Accelerating health system innovation: principles and practices from the Duke Institute for Health Innovation.

The Duke Institute for Health Innovation (DIHI) was launched in 2013. Frontline staff members submit proposals for innovation projects that align with strategic priorities set by organizational leadership. Funded projects receive operational and technical support from institute staff members and a transdisciplinary network of collaborators to develop and implement solutions as part of routine clinical care, ranging from machine learning algorithms to mobile applications.

Associations between body condition, rumen fill, diarrhoea and lameness and ruminal acidosis in Australian dairy herds.

Aims: To investigate associations between ruminal acidosis and body condition score (BCS), prevalence of poor rumen fill, diarrhoea and lameness in dairy cows in New South Wales and Victoria, Australia.

Methods: This was a cross-sectional study conducted in 100 dairy herds in five regions of Australia. Feeding practices, diets and management practices of herds were assessed.

Validation of an LC-MS/MS assay for detecting relevant disaccharides from keratan sulfate as a biomarker for Morquio A syndrome.

Background: Mucopolysaccharidosis IVA (MPS IVA, Morquio A syndrome) is an inherited lysosomal storage disease caused by deficiency of N-acetylgalactosamine-6-sulfatase (GALNS), an enzyme required for stepwise degradation of keratan sulfate (KS). We have developed a selective, sensitive, accurate and precise LC-MS/MS assay for the KS-derived disaccharides Galβ1-4GlcNAc(6S) and Gal(6S)β1-4GlcNAc(6S) in human urine and plasma using keratanase II digestion.

Results: Mean accuracy was 96-106% in urine and 97-108% in plasma.

Training the next generation of physician-executives: an innovative residency pathway in management and leadership.

The rapidly changing field of medicine demands that future physician-leaders excel not only in clinical medicine but also in the management of complex health care enterprises. However, many physicians have become leaders "by accident," and the active cultivation of future leaders is required. Addressing this need will require multiple approaches, targeting trainees at various stages of their careers, such as degree-granting programs, residency and fellowship training, and career and leadership development programs.

Carryover effects of potassium supplementation on calcium homeostasis in dairy cows at parturition.

The purpose of this study was to test whether supplementation with K improves bone mineral density (BMD) in older cows so that by parturition their bone is better able to mobilize Ca. Twenty-four Holstein Friesian cows (6 mo pregnant, lactating, and in their third or later lactation) were allocated to 2 equal groups and individually fed twice daily a total diet comprising low K oaten hay plus a pelleted concentrate fortified with or without K(2)CO(3) to achieve 3.12% K/kg of DM in the total diet of the K-supplemented (KS) cows compared with 1.

Effect of diet, energy balance and milk production on oxidative stress in early-lactating dairy cows grazing pasture.

The aim of this study was to determine the effect of diet, energy balance and milk production on oxidative stress in early-lactating, Holstein-Friesian dairy cows fed to produce either low or high levels of milk. Indicators of energy balance (non-esterified fatty acids, β-hydroxybutyrate, glucose and insulin-like growth factor-1) and indicators of oxidative stress (reactive oxygen metabolites and biological antioxidants) were measured in the first 5 weeks of lactation. Energy balance indicators showed that high producing animals had a lower degree of negative energy balance.

Energy balance and reproduction on dairy cows fed to achieve low or high milk production on a pasture-based system.

This study investigated the energy balance, metabolic changes, reproduction, and health in Australian Holstein-Friesian cows of average genetic merit fed to produce 6,000 L of milk/cow per lactation (restricted production; Rp) on a predominantly grazed pasture diet, or 9,000 L of milk/cow per lactation (high production: Hp) on a more intensive feeding regimen by using a partial mixed ration to supplement pasture. The mean 4% fat-corrected milk (FCM) and standard deviation achieved was 8,466 +/- 1,162 L/cow per lactation for the Hp herd and 6,748 +/- 787 L/cow per lactation for the Rp herd. During early lactation, the degree of estimated negative energy balance was less in the Hp cows than in the Rp cows (-16.

Premilking teat preparation for Australian pasture-based cows milked by an automated milking system.

Economic viability of automatic milking systems (AMS) within an Australian pasture-based farming system will be largely determined by the throughput (cows milked/h), which is the result of processes occurring while the cow is in the AMS milking crate. Premilking udder preparation is automated and optional on all AMS. Yet, very few conventional farms in Australia conduct premilking teat preparation regimens, with the majority (78%) strategically washing only visibly dirty teats before milking cup attachment.

Holstein-Friesian dairy cows under a predominantly grazing system: interaction between genotype and environment.

A 5 yr whole-system study, beginning in June 1994, compared the productivity of high [HGM; Australian Breeding Value (ABV) of 49.1 kg of fat plus protein] and low [LGM; ABV of 2.3 kg of fat plus protein] genetic merit cows.

The definition of acidosis in dairy herds predominantly fed on pasture and concentrates.

This cross-sectional survey examined the prevalence of ruminal acidosis and the effects of acidosis on the production of dairy cattle. Eight fresh cows, 3 primiparous and 5 multiparous (< 100 d in milk), were selected randomly from each of 100 dairy herds in 5 regions of Australia. Rumen fluid was obtained from each cow by rumenocentesis and a stomach tube, and samples were tested for pH.

Optimal choice of dairy forages in eastern Australia.

Although several forage species such as perennial ryegrass are predominant, there is a wide range of forage species that could be grown in subtropical and temperate regions in Australia as dairy pastures. These species have differing seasonal patterns of growth, nutrient quality, and water-use efficiency, as demonstrated in a large experiment evaluating over 30 species at the University of Sydney (Camden, New South Wales, Australia). Some species can be grazed, whereas others require mechanical harvesting, which incurs a further cost.

Should an academic radiation oncologist be allowed to "opt out" of medicare?

Federal law permits physicians to "opt out" of Medicare. When a radiation oncologist chooses this option, he or she may neither bill nor collect from Medicare, but may legally attempt to charge and collect what he or she considers the value of services provided to Medicare-eligible patients. Many academic faculty practice plans permit members to opt out.

Clinical acidosis in a Gippsland dairy herd.

Objective: To report on spontaneous clinical and subclinical acidosis in a large dairy herd, to evaluate the diets and feeding strategies involved, and to report on measures of rumen function in the cows affected.

Design: A Gippsland dairy herd was sampled as part of a wider randomised cross-sectional study that examined the prevalence, risk factors for, and effects of, acidosis on rumen function of dairy cattle. Three herds on the farm were involved in the study: the transition herd (cows 3 weeks prior to calving), the very fresh lactating herd (1 < days in milk < 10, herd 1) and the fresh lactating herd (10 < days in milk < 120, herd 2) including a small lame herd fed separately.

Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome.

Purpose: Many patients with acute respiratory failure die despite prolonged and costly treatment. Our objective was to estimate the cost-effectiveness of providing rather than withholding mechanical ventilation and intensive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome.

Subjects And Methods: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT]) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or =10) who required ventilator support.

Changing pattern of organ dysfunction in early human sepsis is related to mortality.

Objective: We examined the pattern of organ system dysfunction, the evolution of this pattern over time, and the relationship of these features to mortality in patients who had sepsis syndrome.

Design: Prospective, multicenter, observational study.

Setting: Intensive care units in tertiary referral teaching hospitals.

Effect of genetic merit and concentrate feeding on reproduction of grazing dairy cows in a subtropical environment.

This study was conducted to determine the effects of genetic merit for milk production and concentrate feeding on the intervals to the onset of postpartum cyclic ovarian activity, first insemination, and establishment of pregnancy. Other factors considered included biochemical measures of energy balance, liveweight, and measures of production. A farmlet study was conducted with two lines of cattle that differed in Australian Breeding Value by 735 L milk and 47 kg of fat plus protein that were fed 300 or 2000 kg of concentrate per cow per year in a subtropical grazing system based on ryegrass, clover, and kikuyu pasture.

Effects of ibuprofen on the physiology and survival of hypothermic sepsis. Ibuprofen in Sepsis Study Group.

Objectives: The objective was to compare the clinical and physiologic characteristics of febrile septic patients with hypothermic septic patients; and to examine plasma levels of cytokines tumor necrosis factor alpha (TNF-alpha and interleukin 6 (IL-6) and the lipid mediators thromboxane B2 (TxB2) and prostacyclin in hypothermic septic patients in comparison with febrile patients. Most importantly, we wanted to report the effect of ibuprofen treatment on vital signs, organ failure, and mortality in hypothermic sepsis.

Setting: The study was performed in the intensive care units (ICUs) of seven clinical centers in the United States and Canada.

Performance of an algorithm to detect Pneumocystis carinii pneumonia in symptomatic HIV-infected persons. Pulmonary Complications of HIV Infection Study Group.

Study Objectives: To determine whether an algorithm consisting of a chest radiograph and the diffusing capacity of the lung for carbon monoxide (D(LCO)) is effective in detecting Pneumocystis carinii pneumonia (PCP) in symptomatic HIV-infected persons; and to establish a benchmark for future comparisons of alternative algorithms.

Design: Prospective, 64-month study.

Setting: Multicenter, ambulatory care.

Patient empowerment and feedback did not decrease pain in seriously ill hospitalized adults.

We tested a nurse clinician-mediated intervention to relieve pain in a group of seriously ill hospitalized adults using a randomized controlled trial at five tertiary care academic centers in the US. The study included 4804 patients admitted between January 1992 and January 1994 with one or more of nine high mortality diagnoses; 2652 were allocated to the intervention and 2152 to usual care. Specially-trained nurse clinicians assessed patients' pain, educated them and their families about pain control, empowered patients to expect pain relief, informed patients' nurses and physicians about level of pain and suggested or used other pain management resources.

Relationship of body mass index to subsequent mortality among seriously ill hospitalized patients. SUPPORT Investigators. The Study to Understand Prognoses and Preferences for Outcome and Risks of Treatments.

Objective: To determine if body mass Index (BMI = weight [kg]/height [m]2), predictive of mortality in longitudinal epidemiologic studies, was also predictive of mortality in a sample of seriously ill hospitalized subjects.

Design: Prospective, multicenter study.

Setting: Five tertiary care medical centers in the United States.

A prognostic model for patients with end-stage liver disease.

Background & Aims: Survival of patients with end-stage liver disease is variable and difficult to predict. A two-phase prospective cohort study was conducted at five teaching hospitals to develop and evaluate a model for prediction of death.

Methods: Five hundred thirty-eight hospitalized patients with a history of chronic liver disease and two or more signs of decompensation were studied.

Right heart catheterization in acute respiratory failure.

Objective: To review the literature addressing the use of the pulmonary artery catheter (PAC) in patients with respiratory failure.

Data Source: All pertinent English language articles dealing with pulmonary artery catheterization in patients with respiratory failure were retrieved from 1983 through 1996.

Study Selection: Articles were chosen for review if the use of pulmonary artery catheterization in patients with respiratory failure was studied or reviewed.

Outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care in seriously ill hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

Background: Renal failure requiring dialysis in the setting of hospitalization for serious illness is a poor prognostic sign, and dialysis and aggressive care are sometimes withheld.

Objective: To evaluate the clinical outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care for seriously ill hospitalized patients.

Design: Prospective cohort study and cost-effectiveness analysis.

Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

Objective: To evaluate whether the lack of effect of advance directives (ADs) on decision-making in SUPPORT might arise, in part, from the content of the actual documents.

Design: Advance directives placed in the medical records were abstracted for date of completion and content of additional written instructions. We examined directives with instructions to forgo life-sustaining treatment in the current state of health to determine whether care given was consistent with preferences noted in those directives.

Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

Objective: To assess the effectiveness of written advance directives (ADs) in the care of seriously ill, hospitalized patients. In particular, to conduct an assessment after ADs were promoted by the Patient Self-Determination Act (PSDA) and enhanced by the effort to improve decision-making in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), focusing upon the impact of ADs on decision-making about resuscitation.

Design: Observational cohort study conducted for 2 years before (PRE) and for 2 years after (POST) the PSDA, with a randomized, controlled trial of an additional intervention to improve decision-making after PSDA (POST+SUPPORT).