Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel Multicomponent Interdisciplinary Quality Improvement Initiative.

Suboptimal medication prescribing for older adults has been described in a number of emergency department (ED) studies. Despite this, few studies have examined ED-targeted interventions aimed at reducing the use of potentially inappropriate medications (PIMs). Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the ED (EQUiPPED) is an ongoing multicomponent, interdisciplinary quality improvement initiative in eight Department of Veterans Affairs EDs. The project aims to decrease the use of PIMs, as identified by the Beers criteria, prescribed to veterans aged 65 and older at the time of ED discharge. Interventions include provider education; informatics-based clinical decision support with electronic medical record-embedded geriatric pharmacy order sets and links to online geriatric content; and individual provider education including academic detailing, audit and feedback, and peer benchmarking. Poisson regression was used to compare the number of PIMs that staff providers prescribed to veterans aged 65 and older discharged from the ED before and after the initiation of the EQUiPPED intervention. Initial data from the first implementation site show that the average monthly proportion of PIMs that staff providers prescribed was 9.4±1.5% before the intervention and 4.6±1.0% after the initiation of EQUiPPED (relative risk=0.48, 95% confidence interval=0.40-0.59, P<.001). Preliminary evaluation demonstrated a significant and sustained reduction of ED-prescribed PIMs in older veterans after implementation of EQUiPPED. Longer follow-up and replication at collaborating sites would allow for an assessment of the effect on health outcomes and costs.

Gynecologic disorders and menstrual cycle lightheadedness in postural tachycardia syndrome.

OBJECTIVE: To assess differences in gynecologic history and lightheadedness during menstrual cycle phases among patients with POTS and healthy control women. METHODS: In a prospective, questionnaire-based study carried out at Paden Autonomic Dysfunction Center, Vanderbilt University, between April 2005 and January 2009, a custom-designed questionnaire was administered to patients with POTS (n=65) and healthy individuals (n=95). The results were analyzed via Fisher exact test and Mann-Whitney U test. RESULTS: Patients with POTS reported increased lightheadedness through all phases of the menstrual cycle phases as compared with healthy controls. Both groups experienced the greatest lightheadedness during menses, and a decrease in lightheadedness during the follicular phase. Patients with POTS reported a higher incidence of gynecologic diseases as compared with healthy controls. CONCLUSION: The severity of lightheadedness was found to vary during the menstrual cycle, which may relate to changes in estrogen levels. Patients with POTS also reported an increase in estrogen-related gynecologic disease.

The identification of a novel endoplasmic reticulum to Golgi SNARE complex used by the prechylomicron transport vesicle.

Dietary long chain fatty acids are absorbed in the intestine, esterified to triacylglycerol, and packaged in the unique lipoprotein of the intestine, the chylomicron. The rate-limiting step in the transit of chylomicrons through the enterocyte is the exit of chylomicrons from the endoplasmic reticulum in prechylomicron transport vesicles (PCTV) that transport chylomicrons to the cis-Golgi. Because chylomicrons are 250 nm in average diameter and lipid absorption is intermittent, we postulated that a unique SNARE pairing would be utilized to fuse PCTV with their target membrane, cis-Golgi. PCTV loaded with [(3)H]triacylglycerol were incubated with cis-Golgi and were separated from the Golgi by a sucrose step gradient. PCTV-chylomicrons acquire apolipoprotein-AI (apoAI) only after fusion with the Golgi. PCTV became isodense with Golgi upon incubation and were considered fused when their cargo chylomicrons acquired apoAI but docked when they did not. PCTV, docked with cis-Golgi, were solubilized in 2% Triton X-100, and proteins were immunoprecipitated using VAMP7 or rBet1 antibodies. In both cases, a 112-kDa complex was identified in nonboiled samples that dissociated upon boiling. The constituents of the complex were VAMP7, syntaxin 5, vti1a, and rBet1. Antibodies to each SNARE component significantly inhibited fusion of PCTV with cis-Golgi. Membrin, Sec22b, and Ykt6 were not found in the 112-kDa complex. We conclude that the PCTV-cis-Golgi SNARE complex is composed of VAMP7, syntaxin 5, Bet1, and vti1a.