DON, and 3% (4/141) contained >10.0 µg g-1 DON. All DDGS lots contaminated with unacceptable levels of DON evaded detection prior to their commercial distribution and were likely sold as feed products.