Effect of Best Practice Alert (BPA) on Post-Discharge Opioid Prescribing After Minimally Invasive Hysterectomy: A Quality Improvement Study.

Purpose: The aim of this study was to describe the effectiveness of an electronic health record best practice alert (BPA) in decreasing gynecologic post-discharge opioid prescribing following benign minimally invasive hysterectomy.

Patients And Methods: The BPA triggered for opioid orders >15 tablets. Prescribers' options included (1) decrease to 15 ≤ tablets; (2) remove the order/utilize a defaulted order set; or (3) override the alert.

A neural mechanism for learning from delayed postingestive feedback.

Animals learn the value of foods based on their postingestive effects and thereby develop aversions to foods that are toxic and preferences to those that are nutritious. However, it remains unclear how the brain is able to assign credit to flavors experienced during a meal with postingestive feedback signals that can arise after a substantial delay. Here, we reveal an unexpected role for postingestive reactivation of neural flavor representations in this temporal credit assignment process.

A neural substrate of sex-dependent modulation of motivation.

While there is emerging evidence of sex differences in decision-making behavior, the neural substrates that underlie such differences remain largely unknown. Here we demonstrate that in mice performing a value-based decision-making task, while choices are similar between the sexes, motivation to engage in the task is modulated by action value more strongly in females than in males. Inhibition of activity in anterior cingulate cortex (ACC) neurons that project to the dorsomedial striatum (DMS) preferentially disrupts this relationship between value and motivation in females, without affecting choice in either sex.

Neuroscience: Secretin excites the thirst circuit.

Peptides secreted by internal organs and by neurons in the brain are major regulators of eating and drinking. New work shows that the peptide hormone secretin influences drinking by adjusting the excitability of neurons in the brain's thirst circuit.

Opponent control of behavior by dorsomedial striatal pathways depends on task demands and internal state.

A classic view of the striatum holds that activity in direct and indirect pathways oppositely modulates motor output. Whether this involves direct control of movement, or reflects a cognitive process underlying movement, remains unresolved. Here we find that strong, opponent control of behavior by the two pathways of the dorsomedial striatum depends on the cognitive requirements of a task.

Duration of postictal impaired awareness after bilateral tonic-clonic seizures: EEG and patient characteristics.

Objective: Ictal and postictal phenomena that may impact the duration of postictal impaired awareness have not been well studied. Postictal unresponsiveness invariably occurs following bilateral tonic-clonic seizures (BTCS). Bilateral tonic-clonic seizures are a major risk factor for sudden unexpected death in epilepsy (SUDEP).

Effect of Replacing Vendor QTc Alerts with a Custom QTc Risk Alert in Inpatients.

Objective: The aim of the study is to implement a customized QTc interval clinical decision support (CDS) alert strategy in our electronic health record for hospitalized patients and aimed at providers with the following objectives: minimize QTc prolongation, minimize exposure to QTc prolonging medications, and decrease overall QTc-related alerts. A strategy that was based on the validated QTc risk scoring tool and replacing medication knowledge vendor alerts with custom QTc prolongation alerts was implemented.

Methods: This is a retrospective quasi-experimental study with a pre-intervention period (August 2019 to October 2019) and post-intervention period (December 2019 to February 2020).

Incorporating preauthorization into antimicrobial stewardship pharmacist workflow reduces and gastrointestinal panel testing.

Objective: To evaluate whether incorporating mandatory prior authorization for Clostridioides difficile testing into antimicrobial stewardship pharmacist workflow could reduce testing in patients with alternative etiologies for diarrhea.

Design: Single center, quasi-experimental before-and-after study.

Setting: Tertiary-care, academic medical center in Ann Arbor, Michigan.

Layers of signals that regulate appetite.

All meals come to an end. This is because eating and drinking generate feedback signals that communicate to the brain what and how much has been consumed. Here we review our current understanding of how these feedback signals regulate appetite.

Use of Capture-Recapture Analysis to Assess Reporting Completeness of Births to Hepatitis B-Positive Women in New York City, 2013-2014.

Objectives: The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) depends on reporting by health care facilities and laboratories for disease surveillance. Our objective was to evaluate the completeness of DOHMH surveillance to identify births to hepatitis B virus (HBV)-positive women to prevent perinatal transmission.

Methods: We identified infants born to HBV-positive women by matching mothers of all infants born in NYC during May 1, 2013-May 1, 2014, identified from the Citywide Immunization Registry (CIR) to persons with HBV-positive laboratory reports in the Electronic Laboratory Reporting (ELR) system.

A gut-to-brain signal of fluid osmolarity controls thirst satiation.

Satiation is the process by which eating and drinking reduce appetite. For thirst, oropharyngeal cues have a critical role in driving satiation by reporting to the brain the volume of fluid that has been ingested. By contrast, the mechanisms that relay the osmolarity of ingested fluids remain poorly understood.

The Forebrain Thirst Circuit Drives Drinking through Negative Reinforcement.

The brain transforms the need for water into the desire to drink, but how this transformation is performed remains unknown. Here we describe the motivational mechanism by which the forebrain thirst circuit drives drinking. We show that thirst-promoting subfornical organ neurons are negatively reinforcing and that this negative-valence signal is transmitted along projections to the organum vasculosum of the lamina terminalis (OVLT) and median preoptic nucleus (MnPO).

Neural circuits underlying thirst and fluid homeostasis.

Thirst motivates animals to find and consume water. More than 40 years ago, a set of interconnected brain structures known as the lamina terminalis was shown to govern thirst. However, owing to the anatomical complexity of these brain regions, the structure and dynamics of their underlying neural circuitry have remained obscure.

Thirst.

Our bodies are mostly water, and this water is constantly being lost through evaporative and other means. Thus the evolution of robust mechanisms for finding and consuming water has been critical for the survival of most animals. In this Primer, we discuss how the brain monitors the water content of the body and then transforms that physical information into the motivation to drink.

Warm-Sensitive Neurons that Control Body Temperature.

Thermoregulation is one of the most vital functions of the brain, but how temperature information is converted into homeostatic responses remains unknown. Here, we use an unbiased approach for activity-dependent RNA sequencing to identify warm-sensitive neurons (WSNs) within the preoptic hypothalamus that orchestrate the homeostatic response to heat. We show that these WSNs are molecularly defined by co-expression of the neuropeptides BDNF and PACAP.

Hunger neurons drive feeding through a sustained, positive reinforcement signal.

The neural mechanisms underlying hunger are poorly understood. AgRP neurons are activated by energy deficit and promote voracious food consumption, suggesting these cells may supply the fundamental hunger drive that motivates feeding. However recent in vivo recording experiments revealed that AgRP neurons are inhibited within seconds by the sensory detection of food, raising the question of how these cells can promote feeding at all.

Thirst neurons anticipate the homeostatic consequences of eating and drinking.

Thirst motivates animals to drink in order to maintain fluid balance. Thirst has conventionally been viewed as a homeostatic response to changes in blood volume or tonicity. However, most drinking behaviour is regulated too rapidly to be controlled by blood composition directly, and instead seems to anticipate homeostatic imbalances before they arise.

Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system.

Objective: Computerized provider order entry systems commonly contain alerting mechanisms for patient allergies, incorrect doses, or drug-drug interactions when ordering medications. Providers have the option to override (bypass) these alerts and continue with the order unchanged. This study examines the effect of customizing medication alert override options on the appropriateness of override selection related to patient allergies, drug dosing, and drug-drug interactions when ordering medications in an electronic medical record.

Invasive Pneumococcal Disease Following the Introduction of 13-Valent Conjugate Vaccine in Children in New York City From 2007 to 2012.

Importance: Invasive pneumococcal disease (IPD) is a leading cause of pneumonia, meningitis, and bacteremia in children. In March 2010, a 13-valent pneumococcal conjugate vaccine (PCV13) was introduced to the routine childhood immunization schedule. The PCV13 contains 6 serotypes not included in the previously recommended 7-valent pneumococcal conjugate vaccine, including serotype 19A, the predominant cause of IPD prior to the introduction of PCV13.

An evaluation of voluntary 2-dose varicella vaccination coverage in New York City public schools.

Objectives: We assessed coverage for 2-dose varicella vaccination, which is not required for school entry, among New York City public school students and examined characteristics associated with receipt of 2 doses.

Methods: We measured receipt of either at least 1 or 2 doses of varicella vaccine among students aged 4 years and older in a sample of 336 public schools (n = 223 864 students) during the 2010 to 2011 school year. Data came from merged student vaccination records from 2 administrative data systems.

Outbreak of measles among persons with prior evidence of immunity, New York City, 2011.

Background: Measles was eliminated in the United States through high vaccination coverage and a public health system able to rapidly respond to measles. Measles may occur among vaccinated individuals, but secondary transmission from such individuals has not been documented.

Methods: Suspected patients and contacts exposed during a measles outbreak in New York City in 2011 were investigated.