Kimberly Stephens

Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use of the Latest Standards for Electrocardiography trial

PURPOSE The purpose of the study was to examine the appropriate use of arrhythmia, ischemia, and QTc interval monitoring in the acute care setting. METHODS We analyzed baseline data of the Practical Use of the Latest Standards for Electrocardiography (PULSE) trial, a multisite randomized clinical trial evaluating the effect of implementing electrocardiographic monitoring practice standards. Research nurses reviewed medical records for indications for monitoring and observed if arrhythmia, ischemia, and QT interval monitoring was being done on 1816 patients in 17 hospitals. RESULTS Almost all (99%) patients with an indication for arrhythmia monitoring were being monitored, but 85% of patients with no indication were monitored. Of patients with an indication for ischemia monitoring, 35% were being monitored; but 26% with no indication were being monitored for ST-segment changes. Only 21% of patients with an indication for QT interval monitoring had a QTc documented, but 18% of patients with no indication had a QTc documented. CONCLUSION Our data show evidence of inappropriate monitoring: undermonitoring for ischemia and QTc prolongation and overmonitoring for all 3 types of monitoring, especially arrhythmia monitoring.

How our ICU decreased the rate of hospital-acquired pressure ulcers.

We describe 7 strategies our intensive care unit implemented to decrease the rate of hospital-acquired pressure ulcers. These strategies include the following: (1) restructured risk assessment and documentation, (2) translated numeric data into graphs for ease of understanding by staff, (3) increased staff awareness, (4) implemented “turn rounds,” (5) increased prevalence assessments and redesigned structure of the skin team, (6) used evidence-based practice as a basis for care, and (7) created an Access database to track weekly prevalence.

Associations between cytokine gene variations and severe persistent breast pain in women following breast cancer surgery.

UNLABELLED Persistent pain following breast cancer surgery is a significant clinical problem. Although immune mechanisms may play a role in the development and maintenance of persistent pain, few studies have evaluated for associations between persistent breast pain following breast cancer surgery and variations in cytokine genes. In this study, associations between previously identified extreme persistent breast pain phenotypes (ie, no pain vs severe pain) and single nucleotide polymorphisms (SNPs) spanning 15 cytokine genes were evaluated. In unadjusted analyses, the frequency of 13 SNPs and 3 haplotypes in 7 genes differed significantly between the no pain and severe pain classes. After adjustment for preoperative breast pain and the severity of average postoperative pain, 1 SNP (ie, interleukin [IL] 1 receptor 2 rs11674595) and 1 haplotype (ie, IL10 haplotype A8) were associated with pain group membership. These findings suggest a role for cytokine gene polymorphisms in the development of persistent breast pain following breast cancer surgery. PERSPECTIVE This study evaluated for associations between cytokine gene variations and the severity of persistent breast pain in women following breast cancer surgery. Variations in 2 cytokine genes were associated with severe breast pain. The results suggest that cytokines play a role in the development of persistent postsurgical pain.

Implementation of the Re-Engineered Discharge (RED) toolkit to decrease all-cause readmission rates at a rural community hospital.

Overview: National hospital readmission rates average 19%. One in 5 Medicare patients are readmitted within 30 days of discharge each year, resulting in

Reader domain specificity and lysine demethylase-4 family function

17.5 billion in additional costs. Objective/Purpose: The aim of this quality improvement project was to use the methodology outlined by Joint Commission Resources-Hospital Engagement Network and Project Re-Engineered Discharge (Project RED) to redesign the discharge process, reduce hospital 30-day all-cause readmission rates, and improve patient/family involvement in the discharge process. Method: The methodology of the Joint Commission Resources-Hospital Engagement Network and the Agency for Healthcare Research and Quality Project RED toolkit, the After Hospital Care Plan, and a patient discharge questionnaire were used to incorporate best discharge practices into patient care and evaluate the outcomes of the project. Monthly readmission rates and patient/family involvement in the discharge process were examined for 336 patients discharged from a dedicated 30-bed medical-surgical unit in a rural community hospital over a 4-month period. Results: During the 4-month project, readmissions were reduced by 32% (rate 7.12); the overall monthly reduction from baseline was 27%, with a 44% reduction from baseline during the previous 6 months. The patient and family perception of their discharge process was positive.

Epigenetic Regulation and Measurement of Epigenetic Changes

The KDM4 histone demethylases are conserved epigenetic regulators linked to development, spermatogenesis and tumorigenesis. However, how the KDM4 family targets specific chromatin regions is largely unknown. Here, an extensive histone peptide microarray analysis uncovers trimethyl-lysine histone-binding preferences among the closely related KDM4 double tudor domains (DTDs). KDM4A/B DTDs bind strongly to H3K23me3, a poorly understood histone modification recently shown to be enriched in meiotic chromatin of ciliates and nematodes. The 2.28 Å co-crystal structure of KDM4A-DTD in complex with H3K23me3 peptide reveals key intermolecular interactions for H3K23me3 recognition. Furthermore, analysis of the 2.56 Å KDM4B-DTD crystal structure pinpoints the underlying residues required for exclusive H3K23me3 specificity, an interaction supported by in vivo co-localization of KDM4B and H3K23me3 at heterochromatin in mammalian meiotic and newly postmeiotic spermatocytes. In vitro demethylation assays suggest H3K23me3 binding by KDM4B stimulates H3K36 demethylation. Together, these results provide a possible mechanism whereby H3K23me3-binding by KDM4B directs localized H3K36 demethylation during meiosis and spermatogenesis.

Association of Implementation of Practice Standards for Electrocardiographic Monitoring With Nurses’ Knowledge, Quality of Care, and Patient Outcomes: Findings From the Practical Use of the Latest Standards of Electrocardiography (PULSE) Trial

Epigenetic mechanisms provide an adaptive layer of control in the regulation of gene expression that enables an organism to adjust to a changing environment. Epigenetic regulation increases the functional complexity of deoxyribonucleic acid (DNA) by altering chromatin structure, nuclear organization, and transcript stability. These changes may additively or synergistically influence gene expression and result in long-term molecular and functional consequences independent of the DNA sequence that may ultimately define an individual’s phenotype. This article (1) describes histone modification, DNA methylation, and expression of small noncoding RNA species; (2) reviews the most common methods used to measure these epigenetic changes; and (3) presents factors that need to be considered when choosing a specific tissue to evaluate for epigenetic changes.

Associations between genetic and epigenetic variations in cytokine genes and mild persistent breast pain in women following breast cancer surgery

Background— Although continuous electrocardiographic (ECG) monitoring is ubiquitous in hospitals, monitoring practices are inconsistent. We evaluated implementation of American Heart Association practice standards for ECG monitoring on nurses’ knowledge, quality of care, and patient outcomes. Methods and Results— The PULSE (Practical Use of the Latest Standards of Electrocardiography) Trial was a 6-year multisite randomized clinical trial with crossover that took place in 65 cardiac units in 17 hospitals. We measured outcomes at baseline, time 2 after group 1 hospitals received the intervention, and time 3 after group 2 hospitals received the intervention. Measurement periods were 15 months apart. The 2-part intervention consisted of an online ECG monitoring education program and strategies to implement and sustain change in practice. Nurses’ knowledge (N=3013 nurses) was measured by a validated 20-item online test, quality of care related to ECG monitoring (N=4587 patients) by on-site observation, and patient outcomes (mortality, in-hospital myocardial infarction, and not surviving a cardiac arrest; N=95 884 hospital admissions) by review of administrative, laboratory, and medical record data. Nurses’ knowledge improved significantly immediately after the intervention in both groups but was not sustained 15 months later. For most measures of quality of care (accurate electrode placement, accurate rhythm interpretation, appropriate monitoring, and ST-segment monitoring when indicated), the intervention was associated with significant improvement, which was sustained 15 months later. Of the 3 patient outcomes, only in-hospital myocardial infarction declined significantly after the intervention and was sustained. Conclusions— Online ECG monitoring education and strategies to change practice can lead to improved nurses’ knowledge, quality of care, and patient outcomes. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01269736.

Differential expression of voltage-gated sodium channels in afferent neurons renders selective neural block by ionic direct current

HighlightsIL6, CXCL8, and TNF are associated with mild persistent breast pain.CpG methylation in the TNF promoter may contribute to mild persistent breast pain.These genetic and epigenetic variations may help to identify high risk patients. Abstract Persistent pain following breast cancer surgery is a significant problem. Both inherited and acquired mechanisms of inflammation appear to play a role in the development and maintenance of persistent pain. In this longitudinal study, growth mixture modeling was used to identify persistent breast pain phenotypes based on pain assessments obtained prior to and monthly for 6 months following breast cancer surgery. Associations between the “no pain” and “mild pain” phenotypes and single nucleotide polymorphisms (SNPs) spanning 15 cytokine genes were evaluated. The methylation status of the CpG sites found in the promoters of genes associated with pain group membership was determined using bisulfite sequencing. In the multivariate analysis, three SNPs (i.e., interleukin 6 (IL6) rs2069840, C‐X‐C motif chemokine ligand 8 (CXCL8) rs4073, tumor necrosis factor (TNF) rs1800610) and two TNF CpG sites (i.e., c.−350C, c.−344C) were associated with pain group membership. These findings suggest that variations in IL6, CXCL8, and TNF are associated with the development and maintenance of mild persistent breast pain. CpG methylation within the TNF promoter may provide an additional mechanism through which TNF alters the risk for mild persistent breast pain after breast cancer surgery. These genetic and epigenetic variations may help to identify individuals who are predisposed to the development of mild levels of persistent breast pain following breast cancer surgery.

Improving the Patient's Experience With a Multimodal Quiet-at-night Initiative

Researchers investigate the use of ionic direct current to reverse the standard neural stimulation recruitment order. The assertion that large-diameter nerve fibers have low thresholds and small-diameter fibers have high thresholds in response to electrical stimulation has been held in a nearly axiomatic regard in the field of neuromodulation and neuroprosthetics. In contrast to the short pulses used to evoke action potentials, long-duration ionic direct current has been shown to block neural activity. We propose that the main determinant of the neural sensitivity to direct current block is not the size of the axon but the types of voltage-gated sodium channels prevalent in its neural membrane. On the basis of the variants of voltage-gated sodium channels expressed in different types of neurons in the peripheral nerves, we hypothesized that the small-diameter nociceptive fibers could be preferentially blocked. We show the results of a computational model and in vivo neurophysiology experiments that offer experimental validation of this novel phenomenon.