Improving Adherence to Daily Weight Orders on an Inpatient Pediatric Unit

Background: Weight is a crucial metric in the optimal care of pediatric patients in the inpatient setting. A patient’s weight is not only necessary for appropriate medication dosing, but is also often an indicator of fluid and nutritional status. As such, having a documented weight is integral to clinical decision making, and failure to obtain daily weight measurements when needed can result in delays in treatment and discharge plans. The importance of daily weight monitoring as well as the challenges surrounding good adherence to daily weight orders has long been recognized. There is currently no formal standardized process for obtaining daily weights on our inpatient pediatric unit, resulting in suboptimal adherence to daily weight orders. Methods: Our primary outcome measure is adherence to daily weight orders on our inpatient unit of Kravis Children’s Hospital 5th Floor, measured as the percentage of all patient-days for which a weight is recorded when there is an active daily weight order in the EMR. Baseline data was established through retrospective chart review of patients admitted to the unit prior to intervention. With the use of process mapping, we created interventions to standardize the method for obtaining weight measurements, to be implemented through standard PDSA cycles; our first intervention established an official time for weight measurements. Biweekly chart audits of all admitted patients were performed to monitor adherence to weight orders as well as identify further opportunities for improvement. We aim to implement 4 adjustments to our current weight measurement process, including further interventions aimed at weight ordering practices, nursing and PCA workflow, as well as continued education and reinforcement for staff. Results: We hypothesize that our intervention will increase adherence to daily weight orders through standardizing and streamlining the workflow to record daily weights. Preliminary baseline data showed that pre-intervention adherence to daily weight orders on Kravis Children’s Hospital 5th Floor was 73.8%. After our first PDSA cycle, preliminary data suggests improved adherence of 79%. There were also days when weights were obtained in the absence of a daily weight order, as well as days when a daily weight order was missing inappropriately. A balancing measure is to determine whether improved adherence to daily weight orders has any unintended or detrimental effects, such as decreased adherence to other types of weight orders at different frequencies (i.e. biweekly). Conclusions: Current adherence to daily weight orders on Kravis Children’s Hospital 5th Floor is inconsistent. Interventions that standardize the process of obtaining weight measurements in accordance with daily weight orders aims to improve adherence. Further directions may include investigating whether improved adherence to daily weight orders results in more clinically appropriate management, as well as identifying needs in standardizing weight ordering practices to only request measurements at frequencies appropriate for the admission diagnosis or clinical situation; minimizing clinically inappropriate daily weight orders may improve daily weight order adherence

Muscle cells challenged with saturated fatty acids mount an autonomous inflammatory response that activates macrophages

<p>Abstract</p> <p>Obesity is associated with chronic low-grade inflammation. Within adipose tissue of mice fed a high fat diet, resident and infiltrating macrophages assume a pro-inflammatory phenotype characterized by the production of cytokines which in turn impact on the surrounding tissue. However, inflammation is not restricted to adipose tissue and high fat-feeding is responsible for a significant increase in pro-inflammatory cytokine expression in muscle. Although skeletal muscle is the major disposer of dietary glucose and a major determinant of glycemia, the origin and consequence of muscle inflammation in the development of insulin resistance are poorly understood.</p> <p>We used a cell culture approach to investigate the vectorial crosstalk between muscle cells and macrophages upon exposure to physiological, low levels of saturated and unsaturated fatty acids. Inflammatory pathway activation and cytokine expression were analyzed in L6 muscle cells expressing myc-tagged GLUT4 (L6GLUT4<it>myc</it>) exposed to 0.2 mM palmitate or palmitoleate. Conditioned media thereof, free of fatty acids, were then tested for their ability to activate RAW264.7 macrophages.</p> <p>Palmitate -but not palmitoleate- induced IL-6, TNFα and CCL2 expression in muscle cells, through activation of the NF-κB pathway. Palmitate (0.2 mM) alone did not induce insulin resistance in muscle cells, yet conditioned media from palmitate-challenged muscle cells selectively activated macrophages towards a pro-inflammatory phenotype.</p> <p>These results demonstrate that low concentrations of palmitate activate autonomous inflammation in muscle cells to release factors that turn macrophages pro-inflammatory. We hypothesize that saturated fat-induced, low-grade muscle cell inflammation may trigger resident skeletal muscle macrophage polarization, possibly contributing to insulin resistance <it>in vivo</it>.</p

p-NO2-Bn-H(4)neunpa and H(4)neunpa-Trastuzumab:Bifunctional Chelator for Radiometalpharmaceuticals and In-111 Immuno-Single Photon Emission Computed Tomography Imaging

Potentially nonadentate (N5O4) bifunctional chelator p-SCN-Bn-H(4)neunpa and its immunoconjugate H(4)neunpa-trastuzumab for In-111 radiolabeling are synthesized. The ability of p-SCN-Bn H(4)neunpa and H(4)neunpa-trastuzumab to quantitatively radiolabel (InCl3)-In-111 at an ambient temperature within 15 or 30 min, respectively, is presented. Thermodynamic stability determination with In3+, Bi3+, and La3+ resulted in high conditional stability constant (pM) values. In vitro human serum stability assays have demonstrated both In-111 complexes to have high stability over 5 days. Mouse biodistribution of [In-111][In(p-NO2 Bn neunpa)](-), compared to that of [In-111][In(p-NH2-Bn-CHX-A"-diethylenetriamine pentaacetic acid (DTPA))](2-), at 1, 4, and 24 h shows fast clearance of both complexes from the mice within 24 h. In a second mouse biodistribution study, the immunoconjugates In-neunpa trastuzumab and In-111-CHX-A"-DTPA-trastuzumab demonstrate a similar distribution profile but with slightly lower tumor uptake of In-111-neunpa-trastuzumab compared to that of In-111-CHX-A"-DTPA-trastuzumab. These results were also confirmed by immuno-single photon emission computed tomography (immuno-SPECT) imaging in vivo. These initial investigations reveal the acyclic bifunctional chelator p-SCN-Bn-H(4)neunpa to be a promising chelator for In-111 (and other radiometals) with high in vitro stability and also show H(4)neunpa trastuzumab to be an excellent In-111 chelator with promising biodistribution in mice

<i>p</i>‑NO₂–Bn–H₄neunpa and H₄neunpa–Trastuzumab: Bifunctional Chelator for Radiometalpharmaceuticals and ¹¹¹In Immuno-Single Photon Emission Computed Tomography Imaging

Potentially nonadentate (N₅O₄) bifunctional chelator <i>p</i>-SCN–Bn–H₄neunpa and its immunoconjugate H₄neunpa–trastuzumab for ¹¹¹In radiolabeling are synthesized. The ability of <i>p</i>-SCN–Bn–H₄neunpa and H₄neunpa–trastuzumab to quantitatively radiolabel ¹¹¹InCl₃ at an ambient temperature within 15 or 30 min, respectively, is presented. Thermodynamic stability determination with In³⁺, Bi³⁺, and La³⁺ resulted in high conditional stability constant (<i>p</i>M) values. In vitro human serum stability assays have demonstrated both ¹¹¹In complexes to have high stability over 5 days. Mouse biodistribution of [¹¹¹In]­[In­(<i>p</i>-NO₂–Bn–neunpa)]⁻, compared to that of [¹¹¹In]­[In­(<i>p</i>-NH₂–Bn–CHX-A″–diethylenetriamine pentaacetic acid (DTPA))]^2–, at 1, 4, and 24 h shows fast clearance of both complexes from the mice within 24 h. In a second mouse biodistribution study, the immunoconjugates ¹¹¹In-neunpa–trastuzumab and ¹¹¹In–CHX-A″–DTPA–trastuzumab demonstrate a similar distribution profile but with slightly lower tumor uptake of ¹¹¹In-neunpa–trastuzumab compared to that of ¹¹¹In–CHX-A″–DTPA–trastuzumab. These results were also confirmed by immuno-single photon emission computed tomography (immuno-SPECT) imaging in vivo. These initial investigations reveal the acyclic bifunctional chelator <i>p</i>-SCN–Bn–H₄neunpa to be a promising chelator for ¹¹¹In (and other radiometals) with high in vitro stability and also show H₄neunpa–trastuzumab to be an excellent ¹¹¹In chelator with promising biodistribution in mice