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Adoption Rate of a Certified EHR at Medical Practices with Five or Fewer Physicians
Get PDFThe adoption rate of a certified electronic health record (EHR) for small medical practices have been the subject of discussion because prior research shows that larger medical practices have a higher rate of adoption than small medical practices. The major reason for this disparity has been the cost of adoption and implementation as many small practices are not financially equipped to shoulder this burden. The purpose of this research was to determine the adoption rate of a certified EHR for medical practices with five or fewer physicians. Through a google search and filtering the results of the search, the office managers of 20 medical practices in the Metro Atlanta Area (state of Georgia) were interviewed in-person or by phone to assess the certified EHR adoption rate, meaningful use (MU) utilization rate and challenges encounter with implementation. The results showed that the adoption rate of a certified EHR system was 90% among small medical practices with five or fewer physicians and the MU utilization was at 72%. These results showed that despite the challenges that small medical practices face, the majority of them are complying with government mandates in the effort to advance technology in healthcare
Nutrition Informatics: Information Technology Transition for Registered Dieticians
Get PDFThe passing of the Health Information Technology for Economic and Clinical Health Act (HITECH) has created a growing push for healthcare organizations to no longer use paper based records and convert to an Electronic Health Record (EHR). Along with the adoption of an EHR comes a necessary change for ancillary services like nutrition and dietetic services because it affects patient care as well. In order to maintain a professional standard in patient healthcare as other health disciplines have done, the development of nutrition informatics model has become necessary. Nutrition informatics will prove to be a necessary addition to the developing field of healthcare informatics. The training of registered dieticians and nutrition technicians in using information technology along with their knowledge and expertise is what will improve data accuracy, patient care, and quality. The development of a standardized vocabulary will also attribute to the success of developing nutrition informatics along with the willingness to embrace and develop information technology skills necessary to navigate electronic applications and tools. Although skill levels and change obstacles will have to be accessed, the overall findings reveal that dieticians and nutritionist are not very knowledgeable in the area of nutrition informatics but are willing to embrace it through education and training
Hit Identification for PKCζ Inhibitors: Structure-Based Optimization, Virtual Screening, and Biological Evaluation
Get PDFProtein kinase C ζ (PKCζ) is believed to be a promising target for the treatment of some diseases, including inflammatory diseases, obesity and diabetes. Hit identification of PKCζ inhibitors was conducted by structure-based modification, virtual screening and biological evaluation. Among all the compounds selected and synthesized, compound JW-1-60A showed moderate activity against PKCζ at 30 μM and 100 μM. The molecular modeling studies showed that the binding mode of JW-1-61A was very close to the binding mode of JP-3-149, a reported PKCζ inhibitor with very potent activity, which might partially explain the moderate activity of JW-1-61A. Based on the structure of JW-1-60A, we will synthesize a series of its analogs and investigate their selectivity against other kinases in the future
Mild Traumatic Brain Injury with Associated Visual System Dysfunction: Investigating Histopathology, Functional Correlates, and a Novel Therapeutic Immune Modulator
Get PDFBackground. Traumatic brain injury (TBI) is a significant source of morbidity and mortality worldwide. Injuries associated with moderate to severe TBI can be profound, and have historically overshadowed the significant impact mild TBI (mTBI) can have on the lives of affected individuals. Mild TBI can manifest in a number of different ways, but one of the most significant and often debilitating is its impact on the visual system. In order to further investigate the underlying pathology of mTBI and test potential therapeutics, we developed a mouse model of mTBI induced by blast overpressure. In this model, a 50-60 psi blast wave from a highly pressurized bolus of air is directed at a focal region of the left lateral cranium of a mouse, and produces replicable motor, emotional, and visual system deficits with concomitant histopathology. Importantly, this model closely simulates functional visual system damage seen in human cases of mTBI. A major component of the brain’s reaction to trauma is an immune response that can cause additional long-term damage above and beyond that of the initial injury. This response was observed in our model as regions of microglial cell activation throughout areas of the brain important for visual processing. A novel therapeutic drug acting at cannabinoid type 2 receptors (CB2), known as SMM-189, had previously shown promise in improving visual outcome after mTBI in our model, but no studies were done to elucidate the cause of this improvement. The purpose of this dissertation was to further characterize visual system dysfunction and histopathology in our model, as well as investigate how the drug SMM-189 acts to exert its beneficial effects on these areas. Mice were blasted with either 50-psi or sham blast, and then injected over the next two weeks with either drug or vehicle intraperitoneally. Functional tests were administered at 30 days after blast, and perfused tissues were used for subsequent histologic evaluation. Tissue used for histologic analysis was collected from mice at 3 and 7 days post-blast, and in another cohort at 11 weeks after blast.
Functional results. Optokinetic testing was administered to obtain visual acuity (VA) and contrast sensitivity (CS) thresholds in mice at 30 days after blast. It was found that no group showed any defects in VA, but the 50-psi vehicle-treated group (50V) showed significant deficits in the CS function of both eyes, which was completely rescued with drug treatment. Electroretinograms were run both pre- and post-blast on mice to obtain an electrophysiological readout of retinal cellular function over the first month after blast. The left eye of 50V animals showed a pathologic B-wave elevation, but no change in the A-wave, or peak latency times. Drug treatment corrected this abnormality, returning the 50-psi SMM-189 treatment group (50SMM) B-wave average back to control levels.
Structural results. Optical coherence tomography at 30 days post-blast revealed pathologic outer retinal thinning in the left eye of 50V animals, with 50SMM animals showing no such change. Immunohistochemistry (IHC) to visualize microglia in the retina showed a significant microglial increase in the left eye of 50V animals at 3 days post-blast, and a lesser but still pathologic elevation in both left and right eyes at 30 days post-blast. Drug treatment decreased the pathologic microglial elevation at both 3 days and 30 days, indicating its efficacy in quelling inflammatory microglial recruitment. Another readout of pathological response in the retina, GFAP immunoreactivity, was found to be elevated in the left eye of 50V animals at 30 days as well. 50SMM animals did not show any GFAP immunoreactivity at this time point. Brn3a+ RGCs in the retina were visualized using IHC, and no significant changes were seen. Cross-sections through optic nerves (ON) were analyzed from animals 11 weeks after blast. Left ONs from both 50V and 50SMM animals were found to be atrophic compared to controls, while the right eyes were all equivalent. Manual axon counts revealed left ONs from 50V animals had a decreased axon density, as well as a decrease in total axon count. Animals in the 50SMM group had a decreased axon density in the left eye, but the total axon count returned to normal. The right ON of 50V animals also had a decrease in axon density, but the total axon count was not significantly different than controls. In the mouse brain, the right optic tract (ROT) contains predominantly the uncrossed axons originating from the left eye and optic nerve. The ROT of 50V animals at 3 days after blast showed a significant number of pathologic axon bulbs, indicating areas of traumatic axonal disruption. These tracts also showed an increased presence of M1 inflammatory-polarized microglia when compared to controls, as determined by IHC markers specific to the M1 polarization state. In the ROT of 50V animals at 5 and 7 days, large axon bulbs had decreased in number and numerous smaller granular accumulations became apparent, possibly indicating axonal degeneration. Drug treated animals showed a significant decrease in the number of axon bulbs at 3 days post-blast, and 20% of the microglia in this same tract had been converted from M1 to an M2 anti-inflammatory polarization state.
Conclusion. The novel drug SMM-189 was shown to significantly improve many aspects of visual system damage in our model. Histologic evidence supports its role in positively modulating the immune response in neurotrauma, and acting to alter microglial polarization into a more neuroprotective phenotype. Furthermore, histologic benefits were associated with corresponding improvements in visual system function, showing its efficacy in treating mTBI visual system damage, a disease with no currently available pharmacotherapy. Future studies into mTBI-associated visual dysfunction should seek to investigate long-term outcome in this model, and to determine if drug benefit is sustained over an extended period after injury
Repeated Zolpidem Treatment Effects on Sedative Tolerance, Withdrawal, mRNA Levels, and Protein Expression
Get PDFZolpidem and benzodiazepines (BZs) potentiate the inhibitory action of gamma-Aminobutyric acid (GABA) by allosterically binding to GABAA receptors (GABAAR). Prolonged use of GABAAR positive allosteric modulators (PAM) can lead to behavioral tolerance, the diminished response to the same drug dose with repeated use, and withdrawal, a group of symptoms that occur due to abrupt end of drug treatment. Zolpidem is a short-acting, non-BZ GABAAR PAM whose potential for tolerance and withdrawal is unclear. Zolpidem demonstrates sedative efficacy similar to BZs and has become a main treatment of insomnia in lieu of BZs. Zolpidem replaced BZs due to lower incidences of tolerance and withdrawal after prolonged treatment and discontinuation. Despite reported lower incidences, some studies find the occurrence of tolerance and withdrawal similar between zolpidem and BZs. Tolerance and withdrawal symptoms are likely caused by drug-induced neuroadaptive changes in central nervous system (CNS)
functioning, and these alterations may be similar between zolpidem and BZ. Past rodent research suggests that long term use of zolpidem and BZs may produce alterations in normal inhibitory GABAergic and excitatory glutamatergic functioning in the cortex, hippocampus, amygdala, and PFC and that these alterations may underlie sedative tolerance and withdrawal symptoms.
The purpose of this project was to examine the molecular mechanisms involved in the tolerance cross-tolerance, and withdrawal of zolpidem and diazepam in C57/BL6J mice after different treatment durations. Elucidating the mechanisms behind zolpidem tolerance and withdrawal is necessary due to the ongoing usage of subunit specific GABAAR PAMs and, to a broader extent, an understanding of GABAARs themselves.
In Study 1, we measured sedative tolerance, cross-tolerance, and GABAAR associated mRNA levels in 4 regions of interest (ROI; the cortex, prefrontal cortex (PFC), hippocampus, and amygdala) after 3 days of intraperitoneal (i.p.) injections of diazepam and zolpidem in comparison to vehicle. We expected that this “short-term” exposure duration to diazepam and zolpidem would not result is tolerance, cross-tolerance, or changes in mRNA levels. Study 2 examined the same measures as in Study 1, in addition to AMPAR subunits, NDMAR subunits mRNA levels in the ROI, and total, surface, and intracellular GABAAR subunits protein expression due to 7 days of i.p. injections of diazepam and zolpidem compared to vehicle. Based on previous research both groups should become tolerant to zolpidem’s sedative effects and show decreases of GABAAR subunits and increases in NMDAR subunits in the ROI. It is also expected that there will be decreases in total α1 and γ2 in the cortex, a decrease of surface α1 in the cortex, and increases in GluR1 in the hippocampus after zolpidem and diazepam treatment. Study 3 measured the same measures as in Study 1 due to 30 days of i.p. injections of diazepam and zolpidem compared to vehicle. It was expected that both groups would become tolerant to zolpidem’s sedative effects and show decreases of GABAAR subunits in the cortex, PFC, and hippocampus.
The development of sedative tolerance and cross-tolerance to the locomotor impairing effects (measure of sedation) of zolpidem was measured by activity in the open field. Spontaneous withdrawal was also measured by activity and anxiety like behavior in the open field. Flumazenil- induced withdrawal was measured by anxiety- like behaviors in the elevated plus maze (EPM), activity, and anxiety like behavior in the open field. Messenger RNA levels were measured by quantitative real time quantitative reverse transcription polymerase chain reaction (qRT-PCR) and protein expression was measured by western blot. The surface and intracellular proteins were separated using bissulfosuccinimidyl suberate (BS3) cross-linking.
Three days of diazepam but not zolpidem resulted in cross-tolerance to zolpidem in Study 1. Three days of zolpidem but not diazepam resulted in a decrease in the mRNA level of the α5 subunit in the hippocampus in Study 1. After 7 days of zolpidem or diazepam, mice were tolerant and cross-tolerant to zolpidem’s sedative effects. Spontaneous withdrawal resulted in anxiety-like behavior and decreased locomotor activity. Flumazenil did induce a robust withdrawal syndrome as measured in the EPM or open field. Seven days of zolpidem and diazepam caused significant decreases in the mRNA expression of α1, α3, β2, and δ GABAAR subunits in the cortex. Diazepam groups had significant decreases in the mRNA expression of α4, β1, γ2 subunits, GAT, and gephyrin in the cortex and significant decreases of α5- and β3-GABAAR
subunits, and the GluN2A subunit in the hippocampus. Seven days of zolpidem resulted in a decrease in total α2 subunit protein level and 7 days of diazepam decreased total γ2 subunit protein levels. Thirty days of diazepam but not zolpidem resulted in cross-tolerance to zolpidem in Study 3. Thirty days of zolpidem but not diazepam resulted in a decrease in the mRNA levels of α1, α2, α3, β1, β2, β3, γ1, and γ2 subunits in the PFC.
These results suggest that there is a window of time in which sedative tolerance to zolpidem is observed. The lack of zolpidem tolerance and minimal mRNA changes due to 3 days of zolpidem treatment may be due to its pharmacokinetic profile, zolpidem may not be in the system long enough to cause any changes. This may mean that sedative tolerance gradually develops and reaches detectable levels at later time points. Sedative tolerance and cross-tolerance to zolpidem is in line with other studies, however the spontaneous withdrawal is unique. Anxiety- like behavior and decreased activity were observed in our studies unlike other studies. The anxiety- like behavior is a common symptom of BZ withdrawal however the decrease in activity that was observed is not. It is unknown why this occurs though it may be due to a carryover sedative effect or more likely a placebo effect. Few studies have examined changes in protein levels. Study 2 found decreased protein expression of α2 and γ2 in the cortex due to zolpidem and diazepam respectively, indicate GABAARs containing those subunits are associated with tolerance and cross-tolerance to zolpidem’s sedative effects. This implies that the sedative effects of zolpidem is mediated by α1-GABAARs, the development of tolerance is mediated by α2-GABAARs due to zolpidem binding to both. There was also a decrease in the intracellular α1 subunit which may indicate degradation of an intracellular pool of α1 subunits or α1-GABAARs. The lack of zolpidem tolerance due to 30 days of zolpidem may be due to increased metabolism displayed as an increase in CYP3A enzymes. It is unclear what effect the decrease in GABAAR subunits in the PFC due to 30 days of zolpidem implicate. These may affect tolerance to zolpidem’s other effects such as amnesia
Validation of ACTOne CB1 and CB2 Assays, Subsequent Characterization of SMM-189, and Development and Characterization of New CB2 Inverse Agonists
No full textCannabinoids have emerged on the national scene as a promising untapped therapeutic class. In pursuit of development of cannabinoids for pharmacologic use, I established and validated two high-throughput in vitro pharmacological screening systems, the ACTOne cannabinoid 1 and cannabinoid 2 assays, to aid in evaluating cannabinoid compounds for receptor affinity, pharmacologic potency and efficacy, and for selected compounds, antagonist activity. Our lead compound, SMM-189, was evaluated using the ACTOne assays and determined to be a CB2 inverse agonist. Further investigation revealed SMM-189 to exert anti-inflammatory effects on the brain’s immune cells, microglia, through polarization to a pro-wound healing state. Next generation analogs of SMM-189 were also evaluated in the ACTOne assays in the hopes of developing a molecule with improved biochemical characteristics
User Acceptance of Neurology Telemedicine Technology in the Emergency Department
Get PDFThere is currently a significant shortage of trained neurologists in the country. In addition to the shortfall of neurologists, there is an increasing need for this specialty due to an aging population, increase in the incident of neurologic diseases and an increasing demand for healthcare (Freeman, 2013). The development of tele neurology technology has been shown to help address these problems. As with any new technology there are multiple barriers to overcome, one of those being user acceptance of the technology. A survey of users of the telemedicine product VGo was conducted at Hunt Regional Medical Center to access the end-user’s perceived usefulness and ease of use of this technology. The response rate to the survey was 50% and yielded much information about the user’s acceptance of the technology and revealed the difference in perceptions of those with and without experience using the technology. This information will be valuable to the emergency department staff to use in addressing the identified barriers to improve acceptance and use of the product, ultimately improving quality of patient care
Information Governance: An Investigation of Interface Errors Between Source and Receiving Systems
Get PDFThe monitoring of interoperability of information in healthcare organizations is of increasing interest due to patient safety, operational and financial considerations. This monitoring is referred to as information governance (IG) and is a complex topic based on several underlying concepts. Interfacing information at the foundational, structural and semantic level is necessary for meaningful use of health information. Issues that arise range from incongruent transfer of information from source systems to receiving systems, discrepancies in the source system and receiving system and failures in interfacing information. This research project examines information governance from the perspective of failures in interfacing information from the perspective of people, process and technology in monitoring interface errors between health information systems. The research design is evaluation and the methodology is case study in order to evaluate the effectiveness of interfaces between source and receiving systems. Particularly 17 Health Level Seven (HL7) interfaces were reviewed within a Critical Access Hospital (CAH) to investigate information governance from a people, process and technology perspective. This case study helped to identify needed information governance within the organization and plan for implementation of an information governance committee in order to address foundational and structural issues and to monitor unintended consequences caused by interface errors in the areas of patient safety, operational and financial impact due to interface errors
Internet and Social Media: Influence on the parent’s vaccination decision
Get PDFInformation is now abundantly available with a click of a button. Access to more information imaginable can be obtained instantly. Unfortunately, not all of this information is backed by scientifically researched facts. This is causing problems for the healthcare industry, especially in the area of vaccinations. Scientifically sound information provided by the healthcare providers is being challenged by information parents are finding that is provided by the anti-vaccination movement. This information is found on websites, shared on social media, and is spreading rapidly. This research investigates this conflicting information between healthcare providers and the anti-vaccination movement. It is designed to determine if information found on the Internet and Social Media sites has a bigger influence on the parent’s vaccination decision than that provided by government agencies and healthcare providers
Are Bay County Florida Healthcare Facilities Ready for PAMA Imaging CDS Mandate?
Get PDFThe Electronic Health Record (EHR) has been a major player on the healthcare scene in recent years. Its use has ushered in a new phase of focus on quality healthcare combined with and aided by technological integration. Within this technological integration have come adjutant tools including Clinical Decision Support (CDS) tools. Among these applications are those focused on appropriate imaging by use of CDS designed according to Appropriate Use Criteria (AUC). The imaging CDS tools are available to aid the provider in selecting the appropriate imaging study for the clinical indications present. The Protecting Access to Medicare Act (PAMA) passed in April, 2014 outlined requirements to be directed by the Centers for Medicare & Medicaid Services (CMS) with a mandatory implementation of imaging CDS tools for certain providers with an initial deadline of January 2017. Although the deadline has been postponed, the PAMA mandate will be a requirement in the near future. With the imaging CDS mandate implementation looming in the future, affected facilities have an opportunity to prepare their facilities for it and provide education for physicians and staff. However, with the slow adoption rate of the certified EHR, it is likely that there is also that of imaging CDS even though its efficacy has been proven. A survey of affected healthcare facilities was conducted in Bay County, Florida to determine readiness for the impending mandate. While the response rate of the survey was not low, the available sample field was small. Still, the results yielded congruent information to the state adoption rates of the certified EHR and attitudes towards imaging CDS among affected providers. This evidence will be informative to affected facilities and specifically their HIM professionals by means of the information presented. In particular, the survey respondents will benefit from the literature accompanying the survey as some may be unaware of the CMS mandate