Measuring persistence of implementation: QUERI Series

Background

We describe how we used the framework of the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) to develop a program to improve rates of diagnostic testing for the Human Immunodeficiency Virus (HIV). This venture was prompted by the observation by the CDC that 25% of HIV-infected patients do not know their diagnosis – a point of substantial importance to the VA, which is the largest provider of HIV care in the United States.

Methods

Following the QUERI steps (or process), we evaluated: 1) whether undiagnosed HIV infection is a high-risk, high-volume clinical issue within the VA, 2) whether there are evidence-based recommendations for HIV testing, 3) whether there are gaps in the performance of VA HIV testing, and 4) the barriers and facilitators to improving current practice in the VA. Based on our findings, we developed and initiated a QUERI step 4/phase 1 pilot project using the precepts of the Chronic Care Model. Our improvement strategy relies upon electronic clinical reminders to provide decision support; audit/feedback as a clinical information system, and appropriate changes in delivery system design. These activities are complemented by academic detailing and social marketing interventions to achieve provider activation.

Results

Our preliminary formative evaluation indicates the need to ensure leadership and team buy-in, address facility-specific barriers, refine the reminder, and address factors that contribute to inter-clinic variances in HIV testing rates. Preliminary unadjusted data from the first seven months of our program show 3–5 fold increases in the proportion of at-risk patients who are offered HIV testing at the VA sites (stations) where the pilot project has been undertaken; no change was seen at control stations.

Discussion

This project demonstrates the early success of the application of the QUERI process to the development of a program to improve HIV testing rates. Preliminary unadjusted results show that the coordinated use of audit/feedback, provider activation, and organizational change can increase HIV testing rates for at-risk patients. We are refining our program prior to extending our work to a small-scale, multi-site evaluation (QUERI step 4/phase 2). We also plan to evaluate the durability/sustainability of the intervention effect, the costs of HIV testing, and the number of newly identified HIV-infected patients. Ultimately, we will evaluate this program in other geographically dispersed stations (QUERI step 4/phases 3 and 4).     

Steroid Series

3β-Acetoxy-B-nor-5β-cholestan-6-one (Ia) afforded only one isolatable oxime (IIa), while oximation of 3β, 17β-diacetoxy-B-nor-5β-androstan-6-one (Ib) yielded two isomeric oximes (IIb and IIIb). 7-Aza-5β-cholestan-3β-ol (VIa), 7-aza-5β-androstane-3β, 17β-diol (VIc), and 6-aza-5β-androstane-3β, 17β-diol (VIIc) were synthesized by Beckmann rearrangement of these oximes, followed by reduction with lithium aluminium hydride. The structure of the aza-steroids were established by conversion of the intermediate lactams (IVa, b) into the lactones (IXa, b), prepared from the 3β-acetoxy-B-nor-6-oxo-5β-steroids (Ia, b) by Baeyer Villiger reaction.     

Thematic Minireview Series: Metals in Biology 2010

Metals are present in nearly one-half of protein structures analyzed to date and play important roles in many of these enzymes. This prologue introduces the third of the Thematic Minireview Series on Metals in Biology, which is focused on iron homeostasis. The four minireviews in the current series deal with redox cycling in iron metabolism, the biogenesis and assembly of iron-sulfur centers (two articles), and the assembly of iron into heme.     

Acute Sirolimus Overdose: A Multicenter Case Series

BackgroundThere are few data relating to sirolimus overdose in the medical literature. Our objectives were to describe all cases of overdose with sirolimus reported to Swiss, German and Austrian Poisons Centres between 2002-2013.MethodsAn observational case-series analysis was performed to determine circumstances, magnitude, management and outcome of sirolimus overdose.ResultsFive cases of acute sirolimus overdose were reported – three in young children and two in adults. Four were accidental and one was with suicidal intent. Two patients developed symptoms probably related to sirolimus overdose: mild elevation of alkaline phosphatase, fever and gastroenteritis in a 2.5-year-old male who ingested 3 mg, and mild changes in total cholesterol in an 18-year-old female after ingestion of 103 mg. None of these events were life-threatening. Serial blood concentration measurements were performed starting 24 h after ingestion of 103 mg in a single case, and these followed a similar pharmacokinetic time-course to measurements taken after dosing in the therapeutic range.ConclusionsAcute sirolimus overdose occurred accidentally in the majority of cases. Even large overdoses appeared to be well-tolerated, however children might be at greater risk of developing complications. Further study of sirolimus overdose is needed.     

FTSPlot: Fast Time Series Visualization for Large Datasets

The analysis of electrophysiological recordings often involves visual inspection of time series data to locate specific experiment epochs, mask artifacts, and verify the results of signal processing steps, such as filtering or spike detection. Long-term experiments with continuous data acquisition generate large amounts of data. Rapid browsing through these massive datasets poses a challenge to conventional data plotting software because the plotting time increases proportionately to the increase in the volume of data. This paper presents FTSPlot, which is a visualization concept for large-scale time series datasets using techniques from the field of high performance computer graphics, such as hierarchic level of detail and out-of-core data handling. In a preprocessing step, time series data, event, and interval annotations are converted into an optimized data format, which then permits fast, interactive visualization. The preprocessing step has a computational complexity of ; the visualization itself can be done with a complexity of and is therefore independent of the amount of data. A demonstration prototype has been implemented and benchmarks show that the technology is capable of displaying large amounts of time series data, event, and interval annotations lag-free with ms. The current 64-bit implementation theoretically supports datasets with up to bytes, on the x86_64 architecture currently up to bytes are supported, and benchmarks have been conducted with bytes/1 TiB or double precision samples. The presented software is freely available and can be included as a Qt GUI component in future software projects, providing a standard visualization method for long-term electrophysiological experiments.     

Thematic Minireview Series: Molecular Mechanisms of Synaptic Plasticity

The human brain contains ∼86 billion neurons, which are precisely organized in specific brain regions and nuclei. High fidelity synaptic communication between subsets of neurons in specific circuits is required for most human behaviors, and is often disrupted in neuropsychiatric disorders. The presynaptic axon terminals of one neuron release neurotransmitters that activate receptors on multiple postsynaptic neuron targets to induce electrical and chemical responses. Typically, postsynaptic neurons integrate signals from multiple presynaptic neurons at thousands of synaptic inputs to control downstream communication to the next neuron in the circuit. Importantly, the strength (or efficiency) of signal transmission at each synapse can be modulated on time scales ranging up to the lifetime of the organism. This “synaptic plasticity” leads to changes in overall neuronal circuit activity, resulting in behavioral modifications. This series of minireviews will focus on recent advances in our understanding of the molecular and cellular mechanisms that control synaptic plasticity.     

Equidirection: A Measure of Similarity Among Time Series

In the present paper we investigate the concept of equidirection, i.e. similarity in the direction of variation, or parallelism in the broader sense, among m (m ≧ 2) times series, especially under the assumption that the time series are realizations of processes with independent increments. However, the processes need not be stationary. Furthermore, the probabilities for the direction of variation may be unstable, in which case only upper and lower bounds are known. A measure based on the concept of equidirection was developed that enables identification of clusters of similar time series and analysis of relationships among variables.