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BACKGROUND: High concentration oxygen therapy in hypercapnic chronic obstructive pulmonary disease (COPD) is associated with increased mortality. In ward-based patients with acute exacerbation of COPD and hypercapnia, this study examines oxygen prescription and the association between high concentration oxygen therapy and adverse outcome. AIMS: To investigate the association between over-oxygenation and in-hospital adverse events. METHODS: Inpatients with acute exacerbation of hypercapnic COPD at a tertiary Australian hospital over a 1-year period were retrospectively identified. Oxygen prescription and therapy was determined based on chart review. Over-oxygenation was defined as ≥10% of nursing chart observations recording oxygen delivery with oxygen saturation above 92%. A composite adverse outcome was defined as medical emergency team response, recommencement of non-invasive ventilation or death. The association between over-oxygenation and adverse outcome was assessed using survival analysis and conditional logistic regression modelling. RESULTS: The study cohort comprised 106 unique patients and 157 admissions. Oxygen prescription was recorded in 132 (84%) and over-oxygenation occurred in 97 (62%) admissions. Over-oxygenation was higher in non-respiratory ward admissions (76% vs 57%, P = 0.03) and those without any form of oxygen prescription (84% vs 58%, P = 0.01). During follow up, 23 (22%) patients experienced an adverse event. Cox proportional hazards modelling found weak evidence for increased risk of an adverse event in over-oxygenated patients (hazard ratio 2.5; 95% confidence interval 0.8-7.3, P = 0.10). Conditional logistic regression, after matching on age, Charlson comorbidity category and length of follow up, found a similar estimate of association (hazard ratio 2.6; 95% confidence interval 0.8-8.7, P = 0.12). CONCLUSIONS: Over-oxygenation to hypercapnic COPD inpatients is common and rates of oxygen prescription are suboptimal. We found weak evidence of association between over-oxygenation and adverse events, likely due to low statistical power. Larger prospective studies are needed.

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OBJECTIVE: The Periodic fever syndromes (PFS) are a group of disorders of the innate immune system. We investigated patients diagnosed with PFS at the Dartmouth Hitchcock Pediatric Rheumatology Clinic. METHODS: Case acquisition was performed by reviewing ICD 9/10 coded records for familial Mediterranean fever (ICD 9 277.31), laboratory test records for PFS genetic screening, and clinic records between 1/1/2011 and 12/31/2017. RESULTS: Twenty-seven cases had clinical evaluations including PFS genetic screening. Clinical diagnoses included familial Mediterranean fever (FMF) (10 cases), Muckle-Wells (2 cases), tumor necrosis factor receptor associated periodic syndrome (TRAPS) (4 cases), hyper IgD syndrome (HIDS) (1 case), Crohn's Disease (1 case), systemic onset juvenile idiopathic arthritis (SoJIA) (1 case), fever of unknown origin (FUO) (1 case), periodic fever adenitis pharyngitis aphthous ulcer (PFAPA) (6 cases), and cold-induced urticaria (1 case). Fifteen cases were associated with a genetic cause. Seven of the 10 FMF cases were confirmed genetically and were either heterozygous or compound heterozygotes. Both cases of Muckle-Wells had either a compound heterozygote for CIAS 1 or a NOD gene mutation. Both TRAPS cases presented atypically with patients developing systemic lupus erythematosus (SLE) or being asymptomatic. Two patients had novel syndromes. One FMF patient had a TRNT1 gene mutation who responded to intravenous immunoglobulin (IVIg) and colchicine after failing multiple treatments. The other had SoJIA with a LPIN 2 gene mutation but responded to colchicine. Only one of the 15 genetically proven cases had classical presentation and genetics (HIDS secondary to a mevalonate kinase (MVK) gene mutation). CONCLUSION: PFS screening was helpful in over half of the cases to develop therapeutic treatment plans. Given the atypical clinical presentations seen with genetically determined PFS, extensive genetic testing is indicated for all patients presenting with a PFS, excluding classical PFAPA syndrome.

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To facilitate high-quality inpatient care for stroke patients, we built a system within our electronic health record (EHR) to identify stroke patients while they are in the hospital; capture necessary data in the EHR to minimize the burden of manual abstraction for stroke performance measures, decreasing daily time requirement from 2 hours to 15 minutes; generate reports using an automated process; and electronically transmit data to third parties. Provider champions and support from the EHR development team ensured that we balanced the needs of the hospital with those of frontline providers. This work summarizes the development and implementation of our stroke quality system.

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Health information technology (HIT) has great potential for increasing patient engagement. Pediatric hematopoietic cell transplantation (HCT) is a setting ripe for using HIT but in which little research exists. "BMT Roadmap" is a web-based application that integrates patient-specific information and includes several domains: laboratory results, medications, clinical trial details, photos of the healthcare team, trajectory of transplant process, and discharge checklist. BMT Roadmap was provided to 10 caregivers of patients undergoing first-time HCT. Research assistants performed weekly qualitative interviews throughout the patient's hospitalization and at discharge and day 100 to assess the impact of BMT Roadmap. Rigorous thematic analysis revealed 5 recurrent themes: emotional impact of the HCT process itself; critical importance of communication among patients, caregivers, and healthcare providers; ways in which BMT Roadmap was helpful during inpatient setting; suggestions for improving BMT Roadmap; and other strategies for organization and management of complex healthcare needs that could be incorporated into BMT Roadmap. Caregivers found the tool useful and easy to use, leading them to want even greater access to information. BMT Roadmap was feasible, with no disruption to inpatient care. Although this initial study is limited by the small sample size and single-institution experience, these initial findings are encouraging and support further investigation.

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A method for analyzing organoselenium and organic acid metabolites using laser desorption from graphite surfaces coupled to vacuum ultraviolet single photon ionization mass spectrometry (LD/SPI MS) is described. The 1-10-fmol sensitivity and linear dynamic range allows quantitative detection of selenomethionine, trimethylselenonium ion, methylselenogalactosamine, and 1beta-methylseleno-N-acetyl-D-galactosamine in complex biological samples such as human urine. In addition, common urinary metabolites such as tartronic, glutaric, orotic, uric, suberic, and hydroxyhippuric acids, are readily detected. Screening and quantitative detection of these organoselenium and organic acid metabolites is achieved within minutes. The results are also consistent with those obtained using high-performance liquid chromatography tandem mass spectrometry techniques. The study demonstrates the viability of matrix-free LD/SPI MS for molecular characterization and quantitative analysis of biological metabolites in the m/z 10-500 range that are present in complex biological fluids.

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Laser desorption/ionization time-of-flight mass spectra of three thermally labile low molecular weight organoselenium compounds (selenomethionine, selenoethionine, trimethylselenonium iodide) in human urine matrix have been obtained by using surface-assisted laser desorption/ionization mass spectrometry (SALDI-MS). Four active layers, active carbon, silica sol-gel, and silica sol-gel impregnated with crown ether and with active carbon, were deposited on three different support substrates: (i) microscope slide coverslips; (ii) Al foil; and (iii) Cu tapes. Primarily protonated molecular ions and alkali metal adducts were observed in the mass spectra. A mixed-silica sol-gel and active carbon substrate active layer gave the best signal response for all compounds. Sol-gel substrates offered very clean backgrounds compared to the pure active carbon layers; however, the mass spectral signal intensities acquired were substantially lower for the sol-gel surfaces than those of the pure active carbon under the same conditions. Cu tape and Al foil support materials gave strong mass spectra of molecular ions and alkali metal molecular ion adducts, with lower Na and K adducts found with the Cu tape than with Al foil. Glass coverslips gave no response under all experimental conditions examined. Aerosol deposition was used to prepare SALDI substrates to avoid the localized "sweet spot" phenomenon encountered in conventional SALDI substrate preparation. Various nebulizers were examined and found to be effective in producing SALDI films with controlled and reproducible thicknesses. We were able to obtain exact mass identification of all three selenium species by high-resolution TOF-MS. To the best of our knowledge, this is the first time low molecular weight organoselenium compounds have been identified by SALDI-high-resolution TOF-MS.

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