Wisconsin industrial employers' perceptions of the need for graduates of specific industrial technology programs in the Wisconsin Technical College Districts

Includes bibliographical references

High Output Heart Failure, A Lethal and Forgotten Cause of Heart Failure

Introduction Cardiac output (CO) is usually low or normal in patients with heart failure. However, some patients have a high CO deemed high-output heart failure (HOHF). HOHF is not well characterized and continues to be under-recognized clinically. At the Detroit VA, we conducted a quality improvement project to define the characteristics of this unique patient population, identify predictors and increase awareness of this entity. Methods Patients with HOHF were compared to patients with heart failure with preserved ejection fraction (HFpEF) and normal CO. HOHF was defined as CO \u3e8 L/minute on right heart catheterization performed between 2008-2021. Retrospective data regarding hemodynamics, comorbidities, and mortality were collected and compared using descriptive and univariate analyses. Results There were no significant differences in age or race between the groups or in the rate of comorbidities analyzed except for tobacco smoking and CKD which were higher in the HOHF group. Majority of the patients in the HOHF group had preserved EF (91%). Patients had a similar mean wedge pressure, but the HOHF group had significantly lower pulmonary vascular resistance and systemic vascular resistance. Mortality among patients with HOHF was 48.6% compared to the comparative group of 18.9% (p Conclusion In this single center study comparing HOHF to HFpEF, the HOHF group had significantly higher mortality compared to the HFpEF group, despite similar co-morbidities, wedge pressure and demographics. The diagnosis of HOHF was not made in majority of the cases, suggesting under recognition. We aim to create awareness of this entity among providers and highlight the need for early referral for right heart catheterization, given that HOHF can be erroneously diagnosed as HFpEF without invasive measurements. Clinical trials allocated towards management of this entity is overdue

Improving recognition of delirium in clinical practice: a call for action

The purpose of this correspondence article is to report opinion amongst experts in the delirium field as to why, despite on-going training for all health professionals, delirium continues to be under recognised. Consensus was obtained by means of two conference workshops and an online survey of members of the European Delirium Association. Major barriers to recognition at an individual level include ignorance about the benefit of treating delirium. At an organisational level, reflecting socio-cultural attitudes, barriers include a low strategic and financial priority and the fact that delirium is an orphan condition falling between specialties

The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer

© 2014 European Delirium Association et al.; licensee BioMed Central Ltd. Background: Delirium is a common and serious problem among acutely unwell persons. Alhough linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.Discussion: Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.Summary: Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation

Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study [version 1; peer review: 2 approved]

BACKGROUND: Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 ‘A’s Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients. METHODS: 240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium. DISCUSSION: The findings will inform clinical practice regarding delirium assessment in palliative care settings. TRIAL REGISTRATION: ISRCTN ISRCTN97417474 (21/02/2020)

Read-across and new approach methodologies applied in a 10-step framework for cosmetics safety assessment – A case study with parabens

Parabens are esters of para-hydroxybenzoic acid that have been used as preservatives in many types of products for decades including agrochemicals, pharmaceuticals, food and cosmetics. This illustrative case study with propylparaben (PP) demonstrates a 10-step read-across (RAX) framework in practice. It aims at establishing a proof-of-concept for the value added by new approach methodologies (NAMs) in read-across (RAX) for use in a next-generation risk assessment (NGRA) in order to assess consumer safety after exposure to PP-containing cosmetics. In addition to structural and physico-chemical properties, in silico information, toxicogenomics, in vitro toxicodynamic, toxicokinetic data from PBK models, and bioactivity data are used to provide evidence of the chemical and biological similarity of PP and analogues and to establish potency trends for observed effects in vitro. The chemical category under consideration is short (C1–C4) linear chain n-alkyl parabens: methylparaben, ethylparaben, propylparaben and butylparaben. The goal of this case study is to illustrate how a practical framework for RAX can be used to fill a hypothetical data gap for reproductive toxicity of the target chemical PP

Modelling costs and quality of housing units and public spaces for improving public-private collaboration in new residential developments \u96 Case Guayaquil, Ecuador

Workshop 2. Public space iontervention

Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.

PURPOSE:Understanding the quality of evidence of delirium education studies will assist in designing future education interventions that seek to improve the well-known deficits in delirium prevention, detection and care. The aim of this study is to systematically review the methodological strengths and limitations, as well as the impact of delirium educational interventions for healthcare professionals working in inpatient settings. METHODS:MEDLINE, EMBASE, The Cochrane Library, PsychINFO and CINAHL databases were searched according to PRISMA guidelines for delirium educational interventions in hospital inpatient settings from 2007 to 2017. Identified studies were rated using a standardised quality assessment criteria checklist (Kmet). Reported outcomes were organised by level on the Kirkpatrick model for educational outcomes. The search was repeated in March 2018. RESULTS:1354 papers were screened, of which 42 studies met the inclusion criteria. Interventions delivered included face-to-face education (n = 34), e-learning (n = 8) and interprofessional education (n = 8). Quality of studies varied in Kmet score (14-96%). There were 17 high-quality studies (Kmet > 80%) and 4 very high-quality studies (Kmet over > 90%). Thirty-eight studies (90%) reported improved outcomes post-intervention. In terms of Kirkpatrick level of educational outcomes, 6 studies were rated at level 1; 13 studies at level 2; 15 studies at level 3; and 8 studies at level 4. Thirteen studies measured intervention sustainability with variable impacts. CONCLUSIONS:Healthcare professional education has benefits for inpatient delirium care, as shown by the high number of good-quality studies and the majority demonstrating improved outcomes post-intervention. The sustainability of educational interventions warrants further exploration