Abstract
Introduction
The objectives of this performance improvement project is to facilitate earlier goals of care discussions led by the Palliative Care team for burn patients with a high risk of ...mortality, and to improve overall communication with families of patients. The Advanced Care Planning Trigger Tool utilizes the Revised Baux Score, a burn mortality scoring system, which is calculated by adding the patient’s age, total body surface area (TBSA) of the patient’s burn as a whole number, and adding an additional 17 points if the patient has an inhalation injury. From January 1st, 2017 to June 1st, 2018 16 patients were admitted to the Burn Center with a Revised Baux Score of over 100. Of those 16 patients, 11 passed away due to their injuries during admission, equaling a 69% mortality. Palliative Care consults were triggered for 4 out of the 16 patients (25%), and all 4 of these patients passed away during their hospital stay.
Methods
Revised Baux Score is calculated on each new burn admission. A consult to the Palliative Care Team for Advanced Care Planning is triggered within 48 hours of admission, if a patient’s Revised Baux Score is above 110 and they are greater than 60 years old; or any adult patient (over 18 years old) with a score of 130 or greater.
Results
The project was implemented in June of 2018. This tool led to an increase in Palliative Care team involvement early on for patients with a high risk of mortality from their burn injury, more effective care planning discussions with families and improved collaboration between the Burn team and Palliative Care team.
Conclusions
All patients with a Revised Baux Score that triggered the Advanced Care Planning Tool for a consult were ordered palliative care consults within 48 hours of admission.
Applicability of Research to Practice
Advanced Care Planning with the Palliative Care team leads to increased communication and more effective care planning for patients with a high risk of mortality.
Abstract
Introduction
The Burn Resuscitation Critical Reflective Practice (CRP) was started as collaborative meetings to review 1st 48 hours of admission for burn resuscitations (resus) October 2018- ...July 2019. All multi- disciplinary teams were invited.
The problem identified was on average burn resus patients (>20% TBSA) were being over resuscitated in 1st 24 hours of admission.
The goals of the CRP were: 1) Decrease resus fluid in the 1st 24 hours; 2) Increase knowledge of the current fluid resus pathway; 3) Increase communication with interdisciplinary teams during the resus.
Methods
CRP initiated in October 2018. 6 CRPs were held October 2018- July 2019.The average ml/ KG/ TBSA prior to CRP from January 2017- September 2018 was 5.17ml/kg/TBSA (goal: < 4ml).
Chart reviews were done to gather data from each resus (i.e. urine output, fluids, labs, events). Discussions held with staff involved in the 1st 24 hours of resus regarding any communication/process issues.Patient data was presented & staff members present would discuss questions/ issues that came up during the resus.
Multi-disciplinary teams surveyed prior to CRP to assess comfort/competence with current resus pathway and communication. 46 surveys received prior to initiating CRP. After initiating CRP October 2018- July 2019, staff members that had attended >1 CRP were post-surveyed.
Results
January 2017- October 2018 average ml/ KG/ TBSA was 5.17ml/kg/TBSA. October 2018- July 2019 POST CRP implementation, the avg ml/ KG/ TBSA was 3.86 ml LR/ kg/ TBSA in 1st 24 hours of resus.
3 new practices were implemented 1) Decrease fluids by 200ml/hr (instead of 100) when UOP is >100/hr at least 2 hours into resus; 2) Double sign by 2 RNs required when calculating Parkland Formula; 3) Guideline created to guide communication between Burn RNs & trauma bay when burn resus arrives.
Post- survey data showed increase in comfort communicating with physicians regarding resus & increase in comfort/confidence in calculating Parkland Formula. 2 additional subjective questions were added onto the post- CRP survey.
Conclusions
Fluids given in the 1st 24 hours decreased from 5.17 to 3.86 average ml/ kg/ TBSA post- CRP. 3 new practices were implemented as discussed in results. Staff felt more comfortable communicating with team & calculating Parkland formula. Staff had positive responses on the post- survey.
Applicability of Research to Practice
The monthly CRPs are to be continued to discuss all burn resus patients received during the prior month. Allows team members to continue to modify practice as needed by what’s learned through each CRP to help better our patient outcomes and decrease overall resus fluids.
•G-quadruplex separation and purification using ion-exchange chromatography•Method optimization to control and enhance the G-quadruplex formation•Native mass spectrometry was utilized to identify the ...intact G-quadruplex•Ion-pairing denaturing method to confirm the single-stranded oligonucleotide•Comparison between monolithic CIM-QA and particle-based TSKgel SuperQ-5PW columns
The current study investigates a method for purification of the G-quadruplex secondary structure, naturally formed by a guanine-rich 21-mer oligonucleotide strand using a monolithic convective interaction media-quaternary amine (CIM-QA) column under ion-exchange conditions. The monolithic support was initially evaluated on a preparative scale against a highly efficient TSKgel SuperQ-5PW ion-exchange support designed for oligonucleotide purification. The CIM analogue demonstrated clear advantages over the particle-based support on the basis of rapid separation times, while also affording high purity of the G-quadruplex. Various parameters were investigated including the type of mobile phase anion, cation, pH and injection load to induce and control quadruplex formation, as well as enhance chromatographic separation and final purity. Potassium afforded the most prominent quadruplex formation, yet sodium allowed for the highest resolution and purity to be achieved with a 30 mg injection on an 8 ml CIM-QA monolithic column. This method was applied to purify in excess of 300 mg of the quadruplex, with excellent retention time precision of under 1% RSD. Native mass spectrometry was utilized to confirm the identity of the intact G-quadruplex under non-denaturing conditions, while ion-pairing reversed-phase methods confirmed the presence of the single-stranded oligonucleotide in high purity (92%) under denaturing conditions.
The key advantage of the purification method enables isolation of the G-quadruplex in its native state on a milli-gram scale, allowing structural characterization to further our knowledge of its role and function. The G-quadruplex can also be subsequently denaturated at elevated temperature causing single strand formation if additional reactions are to be pursued, such as annealing to form a duplex, and evaluation in in vitro or in vivo studies.
•Two systems models for organizational design and change are proposed.•Change requires enacting the simple rules that lead to adaptivity in organizations.•All organizations are complex adaptive ...systems, irrespective of formal structure.•The complexity of the community context requires complexity-friendly systems models.•These two models are useful for theory and capacity building.
In this article, we present a systems thinking approach to organizational design and change called VMCL (vision, mission, culture/capacity, learning) and describe different community applications to illustrate its theoretical and practical relevance to community operational research (Community OR). VMCL was developed to apply systems thinking and complexity theory to any situation that involves groups of people, such as organizations. Additionally, we elaborate a network-based theory of change called NFST (naysayers, fence-sitters, supporters, thought leaders) for implementing VMCL in any community context. We describe how VMCL was extensively applied to local grassroots movements involving community members, students, staff, teachers, school leaders, and board members to change US school districts. We then discuss the relevance and application of VMCL and NFST to community mobilization by a grassroots movement in Wisconsin, USA. We conclude by discussing the ways in which VMCL and NFST foster systemic Community OR, and how they are useful tools for community organizers and other practitioners.
Heat early warning systems and action plans use temperature thresholds to trigger warnings and risk communication. In this study, we conduct multistate analyses, exploring associations between heat ...and all-cause and cause-specific hospitalizations, to inform the design and development of heat–health early warning systems. We used a two-stage analysis to estimate heat–health risk relationships between heat index and hospitalizations in 1,617 counties in the United States for 2003–2012. The first stage involved a county-level time series quasi-Poisson regression, using a distributed lag nonlinear model, to estimate heat–health associations. The second stage involved a multivariate random-effects meta-analysis to pool county-specific exposure–response associations across larger geographic scales, such as by state or climate region. Using results from this two-stage analysis, we identified heat index ranges that correspond with significant heat-attributable burden. We then compared those with the National Oceanic and Atmospheric Administration National Weather Service (NWS) heat alert criteria used during the same time period. Associations between heat index and cause-specific hospitalizations vary widely by geography and health outcome. Heat-attributable burden starts to occur at moderately hot heat index values, which in some regions are below the alert ranges used by the NWS during the study time period. Locally specific health evidence can beneficially inform and calibrate heat alert criteria. A synchronization of health findings with traditional weather forecasting efforts could be critical in the development of effective heat–health early warning systems.
This paper analyzes the campus ecology (Renn, 2003, 2004) literature from the perspective of Critical Whiteness specifically problematizing perceptions of safety and inclusion on the college campus. ...Relying upon Sullivan's (2006) ontological expansiveness, Mills's (1997) epistemology of ignorance, and Leonardo and Porter's (2010) Fanonian interpretation of racial safety, we argue that there is too high a premium placed on social comfort during the undergraduate experience which actually leaves White students at predominantly White institutions in perpetual states of racial arrested development. We conclude that intentional, targeted racial dissonance is necessary for both White students to develop their racial selves while concurrently being aware of the ugly realities of contemporary racism.
An open repository of real-time COVID-19 indicators Reinhart, Alex; Brooks, Logan; Jahja, Maria ...
Proceedings of the National Academy of Sciences - PNAS,
12/2021, Letnik:
118, Številka:
51
Journal Article
Recenzirano
Odprti dostop
The COVID-19 pandemic presented enormous data challenges in the United States. Policy makers, epidemiological modelers, and health researchers all require up-to-date data on the pandemic and relevant ...public behavior, ideally at fine spatial and temporal resolution. The COVIDcast API is our attempt to fill this need: Operational since April 2020, it provides open access to both traditional public health surveillance signals (cases, deaths, and hospitalizations) and many auxiliary indicators of COVID-19 activity, such as signals extracted from deidentified medical claims data, massive online surveys, cell phone mobility data, and internet search trends. These are available at a fine geographic resolution (mostly at the county level) and are updated daily. The COVIDcast API also tracks all revisions to historical data, allowing modelers to account for the frequent revisions and backfill that are common for many public health data sources. All of the data are available in a common format through the API and accompanying R and Python software packages. This paper describes the data sources and signals, and provides examples demonstrating that the auxiliary signals in the COVIDcast API present information relevant to tracking COVID activity, augmenting traditional public health reporting and empowering research and decision-making.
Objectives:
To evaluate clinical characteristics and outcomes of patients diagnosed with anterior (ASB) or lateral skull base (LSB) spontaneous cerebrospinal fluid (sCSF) leak.
Methods:
Single center ...retrospective review of patients diagnosed with sCSF leaks of ASB or LSB between 1/1/2009 and 11/1/2019 (n = 69). Body mass index (BMI), gender, age at diagnosis, origin of CSF leak (ASB vs LSB), surgical approach, lumbar drain use, recurrence, pre-operative diagnosis of diabetes mellitus (DM), and obstructive sleep apnea (OSA) were collected.
Results:
69 patients included in this study met criteria for sCSF leak without a traumatic or iatrogenic cause (Female: 51 (74%); average BMI: 37.0 ± 7.9). Forty-eight (70.0%) presented with sCSF leaks of the lateral skull base. All ASB leaks were treated with an endoscopic transnasal approach. Eleven (22.9%) LSB leak patients were treated using transmastoid approaches and 35 (72.9%) patients with a middle cranial fossa approach. Eleven patients (15.9%) reported sCSF leak recurrence. Two patients (9.5%) with anterior skull base and 9 patients (18.8%) with lateral skull base leaks had recurrence. LSB sCSF leaks had a relative risk of 2.192 of recurrence compared to ASB leaks (95% CI: 0.431-11.157, P = .483). A 5.017 times increased risk (95% CI: 1.285-19.583, P = .020) was reported for patients with OSA, while the risks for DM and BMI were 1.351 (95% CI: 0.67-9.105, P = .177) and 1.026 (95% CI: 0.963-1.094, P = .426) respectively. Patients with sCSF leak recurrence had significantly lower lumbar drain use (33.3%) than those without recurrence (72.7%) (P = .049).
Conclusion:
Spontaneous CSF leak recurrence is complex and multifactorial, and while patients with both DM and OSA had the higher risk of recurrence, OSA is likely an independent clinical risk factor for sCSF leak recurrence in this patient population.
Research documents that child and adolescent (youth) irritability and anxiety have high co-occurrence, and anxious-irritable presentations are associated with greater impairment than anxious ...nonirritable presentations. This study examines the association between irritability and youth anxiety treatment outcome and tests a conceptual model of the associations among youth irritability, parent accommodation, and youth anxiety severity following cognitive behavioral treatment (CBT). Participants were N = 128 clinic-referred youths ages 6 to 17 years (M = 9.76 years; 57% female) who met criteria for primary anxiety disorder diagnoses and completed a 12- to 14-week CBT anxiety protocol. Parent- and youth-report on youth irritability, parent accommodation of their child's anxiety, and youth anxiety severity were assessed pretreatment and posttreatment. Using parent-report, youth irritability at pretreatment was associated with high parent accommodation of youth anxiety and high youth anxiety severity at posttreatment. The association between irritability and youth anxiety outcome was mediated contemporaneously by parent accommodation at posttreatment. These findings show that parent accommodation of their anxious-irritable children's anxiety may account for high youth anxiety severity following treatment. Developing strategies to target irritability in anxious youth and/or reduce parent accommodation in the presence of youth irritability represent important directions for future research.
Objective
The Interpersonal Theory of Suicide (ITS) implicates thwarted belongingness and perceived burdensomeness as casually related to suicide desire. The self‐report Interpersonal Needs ...Questionnaire (INQ) is the most commonly used measure to assess belongingness and burdensomeness, including in youth. No parent‐report version of the INQ exists. The current study adapted the ten‐item version of the INQ (INQ‐10) for parent report of youth belongingness and burdensomeness, thereby moving ITS research in youth to a multi‐informant measurement approach, and examined its factor structure and convergent and concurrent validity.
Methods
Participants were 168 clinic‐referred youths ages 9–17 years (58.9% female; Mage = 11.91) and their parents.
Results
Findings supported a two‐factor structure of the parent INQ. In support of convergent and concurrent validity, parent‐reported belongingness and burdensomeness were significantly associated with youth‐reported belongingness and burdensomeness, suicide ideation, anxiety symptoms, depressive symptoms, and impairment.
Conclusions
The current study provides initial support the INQ‐parent version as a valid measure to complement youth self‐reports of belongingness and burdensomeness.
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