We postulated that alpha-smooth muscle actin expressed in primary cultured mesangial cells is down-regulated in 3-dimensional (D) culture and up-regulated by high glucose and growth factors.
Primary ...rat mesangial cells were growth-arrested in 5.6 mM (NG) or 30 mM (HG) glucose for 14 days in 3-D Matrigel. Alpha-SM actin expression was analyzed by immunoblotting, real-time PCR and by alpha-SM actin promoter activity in response to 24 h stimulation with endothelin-1 (ET-1), angiotensin II (Ang II) or HG.
Alpha-SM actin mRNA, protein and promoter activity were reduced to significantly lower levels in 3-D cells compared to cells in 2-D. Up-regulation of alpha-SM expression was stimulated by ET-1, Ang II and HG. Specific inhibitors of protein kinase C (PKC)-alpha, -beta or -zeta prevented alpha-SM upregulation in HG. In NG, PKC and ERK1/2 activation were required for alpha-SM actin accumulation in 3-D in response to ET-1 or Ang II. In HG, enhanced expression of alpha-SM actin in response to ET-1 or Ang II was unchanged during PKC or ERK1/2 inhibition.
Mesangial cells in 3-D express low levels of alpha-SM actin representing a more differentiated state. Regulation of alpha-SM actin expression is dependent on specific PKC isozyme and ERK1/2 signaling.
The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates ...identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations.
A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback.
The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality.
CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care.
ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844-01.
The purpose of this study was to identify key concepts and semantic relations necessary to represent standardized and local patient assessment items in an electronic documentation system and to ...evaluate the degree to which coverage of both are represented by ICNP. A total of 805 unique assessment concepts were identified. Forty-three percent had exact matches in ICNP, and an additional 20% had matches in the ICNP classified as narrower, broader or other.
The objectives of this analysis were to 1) estimate prevalence of contraceptive use among women at risk for unintended pregnancy and 2) identify correlates of contraceptive use among women with ...ongoing or potential need for contraceptive services in Puerto Rico during the 2016 Zika virus (ZIKV) outbreak.
We conducted a cell-phone survey July–November, 2016. Women aged 18–49 years living in Puerto Rico were eligible. We completed 3059 interviews; the overall response rate was 69.2%. After weighting, the data provide population-based estimates. For this analysis, we included women at risk for unintended pregnancy, and assessed ongoing or potential need for contraceptive services in this group, excluding women using permanent contraceptive methods.
Most women reported using contraception (82.8%), and use increased with age. Female sterilization and male condoms were most frequently reported (40.8% and 17.1%, respectively). Among women with ongoing or potential need for contraceptive services, 24.7% talked to a healthcare provider about ZIKV, and 31.2% reported a change in childbearing intentions due to ZIKV. Most women were at least a little worried about getting infected with ZIKV (74.3%) or having a baby with a birth defect (80.9%). Being very worried about getting infected with ZIKV and already having Zika were significantly associated with use of any contraception (adjusted prevalence ratio: 1.19, 95% CI: 1.03–1.38 and 1.32, 95% CI: 1.01–1.72, respectively).
These findings underscore the need for regular contraceptive prevalence studies to inform programs about contraceptive needs, especially during public health emergencies.
When the 2016 Zika virus outbreak began in Puerto Rico there were no recent population-based data available on contraceptive prevalence. To fill this information gap, we conducted a population-based survey. Our findings provided baseline contraceptive prevalence estimates to support response planning and allocation of health resources.
Current implementation techniques constrain our ability to rapidly deploy and augment clinical decision support systems at Partners Healthcare Systems. We report on the use of a ...commercially-available rule engine system-iLog Rules-as the basis for a series of prototypes typifying Partners decision support applications. For three prototypical systems, we successfully decoupled the decision support component from application and support logic, and reimplemented that component using iLog. We found that the rule engine itself provides high-performance execution for the small rulesets we evaluated, and that overall application performance was found to be generally acceptable. We note that the major bottleneck to application performance is the ability to rapidly deliver patient data to the rule engine for execution. Future investigation will focus on abstracting features from each of the prototypes and incorporating them into a scalable and reusable decision support service architecture.
The availability of timely, accurate, comprehensive, and coded clinical problem lists is essential for supporting a range of healthcare activities. Evidence and experience suggest, however, that ...problem lists are frequently out-of-date, sometimes omit clinically important problems, and contain uncoded entries. Here, we describe a study being performed at Partners HealthCare System to explore automated techniques for enhancing existing problem lists.
BackgroundThe Women's Health Needs Study (WHNS) collected information on the health characteristics, needs, and experiences, including female genital mutilation (FGM) experiences, attitudes, and ...beliefs, of women aged 18 to 49 years who were born, or whose mothers were born, in a country where FGM is prevalent living in the US. The purpose of this paper is to describe the WHNS design, methods, strengths and limitations, as well as select demographic and health-related characteristics of participants.MethodsWe conducted a cross-sectional survey from November 2020 -June 2021 in four US metropolitan areas, using a hybrid venue-based sampling (VBS) and respondent-driven sampling (RDS) approach to identify women for recruitment.ResultsOf 1,132 participants, 395 were recruited via VBS and 737 RDS. Most were born, or their mothers were born, in either a West African country (Burkina Faso, Guinea, Mali, Mauritania, Sierra Leone, The Gambia) (39.0%) or Ethiopia (30.7%). More than a third were aged 30-39 years (37.5%) with a majority who immigrated at ages ≥13 years (86.6%) and had lived in the United States for ≥5 years (68.9%). Medicaid was the top health insurer (52.5%), followed by private health insurance (30.5%); 17% of participants had no insurance. Nearly half of women reported 1-2 healthcare visits within the past 12 months (47.7%). One in seven did not get needed health care due to cost (14.8%). Over half have ever used contraception (52.1%) to delay or avoid pregnancy and 76.9% had their last pelvic and/or Papanicolaou (pap) exam within the past 3 years. More than half experienced FGM (55.0%). Nearly all women believed that FGM should be stopped (92.0%).ConclusionThe VBS/RDS approach enabled recruitment of a diverse study population. WHNS advances research related to the health characteristics, needs, and experiences of women living in the US from countries where FGM is prevalent.
Creating shareable decision support services is a complex task requiring effort from multiple interdisciplinary role players with a wide variety of experience and expertise. The CDS Consortium ...research project has developed such a service, defining a multi-layer representation of knowledge and building upon an architectural service design created at Partners Health Care, and is demonstrating its use in both a local and an external institutional setting. The process was iterative, and we encountered unexpected requirements based on decisions made at various points. We report in this paper on challenges we faced while pursuing this research: knowledge representation and modeling, data interchange and standards adoption, the process of getting agreement on content, logistics of integrating into a system that already has multiple CDS interventions, legal issues around privacy and access, inter-team communication and organization.
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•Decision support integrated with emergency department workflow is a design challenge.•Sociotechnical models can inform ED decision support design.•The interdisciplinary assessment ...process is an example of an ED sociotechnical theme.•Shared documentation spaces may allow for efficient, accurate data capture in the ED.•Ease of re-using and updating data may enhance decision support use.
Integration of clinical decision support services (CDSS) into electronic health records (EHRs) may be integral to widespread dissemination and use of clinical prediction rules in the emergency department (ED). However, the best way to design such services to maximize their usefulness in such a complex setting is poorly understood. We conducted a multi-site cross-sectional qualitative study whose aim was to describe the sociotechnical environment in the ED to inform the design of a CDSS intervention to implement the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules for children with minor blunt head trauma. Informed by a sociotechnical model consisting of eight dimensions, we conducted focus groups, individual interviews and workflow observations in 11 EDs, of which 5 were located in academic medical centers and 6 were in community hospitals. A total of 126 ED clinicians, information technology specialists, and administrators participated. We clustered data into 19 categories of sociotechnical factors through a process of thematic analysis and subsequently organized the categories into a sociotechnical matrix consisting of three high-level sociotechnical dimensions (workflow and communication, organizational factors, human factors) and three themes (interdisciplinary assessment processes, clinical practices related to prediction rules, EHR as a decision support tool). Design challenges that emerged from the analysis included the need to use structured data fields to support data capture and re-use while maintaining efficient care processes, supporting interdisciplinary communication, and facilitating family-clinician interaction for decision-making.
In the Baby CareLink system, information prescription plays an important role in preparing parents of premature infants for the eventual discharge to home of their children. However, the prescription ...process requires scarce clinician time in order to dispense information, and can become cumbersome as content bases grow in size. We describe the development of an OWL-based knowledge mediator to facilitate information prescription. We describe 1) the initial development of a clinical vocabulary for neonatology using OWL-DL; 2) the reuse of the vocabulary to represent prototypical premature infants and their typical clinical problems and treatments; 3) the software components used to integrate terminology and inferencing services with Baby CareLink. We demonstrate multifaceted uses for description logics in a clinical application, reuse of a base vocabulary for domain knowledge representation, and use of the OWL language in representing clinical vocabularies. We believe that semi-automated knowledge mediation will enhance the process of electronic information prescription using large clinical content collections.
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