Cubilin is a peripheral membrane protein that cooperates with the endocytic receptor megalin to mediate endocytosis of ligands in various polarized epithelia. Megalin is expressed in the male reproductive tract where it has been implicated in the process of sperm membrane remodeling. A potential role for cubilin in the male reproductive tract has not been explored. Using RT‐PCR, we found that cubilin and megalin mRNAs are expressed in the efferent ducts, corpus and cauda epididymis, and proximal and distal vas deferens. Immunohistological analysis revealed that cubilin was expressed in nonciliated cells of the efferent ducts, principal cells of the corpus and cauda epididymis and vas deferens. Immunogold EM showed cubilin in endocytic pits, endocytic vesicles, and endosomes of these cells. The expression profile of cubilin in the male reproductive tract was coincident with that of megalin except in principal cells of the caput epididymis. Double immunogold labeling showed that cubilin and megalin co‐localized within the endocytic apparatus and recycling vesicles of efferent duct cells. Neither protein was found in lysosomes. Injection of RAP, an antagonist of megalin interaction with cubilin, reduced the level of intracellular cubilin in cells of the efferent ducts and vas deferens. In conclusion, cubilin and megalin are co‐expressed in cells of the epididymis and vas deferens and the endocytosis of cubilin in these tissues is dependent on megalin. Together, these findings highlight the potential for a joint endocytic role for cubilin and megalin in the male reproductive tract. Mol. Reprod. Dev. 64: 129–135, 2003. © 2003 Wiley‐Liss, Inc.

The combination of a brief education-based intervention and a computerized FF was more effective than education alone in reducing solitary BC collection in our ED in this time series study. FFs can be a powerful tool in modifying behaviors and processes in the clinical setting.

BackgroundBlood cultures (BCs) are commonly performed in the emergency department (ED). Proper collection is paramount for accurate results, which includes obtaining at least two sets of BCs. In our EDs, an unacceptably high proportion of patients had solitary sets of BCs sent for analysis.ObjectivesTo reduce the rate of solitary sets of BCs being sent to the lab on patients discharged from the ED.MethodsUsing PDSA cycles, we evaluated two sequential interventions. The first intervention included didactic educational sessions and reminders in ED staff huddles. The second intervention added a forcing function (FF) at the point of computer order entry that automatically printed sticker labels for two sets of BCs, instead of the previous default of one. Providers could still send single sets by discarding unused labels. The bi-weekly solitary BC rates were analyzed using statistical process control charts and segmented regression analyses.ResultsThe baseline rate of solitary BCs was 41.1%. The education intervention reduced this rate to 30.3%, and the FF reduced it further to 11.6% (total absolute reduction of 29.5% from baseline). With segmental regression analyses, education alone did not produce a statistically significant change when factoring time-related trends (P=0.071). However, the FF produced a statistically significant improvement (P<0.0005), which was sustained for 6 months.ConclusionsThe combination of an education intervention and a computerized FF was more effective than education alone in reducing solitary BCs in our ED. FFs can be a powerful tool in modifying behaviours and processes in the clinical setting. Table 1Visit data during the duration of the study period (November 2014 to July 2016)MetricSite 1Site 2CombinedTotal ED Visits During Study Period83 747111 621195 368Total ED Ambulatory Visits During Study Period67 04097 538164 578Number of Visits That Had ANY Blood Cultures Sent3 1841 8395 023Blood Cultures (any number of sets) ordered per 100 ambulatory patients4.741.883.05 Table 2Rates of solitary blood cultures sent for patients discharged from the EDTime PeriodSite 1 RateSite 2 RateCombined RateBaseline (November 2014-March 2015)39.3%43.4%41.1%Post Education Intervention (March 2015 – January 2016)32.5%26.3%30.3%Post EPR Intervention (January 2016 – July 2016)12.5%10.2%11.6% Table 3Segmented regression analysisVariableCoefficientP-valueTime-Effect (duration of entire period)−0.00740.132Education Intervention−0.05210.071Time-Effect (post-education)0.00530.294Forcing Function−0.1537<0.0005Time-Effect (post-forcing function)0.00080.778Figure 4

co-designed and patient-centred discharge handouts, we have found a marked improvement in patient understanding, and consequently safer discharge practices. Future efforts will focus on optimizing discharge communication, both verbal and written, tailored to individual patient preferences. Keywords: emergency department discharge, communication, discharge handouts Introduction: Atrial fibrillation (AF) is the most common sustained arrhythmia affecting 1-2% of the population. Oral anticoagulation (OAC) reduces stroke risk by 60-80% in AF patients, but only 50% of indicated patients receive OAC. Many patients present to the ED with AF due to arrhythmia symptoms, however; lack of OAC prescription in the ED has been identified as a significant gap in the care of AF patients. Methods: This was a multi-center, pragmatic, three-phase before-after study, in three Canadian sites. Patients who presented to the ED with electrocardiographically (ECG) documented, nonvalvular AF and were discharged home were included. Phase 1 was a retrospective chart review to determine OAC prescription of AF patients in each ED; Phase 2 was a low-intensity knowledge translation intervention where a simple OAC-prescription tool for ED physicians with subsequent short-term OAC prescription was used, as well as an AF patient education package and a letter to family physicians; phase 3 incorporated Phase 2 interventions, but added immediate follow-up in a community AF clinic. The primary outcome of the study was the rate of new OAC prescriptions at ED discharge in AF patients who were OAC eligible and were not on OAC at presentation. Results: A total of 632 patients were included from June, 2015-November, 2016. ED census ranged from 30000-68000 annual visits. Mean age was 71 ± 15, 67 ± 12, 67 ± 13 years, respectively. 47.5% were women, most responsible ED diagnosis was AF in 75.8%. The mean CHA 2 DS 2 -VASc score was 2.6 ± 1.8, with no difference amongst groups. There were 266 patients eligible for OAC and were not on this at presentation. In this group, the prescription of new OAC was 15.8% in Phase 1 as compared to 54% and 47%, in Phases 2 and 3, respectively. After adjustment for center, components of the CHA 2 DS 2 -VASc score, prior risk of bleeding and most responsible ED diagnosis, the odds ratio for new OAC prescription was 8.0 (95%CI (3.5,18.3) p < 0.001) for Phase 3 vs 1, and 10.0 (95%CI (4.4,22.9) p < 0.001), for Phase 2 vs 1). No difference in OAC prescription was seen between Phases 2 and 3. Conclusion: Use of a simple OACprescription tool was associated with an increase in new OAC prescription in the ED for eligible patients with AF. Further testing in a rigorous study design to assess the effect of this practice on stroke prevention in the AF patients who present to the ED is indicated. MP09