In the summer of 2010, the author became the executive officer / deputy commander of National Naval Medical Center in Bethesda, Maryland. He was the first Army officer to ever hold the job. He ...discusses the different services' primary cultural foundations: for the Navy, independent command at sea; for the Air Force, devotion to technology; and for the Army, service to the country as a citizen-soldier. Cultural differences between the services were among the primary challenges in the medical center merger, and in many ways they posed the greatest risk for its failure. There are also cultural differences between the Army and Navy that have their basis in the characteristics inherent to Army operations on the battlefield in contrast to those of Navy operations at sea -- the battlefield versus the battleship. Cultural differences clearly carry over and can be leveraged into advantage in the civilian business world.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NMLJ, NUK, ODKLJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
The number of children and adolescents seen in emergency departments (EDs) and primary care settings for mental health problems has skyrocketed in recent years, with up to 23% of patients in both ...settings having diagnosable mental health conditions. Even when a mental health problem is not the focus of an ED or primary care visit, mental health conditions, both known and occult, may challenge the treating clinician and complicate the patient's care. Chun et al discuss the evaluation and management of children with acute mental health or behavioral problems.
Cassini's Titan Radar Mapper imaged the surface of Saturn's moon Titan on its February 2005 fly-by (denoted T3), collecting high-resolution synthetic-aperture radar and larger-scale radiometry and ...scatterometry data. These data provide the first definitive identification of impact craters on the surface of Titan, networks of fluvial channels and surficial dark streaks that may be longitudinal dunes. Here we describe this great diversity of landforms. We conclude that much of the surface thus far imaged by radar of the haze-shrouded Titan is very young, with persistent geologic activity.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Fasting is frequently imposed before extubation in patients in intensive care units, with the aim to reduce risk of aspiration. This unevaluated practice might delay extubation, increase workload, ...and reduce caloric intake. We aimed to compare continued enteral nutrition until extubation with fasting before extubation in patients in the intensive care unit.
We conducted an open-label, cluster-randomised, parallel-group, non-inferiority trial in 22 intensive care units in France. Patients aged 18 years or older were eligible for enrolment if they had received invasive mechanical ventilation for at least 48 h in the intensive care unit and received prepyloric enteral nutrition for at least 24 h at the time of extubation decision. Centres were randomly assigned (1:1) to continued enteral nutrition until extubation or 6-h fasting with concomitant gastric suctioning before extubation, to be applied for all patients within the unit. Masking was not possible because of the nature of the trial. The primary outcome was extubation failure (composite criteria of reintubation or death) within 7 days after extubation, assessed in both the intention-to-treat and per-protocol populations. The non-inferiority margin was set at 10%. Pneumonia within 14 days of extubation was a key secondary endpoint. This trial is now complete and is registered with ClinicalTrials.gov, NCT03335345.
Between April 1, 2018, and Oct 31, 2019, 7056 patients receiving enteral nutrition and mechanical ventilation were admitted to the intensive care units and 4198 were assessed for eligibility. 1130 patients were enrolled and included in the intention-to-treat population and 1008 were included in the per-protocol population. In the intention-to-treat population, extubation failure occurred in 106 (17·2%) of 617 patients assigned to receive continued enteral nutrition until extubation versus 90 (17·5%) of 513 assigned to fasting, meeting the a priori defined non-inferiority criterion (absolute difference -0·4%, 95% CI -5·2 to 4·5). In the per-protocol population, extubation failure occurred in 101 (17·0%) of 595 patients assigned to receive continued enteral nutrition versus 74 (17·9%) of 413 assigned to fasting (absolute difference -0·9%, 95% CI -5·6 to 3·7). Pneumonia within 14 days of extubation occurred in ten (1·6%) patients assigned to receive continued enteral nutrition and 13 (2·5%) assigned to fasting (rate ratio 0·77, 95% CI 0·22 to 2·69).
Continued enteral nutrition until extubation in critically ill patients in the intensive care unit was non-inferior to a 6-h fasting maximum gastric vacuity strategy comprising continuous gastric tube suctioning, in terms of extubation failure within 7 days (a patient-centred outcome), and thus represents a potential alternative in this population.
French Ministry of Health.
For the Chinese translation of the abstract see Supplementary Materials section.
Objective
To evaluate the consistency, reliability, and validity of an implicit review instrument that measures the quality of care provided to children in the emergency department (ED).
Data ...Sources/Study Setting
Medical records of randomly selected children from 12 EDs in the Pediatric Emergency Care Applied Research Network (PECARN).
Study Design
Eight pediatric emergency medicine physicians applied the instrument to 620 medical records.
Data Collection/Extraction Methods
We determined internal consistency using Cronbach's alpha and inter‐rater reliability using the intraclass correlation coefficient (ICC). We evaluated the validity of the instrument by correlating scores with four condition‐specific explicit review instruments.
Principal Findings
Individual reviewers' Cronbach's alpha had a mean of 0.85 with a range of 0.76–0.97; overall Cronbach's alpha was 0.90. The ICC was 0.49 for the summary score with a range from 0.40 to 0.46. Correlations between the quality of care score and the four condition‐specific explicit review scores ranged from 0.24 to 0.38.
Conclusions
The quality of care instrument demonstrated good internal consistency, moderate inter‐rater reliability, high inter‐rater agreement, and evidence supporting validity. The instrument could be useful for systems' assessment and research in evaluating the care delivered to children in the ED.
This clinical report is a revision of "Preparing for Pediatric Emergencies: Drugs to Consider." It updates the list, indications, and dosages of medications used to treat pediatric emergencies in the ...prehospital, pediatric clinic, and emergency department settings. Although it is not an all-inclusive list of medications that may be used in all emergencies, this resource will be helpful when treating a vast majority of pediatric medical emergencies. Dosage recommendations are consistent with current emergency references such as the
and
textbooks and American Heart Association resuscitation guidelines.
Management of Pediatric Trauma Shook, Joan E.; Chun, Thomas H.; Conners, Gregory P. ...
Pediatrics (Evanston),
08/2016, Letnik:
138, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Injury is still the number 1 killer of children ages 1 to 18 years in the United States (http://www.cdc.gov/nchs/fastats/children.htm). Children who sustain injuries with resulting disabilities incur ...significant costs not only for their health care but also for productivity lost to the economy. The families of children who survive childhood injury with disability face years of emotional and financial hardship, along with a significant societal burden. The entire process of managing childhood injury is enormously complex and varies by region. Only the comprehensive cooperation of a broadly diverse trauma team will have a significant effect on improving the care of injured children.
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