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Biological sulfate (SO42−) reduction was examined in anaerobic sequential batch reactors (ASBRs) operated under different hydraulic retention times (HRTs) ranging from 12 to 36 h and COD (Chemical Oxygen Demand)/SO42−) ratios of 2.4, 1.6 and 0.8. Competition between SO42− reducing bacteria (SRBs), methane producing archaea (MPAs) and homoacetogens (HACs) was examined in controls and cultures treated with linoleic acid (LA). The ASBR performance was influenced by the COD/SO42− ratio in control cultures with a SO42− reduction of 87% at a COD/SO42− ratio of 0.8. At a 12 h HRT, in both control and LA treated cultures, greater than 75% SO42− removal was observed under all the conditions examined. In control reactors operating at a 36 h HRT, high levels of MPAs belonging to Methanobacteriales and Methanosarcinales were detected; however, in comparison, under low COD/SO42− ratio and with decreasing HRT conditions, a relative increase in SRBs belonging to Desulfovibrio and Desulfatibacillum was observed. Adding 0.5 g·L−1 LA suppressed Methanobacteriales, while increasing the LA concentration to 1 g·L−1 completely suppressed MPAs with a relative increase in SRBs. HACs belonging to Bacteroidetes were observed in the control and in cultures operated at 12 h HRT with a COD/SO42− ratio of 1.6 and fed 0.5 g·L−1 LA; however, with all other LA levels (0.5 and 1.0 g·L−1) and HRTs (12, 24 and 36 h), HACs were not detected.

Taguchi statistical design, an orthogonal array (OA) method, was used to study the impact of the COD/SO42− ratio, hydraulic retention time (HRT) and linoleic acid (LA) concentration on sulfate (SO42−) reduction in an anaerobic sequencing batch reactor using glucose as the electron donor. Based on the OA, optimum condition for maximum SO42− reduction was evaluated. Increasing the COD/SO42− ratio and HRT caused decreasing SO42− reduction while increased SO42− reduction was observed with increasing LA concentration (1 g L−1). In control (not fed LA) cultures, higher SO42− reduction (87% ± 3%) was observed at a low COD/SO42− ratio of 0.8. This indicates that increasing SO42− reduction was observed at increasing SO42− loading rates. In general, results from this study reveal that limiting the substrate concentration with high SO42− levels (low COD/SO42− ratio) favors high SO42− removal. Surface plots were used to evaluate the significant interactions between the experimental factors. Accuracy of the model was verified using an analysis of residuals. Optimum conditions for maximum SO42− reduction (97.61%) were observed at a COD/SO42− ratio of 0.8 (level 1), 12 h HRT (level 1) together with 1000 mg L−1 LA addition (level 3). In general, the Taguchi OA provided a useful approach for predicting the percent SO42− reduction in inhibited mixed anaerobic cultures within the factor levels investigated.

Biological sulfate (SO42-) reduction was examined in anaerobic sequential batch reactors (ASBRs) operated under different hydraulic retention times (HRTs) ranging from 12 to 36 h and COD (Chemical Oxygen Demand)/SO42- ratios of 2.4, 1.6 and 0.8. Competition between SO42- reducing bacteria (SRBs), methane producing archaea (MPAs) and homoacetogens (HACs) was examined in controls and cultures treated with linoleic acid (LA). The ASBR performance was influenced by the COD/SO42- ratio in control cultures with a SO42- reduction of 87% at a COD/SO42- ratio of 0.8. At a 12 h HRT, in both control and LA treated cultures, greater than 75% SO42- removal was observed under all the conditions examined. In control reactors operating at a 36 h HRT, high levels of MPAs belonging to Methanobacteriales and Methanosarcinales were detected; however, in comparison, under low COD/SO42- ratio and with decreasing HRT conditions, a relative increase in SRBs belonging to Desulfovibrio and Desulfatibacillum was observed. Adding 0.5 g∙L-1 LA suppressed Methanobacteriales, while increasing the LA concentration to 1 g∙L-1 completely suppressed MPAs with a relative increase in SRBs. HACs belonging to Bacteroidetes were observed in the control and in cultures operated at 12 h HRT with a COD/SO42- ratio of 1.6 and fed 0.5 g∙L-1 LA; however, with all other LA levels (0.5 and 1.0 g∙L-1) and HRTs (12, 24 and 36 h), HACs were not detected. [ABSTRACT FROM AUTHOR]

Taguchi statistical design, an orthogonal array (OA) method, was used to study the impact of the COD/SO4 2– ratio, hydraulic retention time (HRT) and linoleic acid (LA) concentration on sulfate (SO4 2–) reduction in an anaerobic sequencing batch reactor using glucose as the electron donor. Based on the OA, optimum condition for maximum SO4 2– reduction was evaluated. Increasing the COD/SO4 2– ratio and HRT caused decreasing SO4 2– reduction while increased SO4 2– reduction was observed with increasing LA concentration (1 g L-1). In control (not fed LA) cultures, higher SO4 2– reduction (87% ± 3%) was observed at a low COD/SO4 2– ratio of 0.8. This indicates that increasing SO4 2– reduction was observed at increasing SO4 2– loading rates. In general, results from this study reveal that limiting the substrate concentration with high SO4 2– levels (low COD/SO4 2– ratio) favors high SO4 2– removal. Surface plots were used to evaluate the significant interactions between the experimental factors. Accuracy of the model was verified using an analysis of residuals. Optimum conditions for maximum SO4 2– reduction (97.61%) were observed at a COD/SO4 2– ratio of 0.8 (level 1), 12 h HRT (level 1) together with 1000 mg L-1 LA addition (level 3). In general, the Taguchi OA provided a useful approach for predicting the percent SO4 2– reduction in inhibited mixed anaerobic cultures within the factor levels investigated. [ABSTRACT FROM AUTHOR]

Proposes three different error functions for faster convergence of the constant modulus algorithm for blind channel equalization. Uses of blind equalizers; Purpose of showing the signed error versions of the constant modulus algorithm; Assumptions used in the construction of error functions.

Focuses on the wavelet-based coder-decoder (codec) structure defined for baseband waveform coding. Given numerical results for bandwidth efficiency; Comparison between several different wavelets; How the wavelets obey Nyquist pulse shaping condition and provide a unified framework for analog pulse shaping concepts of communication.

Extensive irrigation by the effluents released from a paper mill near Nanjangud have led to the accumulation of heavy metals in the soil and different parts of the paddy crops. In this paper, the physicochemical characteristics of paper mill effluents and the accumulation ofheavy metals (Cu, Zn, Pb, Co, Cd, Cr, and Ni) in the soil and different parts (root, leaf, and seed) of the paddy crops growing in the irrigated area are described and compared with the soil and paddy cropsirrigated by natural waters (unpolluted). Chemical and biological oxygen demands of wastewater were found to be 437 and 1070 ppm respectively, which are beyond the tolerance limits set by Indian standards. The total dissolved and suspended solids are 1754 and 900 ppm respectively. The concentration of heavy metals (except Zn) in the seeds is remarkably less than that in the roots and leaves of the paddy crops.The heavy metal uptake by plants shows the greatest accumulation of Cu, Cr, Co, and Pb in the roots; Cd and Ni in the leaves; and Zn in the seeds of rice. The heavy metal content of the soil and their totaluptake by paddy roots has the relation: Pb>Zn>Cu>Cd and Pb>Cu>Zn>Cd.Survival of paddy crops irrigated by polluted waters indicates tolerance to toxic heavy metals. In conclusion, since in many tropical countries the common diet of people is rice, the accumulation of toxic heavy metals in rice may lead to health disorders. [ABSTRACT FROM AUTHOR]

Aim: Learning communities (LCs) have been identified as a structure to support student wellness as well as create a positive learning environment and have been increasingly adopted in undergraduate medical education (UGME). In 2016, Michigan State University College of Human Medicine made curricular changes which integrated basic, social, and clinical sciences. One of the major strategies adopted to deliver this integrated curriculum was to create LCs that served as a central scaffold for students' academic development. Our primary aim is to describe how the school utilized LC faculty to deliver this core integrated curriculum., Methods: Students were surveyed about their perceptions of the effectiveness of the LCs in delivering an integrated science curriculum. Student academic performance in the new curriculum was compared to that of students from the legacy curriculum as a measure of the effectiveness of the curricular changes., Results: The percentage of students in each class who responded to surveys ranged between 78.7% and 95.8%. Mean Likert responses (1 = strongly disagree; 5 = strongly agree) for statements 'the Faculty Fellow is effective in helping me learn the scholar group content', 'the Faculty Fellow is an effective teacher in our scholar group', and 'the Faculty Fellow is well prepared for our scholar group' ranged from 4.37 to 4.78, 4.72 to 4.76, and 4.81 to 4.86, respectively. In addition, a comparison of summative exam scores of the new curriculum's students to the legacy curriculum's students demonstrated comparable or better performances in the new curriculum., Conclusions: Utilizing LCs to deliver an integrated science curriculum is an underutilized strategy in UGME. Surveys on student satisfaction and academic performance are encouraging. Additional outcome measures are planned to continually evaluate this innovative multifaceted integration.

Background and Aims: The COVID-19 pandemic led to significant infections among healthcare workers and deaths warranting the need for personal protective equipment. This study aimed to estimate the proportion of anaesthesiologists adhering to safety precautions and to evaluate their adherence patterns, difficulties faced and coping mechanisms in the operation theatre during the pandemic., Methods: This was a multicentric mixed methods study conducted among anaesthesiologists from two tertiary care hospitals. A paper-based questionnaire was given to all participants. The first part consisted of 21 questions regarding safety measures and extent of adherence. The second part was a response sheet regarding the various difficulties faced and coping mechanisms adopted. Following this, an in-depth interview was conducted to understand the same. The proportion of anaesthesiologists in different categories of adherence, patterns of adherence, difficulties faced, and coping mechanisms were computed and compared. Thematic framework analysis was done for in-depth interview., Results: Sixty participants were included. The adherence levels for N95 masks and face shields were higher. Most participants practised frequent handwashing and took showers after work. Fogging, difficulty in communication, marks on the face were the commonly faced difficulties. Self reassurance, adjusting the fit of masks/face shields, or taking breaks were the coping mechanisms mostly followed. Themes generated from in-depth interview include waning of caution, adaptation through innovative methods and stress due to uncertainty., Conclusion: The N95 mask was the most preferred safety precaution. Ease of use and safety were important considerations for adherence. Physical and mental acclimatisation and improved knowledge of disease played a vital role., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Journal of Anaesthesia.)

Objectives: This study aimed to determine the association between Helicobacter pylori infection and variceal bleeding as well as rebleeding in cases of cirrhosis with portal hypertension., Methods: This prospective cohort study included patients with bleeding oesophageal varices and was conducted at the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, from August 2016 to July 2018., Results: A total of 190 patients were assessed for eligibility, of which 159 patients were included in this study. Among the 159 patients, 124 (78.0%) had alcohol-related liver disease and eight had hepatitis B virus-related liver disease. Seven patients with varices had bled neither at presentation nor during the follow-up period. A total of 78 (49.1%) patients were H. pylori infected. The primary outcome, which was correlation between prevalence of H. pylori and the incidence of bleeding/rebleeding from varices as well as encephalopathy found that patients with oesophageal varices (adjusted risk [AR] = 0.714) and H. pylori infection (AR = 0.682) had a lower risk of variceal rebleeding. Among H. pylori -negative patients, pepsinogen I was higher in patients with rebleeding (30.7 versus 14.4 ng/mL; P <0.001). The secondary outcome, which was correlation of the site of bleeding with H. pylori infection and the association of the ratio of pepsinogen I/II with bleeding showed that among H. pylori -positive patients, the ratio of pepsinogen I/II was higher in patients with rebleeding (2.9 versus 1.3 ng/mL; P = 0.023)., Conclusion: H. pylori infection was associated with a lower risk of rebleeding in cases of cirrhosis with portal hypertension. Irrespective of the status of the H. pylori infection, rebleeding was associated with increased levels of gastric acid output, as demonstrated by the level of pepsinogen., Competing Interests: CONFLICTS OF INTEREST The authors declare no conflicts of interest., (© Copyright 2022, Sultan Qaboos University Medical Journal, All Rights Reserved.)

Summary: A 49-year-old teacher presented to his general physician with lethargy and lower limb weakness. He had noticed polydipsia, polyuria, and had experienced weight loss, albeit with an increase in central adiposity. He had no concomitant illnesses and took no regular medications. He had hypercalcaemia (adjusted calcium: 3.34 mmol/L) with hyperparathyroidism (parathyroid hormone: 356 ng/L) and hypokalaemia (K: 2.7 mmol/L) and was admitted for i.v. potassium replacement. A contrast-enhanced CT chest/abdomen/pelvis scan revealed a well-encapsulated anterior mediastinal mass measuring 17 × 11 cm with central necrosis, compressing rather than invading adjacent structures. A neck ultrasound revealed a 2 cm right inferior parathyroid lesion. On review of CT imaging, the adrenals appeared normal, but a pancreatic lesion was noted adjacent to the uncinate process. His serum cortisol was 2612 nmol/L, and adrenocorticotrophic hormone was elevated at 67 ng/L, followed by inadequate cortisol suppression to 575 nmol/L from an overnight dexamethasone suppression test. His pituitary MRI was normal, with unremarkable remaining anterior pituitary biochemistry. His admission was further complicated by increased urine output to 10 L/24 h and despite three precipitating factors for the development of diabetes insipidus including hypercalcaemia, hypokalaemia, and hypercortisolaemia, due to academic interest, a water deprivation test was conducted. An 18flurodeoxyglucose-PET (FDG-PET) scan demonstrated high avidity of the mediastinal mass with additionally active bilateral superior mediastinal nodes. The pancreatic lesion was not FDG avid. On 68Ga DOTATE-PET scan, the mediastinal mass was moderately avid, and the 32 mm pancreatic uncinate process mass showed significant uptake. Genetic testing confirmed multiple endocrine neoplasia type 1., Learning Points: In young patients presenting with primary hyperparathyroidism, clinicians should be alerted to the possibility of other underlying endocrinopathies. In patients with multiple endocrine neoplasia type 1 (MEN-1) and ectopic adrenocorticotrophic hormone syndrome (EAS), clinicians should be alerted to the possibility of this originating from a neoplasm above or below the diaphragm. Although relatively rare compared with sporadic cases, thymic carcinoids secondary to MEN-1 may also be associated with EAS. Electrolyte derangement, in particular hypokalaemia and hypercalcaemia, can precipitate mild nephrogenic diabetes insipidus.

In the present study, a machine learning (ML) model was developed to predict the epistatic phenomena of combination mutants to improve the anticancer antibody-drug trastuzumab's binding affinity towards its antigen human epidermal growth factor receptor 2 (HER2). An ML algorithm, Support Vector Regression (SVR) was used to develop ML models with a data set consists of 193 affinity values of single mutants of trastuzumab and its associated various amino acid sequence derived descriptors. The subset selection of descriptors and SVR hyperparameters were done using the Genetic Algorithm (GA) within the SVR and the wrapper approach called GA-SVR. A 100 evolutionary cycles of GA produced the best 100 probable GA-SVR models based on their fitness score   ( Q 2 ) estimated using a stratified 5 fold cross-validation procedure. The final ML model found to be highly predictive of test data set of six combination mutants and one single mutant with R pre 2 = 0.71. The analysis of descriptors in the ML model highlighted the importance of mutant induced secondary structural variation causes the binding affinity variation of the trastuzumab. The same was verified using a short 20 ns and a long 100 ns in duplicate molecular dynamics simulation of a wild and mutant variant of trastuzumab. The secondary structure induced affinity change due to mutations in the CDR-H3 is a novel insight that came out of this study. That should help rational mutant selection to develop a biobetter trastuzumab with a multifold improved binding affinity into the market quickly.Communicated by Ramaswamy H. Sarma.

Background: Implant supported crowns can either be screw retained or cement retained. Recent advances in implant dentistry has improved the longevity of the implant restoration and has placed importance on esthetics and function. Cement retained restoration has added advantage of superior esthetics and is preferred by the clinician. However, selecting the ideal type of cement for luting implant supported crown has been a topic of debate., Methodology: A study was conducted at ESIC Dental College & Hospital, Kalaburagi to determine the retentive ability of three different luting agents. 30 samples were divided into three groups and luted with Zinc phosphate, Zinc Polycarboxylate and Glass ionomer cement. The retentive strength was evaluated using universal testing machine., Results: Results proved that zinc poly carboxylate cement had the highest retentive value followed by glass ionomer and zinc phosphate., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Pharmacy and Bioallied Sciences.)

Endometriosis is a benign estrogen-dependent disorder affecting women in their reproductive age group. Endometriosis means 'abnormal growth of endometrial glands' outside the uterus. Multiple theories on aetiopathogenesis of endometriosis have been postulated, Halban's theory on 'Benign Metastasis' which proposed the presence of endometriotic cells in lymphatic vessels and lymph nodes provides the basis of this case report. Here, we report a case of 26-year-old nulliparous woman who presented with grossly elevated CA 125 with endometriosis in her para-aortic nodes mimicking as ovarian cancer., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Poor health care-seeking behaviour, access to services and availability of service delivery have implications for the health of the community. This study explored the perceptions, practices and challenges related to maternal and neonatal care in the teagarden community in Bangladesh. The study also identified service gaps and problems prevalent in teagarden health facilities. A qualitative study was conducted in five teagardens in the Moulvibazar district of Bangladesh. Six focus group discussions (FGDs) were completed with individuals from the teagarden community, and twelve in-depth interviews (IDIs) were performed with health facility staff working in those teagarden facilities. Misconceptions and harmful traditional practices were found to exist among the families in the teagardens, restricting them from accessing quality health care. Pregnant women are not aware of antenatal care, and deliveries are being conducted at home by untrained birth attendants. Unhygienic and harmful postnatal practices are used. Teagarden health facilities are not well equipped or prepared to provide good care. Inequities exist within the teagarden communities, with unregistered workers having even poorer access to care. Improvement of the quality of maternal health care for this marginalised community is needed to progress maternal health.

An increasing number of medical schools are implementing curricular changes that better integrate clinical and basic sciences throughout all four years of medical school. One of the most frequently cited reasons is to improve medical student clinical reasoning skills while simultaneously aiming to decrease the attrition of basic science knowledge. Multiple pedagogical strategies have been explored to achieve this goal. We have found that simulation is a viable medium to integrate basic science within standardized patient encounters for early medical students., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© International Association of Medical Science Educators 2020.)

Postpartum depression (PPD) is one of the most common and severe postpartum morbidity, affecting 10%-20% of mothers within the first year of childbirth. The adverse effects of PPD, namely, prevention of mother-baby bonding and early cessation of breastfeeding, adversely affects infant growth and brain development. Studies have found that up to 50% of women with PPD go undiagnosed. Despite the American Academy of Pediatrics (AAP) recommendations, only a small percentage of paediatricians are currently screening for PPD. This project aimed to improve PPD screening using a validated tool to 75% in a primary care inner-city clinic serving a predominantly underserved population as per AAP recommendations. Baseline data for 40 charts of 2-month-old and 4-month-old well-child visits showed no documentation of PPD screening. The screening tool used for this project was the Edinburgh Postpartum Depression Scale (EPDS), which is a validated 10-item screening questionnaire for PPD. Three Plan-Do-Study-Act (PDSA) cycles were implemented involving educational strategies, system-based practice improvement and stakeholder participation. Improvement seen after PDSA cycle 1 was minimal. At the end of cycle 2, 16/50 (33%) charts had documentation of screening using EPDS. At the end of cycle 3, 33/40 (82%) charts had EPDS documentation, an increase of 49% from cycle 2. There were eight in total positive PPD screenings between cycles 2 and 3. These patients were provided counselling support through a social worker and referral services through the local community mental health organisation. We achieved more than our 75% target goal for PPD screening implementation at the residency clinic, thereby increasing residents' awareness of PPD and the importance of PPD screening. Poststudy follow-up shows that screening was maintained at a higher rate but never reached 100%., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The aim of this study was to compare the effects of dexmedetomidine, esmolol, and combination of both on control of sympathetic response to laryngoscopy and tracheal intubation in coronary artery disease patients., Material and Methods: A prospective, randomized, double-blinded clinical study included 90 patients scheduled for elective coronary artery bypass surgery. Patients were randomly allocated into three groups of 30 each: dexmedetomidine group (Group D) 1 μg/kg, esmolol group (Group E) 2 mg/kg, and group dexmedetomidine with esmolol (Group DE) 0.5 μg/kg of dexmedetomidine with 1 mg/kg of esmolol. Each drug was diluted with 0.9% normal saline to 20 ml volume and infused in 10 min before induction of anesthesia. Hemodynamic changes (heart rate [HR], arterial blood pressure, and pulmonary artery pressure) were compared at various time intervals as follows-baseline, after study drug, after induction, and 1, 3, and 5 min after intubation. Statistical analysis included analysis of variance, Chi-square, and Fisher's exact test., Results: In Group DE, there was no significant increase in HR at all-time intervals, and the HR was stable compared to Group D and Group E. Blood pressure values were comparable in all groups except in Group E at 5 min. The pulmonary arterial pressures were statistically less in DE group except at 3 and 5 min., Conclusions: The combination of dexmedetomidine and esmolol group has beneficial effect on HR and pulmonary arterial pressures but has no additional advantage with respect to arterial blood pressure when compared with dexmedetomidine and esmolol groups in patients undergoing elective coronary artery bypass grafting.

Dental caries affect 97% of people during their lifetime. A total of 59% of children aged 12-19 will have at least one documented cavity. The American Academy of Pediatrics recommends fluoridated toothpaste to all children starting at tooth eruption, regardless of caries risk. Besides, fluoride varnish is recommended for all children every 3-6 months from tooth emergence until they have a permanent dental home. This project aimed to increase oral fluoride varnish application for children starting at 6 months or the time of tooth eruption up to 3 years of age by at least 50% over 18 months. The stakeholders identified were physicians, nurses, medical assistants and the health information team. We obtained baseline data about oral health screening and fluoride varnish from both the clinic sites. The quality improvement (QI) project was based on Plan-Do-Study-Act (PDSA) cycles with a 6-month gap in-between the three cycles. For the first cycle, all medical staff members participated in 2-hour knowledge and skills training on dental caries and current recommendations on fluoride varnish. PDSA cycle 2 involved having automatic reminders for providers in electronic medical records. PDSA cycle 3 planned to have automatic fluoride orders for the recommended age groups. The QI team analysed the results after every 6 months, and improvements were made based on the input from data and medical staff. The number of patients who had fluoride varnish applied increased from 14% (n=50) to 55% at the end of PDSA cycle 3. Administration of the varnish did not affect the flow of the patients in busy primary care practice. The rate of improvement was across all the age groups, providers and in both clinical sites. It is possible to adhere to the oral fluoride varnish guidelines in a busy primary care practice, which may help benefit young children who are at risk for caries., Competing Interests: Competing interests: None declared.

Background and Aims: Propofol (2, 6-di-isopropylphenol) used for the induction of anaesthesia often causes mild to severe pain or discomfort on injection. We designed this double-blind study to compare the efficacy of methylprednisolone and lignocaine in reducing the pain of propofol injection in patients scheduled for cardiac surgery., Methods: A total of 165 adult patients, scheduled for elective cardiac surgery, were divided into three groups: saline (group S, n = 55), lignocaine 20 mg (Group L, n = 55) and methylprednisolone 125 mg diluted into 2 ml of distilled water (Group MP, n = 55). Drugs were administered after tourniquet application and occlusion was released after 1 min and 1/4 th of the total dose of propofol (2 mg/kg) was administered at the rate of 0.5 ml/s. Pain on propofol injection was evaluated by four-point verbal rating scale. Statistical methods used included Student's t -test and Chi-square test/Fisher's exact test., Results: The overall incidence of pain was 70.9% in the saline group, 30.9% in the lignocaine group and 36.4% in the methylprednisolone group. The intensity of pain was significantly less in patients receiving methylprednisolone and lignocaine than those receiving saline ( P < 0.012)., Conclusion: Pre-treatment with intravenous methylprednisolone was found to be as effective as lignocaine in reducing propofol injection-induced pain., Competing Interests: There are no conflicts of interest.

Asthma is the most commonly encountered chronic disease in children. Periodic assessment of asthma severity and control is an integral part of asthma management, but patients with uncontrolled asthma don't always schedule routine asthma care visits. The aim of this project was to improve asthma control and severity screening in a primary care setting by using a validated tool for all visits for patients with a diagnosis of asthma aged 4-21 years. Our QI team developed a protocol to administer the Asthma Control Test (TM), a validated questionnaire to assess asthma control. The stakeholders involved were the physicians, nursing staff, and the Health Information Team (HIT). All patients who had a prior diagnosis of asthma or with an asthma medication in their chart, who presented for any clinical visit including asthma were administered ACT. The staff scored the ACT and included the form in the encounter sheet so that the physicians can review the scores, address the asthma control, severity, and document in the chart. The number of patients whose asthma control was assessed improved from 10% per year to 85% after the three PDSA cycles. Administration of the tool did not impact the flow of the patients in a busy primary care practice. Screening asthma severity and control for patients diagnosed with asthma with a validated questionnaire when presenting for any chief complaint including asthma will help the provider address the severity and control of asthma symptoms in a timely manner and would potentially help prevent unwanted emergency department or urgent care usage.

Reach out and Read program (ROR) prepares young children to succeed in school by partnering with physicians and training them in handing out age appropriate books and to counsel parents about the importance of reading aloud to their children. Children served by ROR enter kindergarten with stronger vocabulary and language skills. The aim of this project was to improve the rate of distribution of books and physician advice about reading, to the families at each well child visit in the age range of six months to five years. This Quality Improvement (QI) project was conducted in a large inner-city pediatric residency clinic serving a lower socio-economic status under-served population. After reviewing the data from the past two years, we noticed that there was a tremendous drop in the percentage of books handed out at well visits and advice given to parents about benefits of reading aloud and self-reporting of parents reading to their child for four or more days in a week. Two goals were established: 1. To increase the rate of distributing books at every well child visit (WCV) from six months to five years of age by at least 80%. 2. To improve the rate of counseling given by the resident physicians to the families by at least 75%. A workflow was created to efficiently distribute books at well visits. A presentation about the ROR program was attended by all the physicians and residents. Reading tips in each exam room were posted to serve as a reminder for all providers and for the parents. A three question survey was collected from the families at the end of their well visit. A total of 210 surveys were collected from parents over a six month period. The percentage of handing out books at all well child visits increased from 30% to 96%. The rate of providers giving advice about the benefits of reading increased from 26% to 87%. The percentage of parents reading to their child greater than four days per week increased from 56% to 80%. Reading aloud is widely recognized as the single most important activity leading to literacy acquisition. With the above interventions, families participating in the ROR model at our clinic were more likely to read to their children, more likely to report reading aloud at bedtime, and to read aloud four or more days per week.

The pediatric clinics of the Michigan State University College of Human Medicine (MSU-CHM) consist of academic pediatricians serving two clinics with a patient population of 5200. The internal quality measures published by the MSU health team had consistently indicated our generic medications prescription rate to be very low, with an average of about 21% for the years 2009, 2010, and 2011. There was an earnest need to increase our generic medication prescription rates, which is considered an indicator of good practice. The stakeholders identified were physicians, nurses, care managers, and the health information technology (HIT) team. The purpose of the project was to increase the prescribing rate of viable low cost and approved generic medications for the patients of the MSU-CHM general pediatric clinics. The stakeholders regularly met every few months to work on increasing the generic medication prescription rates based on the PDSA cycle. Help was sought from HIT to identify and acquire the top 10 brand names the group was prescribing along with individual provider data. The team reviewed the brand names most prescribed, and made a recommendation that the best group to target were the stimulant medications, allergy and asthma medications, and other psychotropics. The HIT team was then requested to add the available generics for all stimulant medications, asthma medications, and others in the electronic medical record (EMR). They were also clearly marked for ease of use, for example: amphetamine-dextroamphetamine extended release "generic for Adderall XR." It was decided that providers would prescribe all stimulants as a generic, unless not available, and nurses would change each brand name of stimulants to a generic every time they refilled a medicine, based on a protocol outlining the appropriate generic medications corresponding to the respective brand names. The physicians and nurses were also urged to discuss with the patients the substitution process and answer any questions from parents. Monthly reports were obtained from the HIT about our progress. After 12 months of implementing this project, the overall generic prescription rate increased from 20% at the end of first quarter 2012 to 53% at the end of 12 months, and 65.5% at the end of two years. This was well above the MSU health team (about six large group practices) primary care average of 34.6%. All brand name medication prescription rates were also decreased. This is a positive outcome for this project in a relatively short period of time, and a further plan will be to repeat the cycle and continue to improve on the generic prescription rate, thereby saving valuable dollars spent on health care.

Adolescent depression, has been identified as one of the important risk factors for adolescent safety. The American Academy of Pediatrics (AAP) recommends screening the adolescent population for depression with a validated screening tool at least once a year. Given the time constraints in primary care, many physicians tend to rely more on clinical questioning to screen depression.This has the potential to miss many adolescents who may have mild to moderate depression which may prove detrimental to their emotional and physical health. Quality measures had consistently indicated that the validated adolescent depression screening rate in our two pediatric clinics was 10-15% in the past two years starting from 2012. There was a need to increase our screening rate for adolescent depression with a validated questionnaire. The stakeholders identified were physicians, nurses and the health information team (HIT). The Patient Health Questionnaire-2 (PHQ-2) is a standardized tool and serves as a good first step rapid screening of the population. A decision was made to implement the use of PHQ-2 to all the adolescents aged 11-21. A clinic flow protocol was developed. As the patient checks in, there will be a computer pop-up reminding nurses to administer the PHQ-2. The PHQ-2 self-scores in the Electronic Health Record (EHR) and if the score is three or more the nurses would automatically administer the PHQ-9 which is also embedded and self-scored in the EHR. After 12 months of implementing this project with four PDSA cycles, the adolescent depression-screening rate improved from 10-15% from the previous two years to 65% (six month period) and 82% at the end of the 12 month period. The rate of referral to mental health services had also increased in the same time period compared to the previous years. In conclusion, screening for adolescent depression with a brief validated tool in a busy primary care office is possible with the help of the EHR.

Objectives: The purpose of this study was to determine analgesic efficacy of dexmedetomidine used as a continuous infusion without loading dose in postcardiac surgery patients., Settings and Design: A prospective, randomized, double-blind clinical study in a single tertiary care hospital on patients posted for elective cardiac surgery under cardiopulmonary bypass., Interventions: Sixty-four patients who underwent elective cardiac surgery under general anesthesia were shifted to intensive care unit (ICU) and randomly divided into two groups. Group A (n = 32) received a 12 h infusion of normal saline and group B (n = 32) received a 12 h infusion of dexmedetomidine 0.4 μg/kg/h. Postoperative pain was managed with bolus intravenous fentanyl. Total fentanyl consumption, hemodynamic monitoring, Visual Analogue Scale (VAS) pain ratings, Ramsay Sedation Scale were charted every 6(th) hourly for 24 h postoperatively and followed-up till recovery from ICU. Student's t-test, Chi-square/Fisher's exact test has been used to find the significance of study parameters between the groups., Results: Dexmedetomidine treated patients had significantly less VAS score at each level (P < 0.001). Total fentanyl consumption in dexmedetomidine group was 128.13 ± 35.78 μg versus 201.56 ± 36.99 μg in saline group (P < 0.001). A statistically significant but clinically unimportant sedation was noted at 6 and 12 h (P < 0.001, and P = 0.046 respectively). Incidence of delirium was less in dexmedetomidine group (P = 0.086+). Hemodynamic parameters were statistically insignificant., Conclusions: Dexmedetomidine infusion even without loading dose provides safe, effective adjunct analgesia, reduces narcotic consumption, and showed a reduced trend of delirium incidence without undesirable hemodynamic effects in the cardiac surgery patients.

Background: Propofol causes a high incidence of pain during intravenous (IV) injection. The aim of this randomized, placebo-controlled, double-blinded study was to determine whether pre-treatment with IV ramosetron, used for prophylaxis of postoperative nausea and vomiting (PONV), would reduce propofol-induced pain as an equivalent to lidocaine., Materials and Methods: Hundred and twenty American Society of Anesthesiologists grade (ASA) I and II patients were randomly assigned into three groups (40 in each). Group N received 2 ml of 0.9% saline, Group L received 2 ml of lidocaine, and Group R received 2 ml of ramosetron. Mid forearm was occluded manually before injection and released after 1 min and then propofol was injected over 5 s. Patients were observed and questioned 15 s later if they had pain in the arm and pain was scored on a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain. Unpaired Student's t-test and chi-square test/Fisher' exact test were used to analyze results., Results: The incidence of pain in groups N, L, and R were 65, 35, and 30%, respectively. Pain was reduced significantly in the groups L and R (P < 0.05). Two patients each in Groups L and R (5% each) had moderate and severe pain. This difference in pain was statistically insignificant, but when compared to Group N (25 and 30%, respectively) it was statistically significant., Conclusion: Pretreatment with ramosetron 0.3 mg and lidocaine 40 mg are equally effective in preventing pain from propofol injection.