Trials comparing balanced crystalloids with normal saline have yielded mixed results regarding reductions in kidney complications and mortality for hospitalized patients receiving intravenous fluids.
...To evaluate the association of a multifaceted implementation program encouraging the preferential use of lactated Ringer solution with patient outcomes and intravenous fluid-prescribing practices in a large, multilevel health care system.
This type 2 hybrid implementation and comparative effectiveness study enrolled all patients 18 years or older who received 1 L or more of intravenous fluids while admitted to an emergency department and/or inpatient unit at 1 of 22 hospitals in Idaho and Utah between November 1, 2018, and February 29, 2020. An interrupted time series analysis was used to assess study outcomes before and after interventions to encourage use of lactated Ringer solution.
Implementation program combining order set modification, electronic order entry alerts, and sequential clinician-targeted education to encourage prescribing of lactated Ringer solution instead of normal saline.
The primary implementation outcome was the patient-level proportion of intravenous fluids that was balanced crystalloids. The primary effectiveness outcome was the incidence of major adverse kidney events (MAKE30)-a composite of new persistent kidney dysfunction, new initiation of dialysis, and death-at 30 days.
Among 148 423 patients (median IQR age, 47 30-67 years; 91 302 women 61%), the proportion of total fluids received that was lactated Ringer solution increased from 28% to 75% in the first week vs the last week of the study (immediate implementation effect odds ratio OR, 3.44; 95% CI, 2.79-4.24). The estimated MAKE30 absolute risk reduction was 2.2% (95% CI, 1.3%-3.3%) based on interrupted time series analysis showing a decrease in the week-on-week trend for MAKE30 (OR difference, 0.03; 95% CI, 0.03-0.03, P < .001). The immediate postimplementation OR for MAKE30 was 0.88 (95% CI, 0.76-1.01), with a decrease in persistent kidney dysfunction (OR, 0.80; 95% CI, 0.69-0.93) and mortality (OR, 0.78; 95% CI, 0.65-0.93) but not dialysis (OR, 1.00; 95% CI, 0.76-1.32).
In this comparative effectiveness study, an implementation program was associated with an increase in the proportion of fluids administered as lactated Ringer solution compared with normal saline and was associated with a reduction in MAKE30 events among patients treated in a large integrated health care system.
Advances of industry 4.0 are enabling augmented reality (AR) devices to be deployed across the manufacturing sector to enhance worker engagement and performance. This evolution of AR in the workspace ...is driving changes in how workers on the factory floor interact with the enterprise. AR is evolving to provide work instructions for assembly and maintenance. Recent demonstrations show the capability to allow for quality inspection to be integrally evaluated as part of the AR workflow. Previous integrations of quality include the ability for manual assessment to be logged into the enterprise as part of completing work instructions; however, this is largely based on the perception of the user to determine if they accurately performed the AR instructions. This study is designed to demonstrate the ability of an enterprise-level AR maintenance experience to go beyond manual inspection by embedding real-time quality assessment into the work instructions. Essentially, the goal is to enable the enterprise to perform a self-assessment of the quality of the work performed by maintenance personnel. Furthermore, the AR instructions enable additional instruction to empower maintenance personnel to correct their work prior to moving on to other tasks. The novelty of this work is focused on deployment on a mobile device with integrated vision inspection using the same device that is being used to deploy the AR work instructions. This work enumerates several essential qualities of mobile quality inspection tools and outlines some of the challenges associated with the development of such a system. Finally, results from testing the system demonstrate that handheld mobile devices can be used to capture inspection images while simultaneously deploying AR work instructions. Analysis of the image correction, timing for vision process of the quality check, and overall performance of the integrated system are presented.
Thin, porous zirconia-based ceramic components are of high interest in energy application devices where they are used as structural ceramics. Mechanical reliability of such devices is not only ...dependent on the fracture toughness of the ceramic components, but also on their sensitivity to slow crack growth (SCG). In this work, the fracture toughness and SCG behavior of porous (4.5–45.5%) and thin (∼ 0.25 mm) 3Y-TZP ceramics are investigated using the Double Torsion method. The analysis of the double torsion data, previously developed for dense materials, was here assessed and adapted. The compliance of the samples was observed to change linearly with crack length and the measured stress intensity factor was dependent on crack length, as for dense materials. This dependency decreased by increasing the sample porosity. For all materials, the ratio of the SCG threshold to fracture toughness was of 0.56 ± 0.06.
The rich diversity of morphology and behavior displayed across primate species provides an informative context in which to study the impact of genomic diversity on fundamental biological processes. ...Analysis of that diversity provides insight into long-standing questions in evolutionary and conservation biology and is urgent given severe threats these species are facing. Here, we present high-coverage whole-genome data from 233 primate species representing 86% of genera and all 16 families. This dataset was used, together with fossil calibration, to create a nuclear DNA phylogeny and to reassess evolutionary divergence times among primate clades. We found within-species genetic diversity across families and geographic regions to be associated with climate and sociality, but not with extinction risk. Furthermore, mutation rates differ across species, potentially influenced by effective population sizes. Lastly, we identified extensive recurrence of missense mutations previously thought to be human specific. This study will open a wide range of research avenues for future primate genomic research.
Recently, two new phenomena linking stress field and reduction rates in anode‐supported solid oxide fuel cells (SOFCs) have been demonstrated, so‐called accelerated creep during reduction and ...reduction rate enhancement and nucleation due to stress (Frandsen et al., 2014). These complex phenomena are difficult to study and it is demonstrated here that energy‐resolved neutron imaging is a feasible technique for combined mechanics–chemical composition studies of SOFC components, including commercially produced ones. Cermet anode supports, which prior to the measurements were reduced under varying conditions such as different temperatures, various times and different values of applied stress, have been measured. Thus, samples with different contents (and gradients) of Ni and NiO phases were investigated. The first Bragg edge transmission neutron measurements applied for the studies of the reduction progress in these samples were performed at two neutron beamline facilities (ISIS in the UK, Helmholtz Zentrum Berlin in Germany). The obtained results demonstrate the possibility to image and distinguish NiO and Ni phases within SOFC anode supports by energy‐resolved neutron imaging and the potential of the neutron imaging method for in situ studies of reduction processes.
Bortezomib is approved for the treatment of multiple myeloma but increasingly used in heart transplant (HTx) recipients with antibody‐mediated rejection (AMR). Severe pulmonary toxicity is a rare ...complication in multiple myeloma patients treated with bortezomib, but has not been described in a solid organ transplant recipient. A 20‐year‐old man 7 years post‐HTx presented with acute rejection with hemodynamic compromise. Endomyocardial biopsy showed mixed rejection (ISHLT grade 2R‐3R acute cellular rejection (ACR) and pAMR 1 (I+) with diffuse C4d staining). Two new high MFI circulating MHC class‐II donor‐specific antibodies (DSA) were detected. Treatment included corticosteroids, antithymocyte globulin, plasmapheresis, IVIG, rituximab, and bortezomib (1.3 mg/m2). Due to rebound in DSA, a second course of bortezomib was started. Thrombocytopenia and peripheral neuropathy prompted a 50% dose reduction during the 2nd course. Shortly after the 3rd reduced dose, the patient developed hypoxemic respiratory failure. Bronchoscopy revealed pulmonary hemorrhage with negative infectious studies. Chest CT showed bilateral parenchymal disease with bronchiectasis and alveolar bleeding. Despite treatment with high‐dose steroids, severe ARDS ensued with multisystem organ failure. The patient expired 23 days after the final dose of bortezomib. Post‐mortem lung histology revealed diffuse alveolar damage, pulmonary fibrosis, and hemorrhage. Cardiac histology showed resolving/residual ACR 1R and pAMR 1 (I+). While rare, bortezomib‐induced lung toxicity (BILT) can occur in HTx recipients and can carry a high risk of mortality. Drug reaction and immediate drug withdrawal should be considered in patients who develop respiratory symptoms, though optimal management of BILT is unclear.
Noncoding DNA is central to our understanding of human gene regulation and complex diseases
, and measuring the evolutionary sequence constraint can establish the functional relevance of putative ...regulatory elements in the human genome
. Identifying the genomic elements that have become constrained specifically in primates has been hampered by the faster evolution of noncoding DNA compared to protein-coding DNA
, the relatively short timescales separating primate species
, and the previously limited availability of whole-genome sequences
. Here we construct a whole-genome alignment of 239 species, representing nearly half of all extant species in the primate order. Using this resource, we identified human regulatory elements that are under selective constraint across primates and other mammals at a 5% false discovery rate. We detected 111,318 DNase I hypersensitivity sites and 267,410 transcription factor binding sites that are constrained specifically in primates but not across other placental mammals and validate their cis-regulatory effects on gene expression. These regulatory elements are enriched for human genetic variants that affect gene expression and complex traits and diseases. Our results highlight the important role of recent evolution in regulatory sequence elements differentiating primates, including humans, from other placental mammals.
PDF
