Jungwha Lee

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

BACKGROUND Effective collaboration and teamwork is essential to providing safe hospital care. The objective of this study was to assess the effect of an intervention designed to improve interdisciplinary collaboration and lower the rate of adverse events (AEs). METHODS The study was a controlled trial of an intervention, Structured Inter-Disciplinary Rounds, implemented in 1 of 2 similar medical teaching units in a tertiary care academic hospital. The intervention combined a structured format for communication with a forum for regular interdisciplinary meetings. We conducted a retrospective medical record review evaluating 370 randomly selected patients admitted to the intervention and control units (n = 185 each) in the 24 weeks after and 185 admitted to the intervention unit in the 24 weeks before the implementation of Structured Inter-Disciplinary Rounds (N = 555). Medical records were screened for AEs. Two hospitalists confirmed the presence of AEs and assessed their preventability and severity in a masked fashion. We used multivariable Poisson regression models to compare the adjusted incidence of AEs in the intervention unit to that in concurrent and historic control units. RESULTS The rate of AEs was 3.9 per 100 patient-days for the intervention unit compared with 7.2 and 7.7 per 100 patient-days, respectively, for the concurrent and historic control units (adjusted rate ratio, 0.54; P = .005; and 0.51; P = .001). The rate of preventable AEs was 0.9 per 100 patient-days for the intervention unit compared with 2.8 and 2.1 per 100 patient-days for the concurrent and historic control units (adjusted rate ratio, 0.27; P = .002; and 0.37; P = .02). The low number of AEs rated as serious or life-threatening precluded statistical analysis for differences in rates of events classified as serious or serious and preventable. CONCLUSION Structured Inter-Disciplinary Rounds significantly reduced the adjusted rate of AEs in a medical teaching unit.

Improving Teamwork: Impact of Structured Interdisciplinary Rounds on a Medical Teaching Unit

BACKGROUNDEffective collaboration and teamwork is essential in providing safe and effective hospital care. Prior research reveals deficiencies in collaboration on medical teaching units.OBJECTIVEThe aim of this study was to assess the impact of an intervention, structured inter-disciplinary rounds (SIDR), on hospital care providers’ ratings of collaboration and teamwork.METHODSThe study was a controlled trial comparing an intervention medical teaching unit with a similar control unit. The intervention, SIDR, combined a structured format for communication with a forum for regular interdisciplinary meetings. We surveyed providers on each unit and asked them to rate the quality of communication and collaboration they had experienced with other disciplines using a five-point ordinal scale. We also assessed the teamwork and safety climate using a validated instrument. Multivariable regression analyses were used to assess the impact on length of stay (LOS) and cost.RESULTSOne hundred forty-seven of 159 (92%) eligible providers completed the survey. Although resident physicians on each unit rated the quality of communication and collaboration with nurses similarly, a greater percentage of nurses gave high ratings to the quality of collaboration with resident physicians on the intervention unit as compared to the control unit (74% vs. 44%; p = 0.02). Providers on the intervention unit rated the teamwork climate significantly higher as compared to the control unit (82.4 ± 11.7 vs. 77.3 ± 12.3; p = 0.01). The difference was explained by higher teamwork climate ratings on the part of nurses on the intervention unit (83.5 ± 14.7 vs. 74.2 ± 14.1; p = 0.005). Ratings of the safety climate were not significantly different between units. Adjusted LOS and hospital costs were not significantly different between units.CONCLUSIONSSIDR had a positive effect on nurses’ ratings of collaboration and teamwork on a medical teaching unit. Further study is required to assess the impact of SIDR on patient safety measures.

Sedentary Time in US Older Adults Associated With Disability in Activities of Daily Living Independent of Physical Activity

BACKGROUND The harmful relationship of sedentary behavior to health may reflect an exchange of sedentary activity for moderate-to-vigorous physical activity (MVPA), or sedentary behavior may be a separate risk factor. We examined whether time spent in sedentary behavior is related to disability in activities of daily living (ADL), independent of time spent in MVPA in older adults. METHODS The nationally representative 2003-2006 National Health and Nutrition Examinations Surveys (NHANES) included 2286 adults aged 60 years and older in whom physical activity was assessed by accelerometer. The association between ADL task disability and the daily percentage of sedentary time was evaluated by multiple logistic regression. RESULTS These adults on average spent 9h/d being sedentary during waking hours and 4.5% reported ADL disability. The odds of ADL disability were 46% greater (odds ratio, 1.46; 95% confidence interval, 1.07-1.98) for each daily hour spent in sedentary behavior, adjusted for MVPA and socioeconomic and health factors. CONCLUSION These US national data show a strong relationship between greater time spent in sedentary behavior and the presence of ADL disability, independent of time spent in moderate or vigorous activity. These findings support programs encouraging older adults to decrease sedentary behavior regardless of their engagement in moderate or vigorous activity.

Understanding Readmission After Primary Total Hip and Knee Arthroplasty: Who’s at Risk?

Readmission has been cited as an important quality measure in the Patient Protection and Affordable Care Act. We queried an electronic database for all patients who underwent Total Hip Arthroplasty or Total Knee Arthroplasty at our institution from 2006 to 2010 and identified those readmitted within 90 days of surgery, reviewed their demographic and clinical data, and performed a multivariable logistic regression analysis to determine significant risk factors. The overall 90-day readmission rate was 7.8%. The most common readmission diagnoses were related to infection and procedure-related complications. An increased likelihood of readmission was found with coronary artery disease, diabetes, increased LOS, underweight status, obese status, age (over 80 or under 50), and Medicare. Procedure-related complications and wound complications accounted for more readmissions than any single medical complication.

Molecular signatures in skin associated with clinical improvement during mycophenolate treatment in systemic sclerosis.

Heterogeneity in systemic sclerosis/SSc confounds clinical trials. We previously identified ‘intrinsic’ gene expression subsets by analysis of SSc skin. Here we test the hypotheses that skin gene expression signatures including intrinsic subset are associated with skin score/MRSS improvement during mycophenolate mofetil (MMF) treatment. Gene expression and intrinsic subset assignment were measured in 12 SSc patients’ biopsies and ten controls at baseline, and from serial biopsies of one cyclophosphamide-treated patient, and nine MMF-treated patients. Gene expression changes during treatment were determined using paired t-tests corrected for multiple hypothesis testing. MRSS improved in four of seven MMF-treated patients classified as the inflammatory intrinsic subset. Three patients without MRSS improvement were classified as normal-like or fibroproliferative intrinsic subsets. 321 genes (FDR <5%) were differentially expressed at baseline between patients with and without MRSS improvement during treatment. Expression of 571 genes (FDR <10%) changed between pre- and post-MMF treatment biopsies for patients demonstrating MRSS improvement. Gene expression changes in skin are only seen in patients with MRSS improvement. Baseline gene expression in skin, including intrinsic subset assignment, may identify SSc patients whose MRSS will improve during MMF treatment, suggesting that gene expression in skin may allow targeted treatment in SSc.

Behavioral hearing thresholds between 0.125 and 20 kHz using depth-compensated ear simulator calibration.

Objectives: The purpose of this study was to obtain behavioral hearing thresholds for frequencies between 0.125 and 20 kHz from a large population between 10 and 65 yr old using a clinically feasible calibration method expected to compensate well for variations in the distance between the eardrum and an insert-type sound source. Previous reports of hearing thresholds in the extended high frequencies (>8 kHz) have either used calibration techniques known to be inaccurate or specialized equipment not suitable for clinical use. Design: Hearing thresholds were measured from 352 human subjects between 10 and 65 yr old having clinically normal-hearing thresholds (<20 dB HL) up to 4 kHz. An otoacoustic emission probe fitted with custom sound sources was used, and the stimulus levels individually tailored on the basis of an estimate of the insertion depth of the measurement probe. The calibrated stimulus levels were determined on the basis of measurements made at various depths of insertion in a standard ear simulator. Threshold values were obtained for 21 frequencies between 0.125 and 20 kHz using a modified Békésy technique. Forty-six of the subjects returned for a second measurement months later from the initial evaluation. Results: In agreement with previous reports, hearing thresholds at extended high frequencies were found to be sensitive to age-related changes in auditory function. In contrast with previous reports, no gender differences were found in average hearing thresholds at most evaluated frequencies. Two aging processes, one faster than the other in time scale, seem to influence hearing thresholds in different frequency ranges. The standard deviation (SD) of test–retest threshold difference for all evaluated frequencies was 5 to 10 dB, comparable to that reported in the literature for similar measurement techniques but smaller than that observed for data obtained using the standard clinical procedure. Conclusions: The depth-compensated ear simulator-based calibration method and the modified Békésy technique allow reliable measurement of hearing thresholds over the entire frequency range of human hearing. Hearing thresholds at the extended high frequencies are sensitive to aging and reveal subtle differences, which are not evident in the frequency range evaluated regularly (⩽8 kHz). Previously reported gender-related differences in hearing thresholds may be related to ear-canal acoustics and the calibration procedure and not because of differences in hearing sensitivity.

Levels of adiponectin, a marker for PPAR-gamma activity, correlate with skin fibrosis in systemic sclerosis: potential utility as biomarker?

IntroductionProgressive fibrosis in systemic sclerosis (SSc) is linked to aberrant transforming growth factor beta (TGF-beta) signaling. Peroxisome proliferator-activated receptor gamma (PPAR-gamma) blocks fibrogenic TGF-beta responses in vitro and in vivo. Reduced expression and function of PPAR-gamma in patients with SSc may contribute to progression of fibrosis. Here we evaluated the levels of adiponectin, a sensitive and specific index of PPAR-gamma activity, as a potential fibrogenic biomarker in SSc.MethodsAdiponectin levels were determined in the sera of 129 patients with SSc and 86 healthy controls, and serial determinations were performed in 27 patients. Levels of adiponectin mRNA in skin biopsies from SSc patients were assessed in an expression profiling microarray dataset. Regulation of adiponectin gene expression in explanted human subcutaneous preadipocytes and fibroblasts was examined by real-time quantitative PCR.ResultsPatients with diffuse cutaneous SSc had reduced serum adiponectin levels. A significant inverse correlation between adiponectin levels and the modified Rodnan skin score was observed. In longitudinal studies changes in serum adiponectin levels were inversely correlated with changes in skin fibrosis. Skin biopsies from a subset of SSc patients showed reduced adiponectin mRNA expression which was inversely correlated with the skin score. An agonist ligand of PPAR-gamma potently induced adiponectin expression in explanted mesenchymal cells in vitro.ConclusionsLevels of adiponectin, reflecting PPAR-gamma activity, are correlated with skin fibrosis and might have potential utility as a biomarker in SSc.

Sedentary behavior and physical function: objective evidence from the Osteoarthritis Initiative.

Investigate the relationship between sedentary behavior and physical function in adults with knee osteoarthritis (OA), controlling for moderate–vigorous physical activity (MVPA) levels.

Obesity and other modifiable factors for physical inactivity measured by accelerometer in adults with knee osteoarthritis

To investigate the public health impact of obesity and other modifiable risk factors related to physical inactivity in adults with knee osteoarthritis (OA).

Public health impact of risk factors for physical inactivity in adults with rheumatoid arthritis

To investigate the potential public health impact of modifiable risk factors related to physical inactivity in adults with rheumatoid arthritis (RA).