Implementation of a Heart Failure Quality Initiative in a Skilled Nursing Facility: Lessons Learned

Skilled nursing facilities (SNFs) are organizations that represent complex adaptive systems, offering barriers to the implementation of quality improvement (QI) initiatives. The current article describes the authors’ efforts to use the approach of reflective adaptive process to implement a new model of care (i.e., the Skilled Heart Unit Program) for effective heart failure (HF) care in one SNF. A team of stakeholders from the local hospital system and a local SNF was convened to design and implement this new model. Evaluation of the implementation processes confirmed the value of the implementation approach, which centered on team-based approaches, staff engagement, and flexibility of processes to respect the SNF’s needs and culture. Interviews with facility staff and the administrator revealed their perceptions that the strategy resulted in better HF care, enhanced teamwork between staff and clinicians, and improved staff job satisfaction. This work provides a unique blueprint of strategic QI implementation for patients with HF in the SNF setting

The Analysis of Asymetric Dimethylarginine and Homocysteine in Patients with Chronic Kidney Disease

BACKGROUND: Asymmetric dimethylarginine (ADMA) is a competitive inhibitor of nitric oxide synthase (NOS). ADMA reduces NO synthesis when its concentration elevates. ADMA is a novel risk factor for cardiovascular disease. Plasma ADMA accumulates in patients with endstage renal disease, due to reduced renal clearance. Hyperhomocysteinemia is often found in patients with chronic kidney disease (CKD). Homocysteine may cause ADMA to accumulate; however, the mechanism by which ADMA level elevates in hyperhomocysteinemia is still unclear. Objective of this study was to analyze the concentrations of homocysteine and ADMA and to assess the correlation between homocysteine and ADMA concentrations with the severity of chronic kidney disease.METHODS: This was a cross-sectional study on 75 patients with CKD, comprising men and women aged 40-70 years. Assessments were done on the concentrations of creatinine, homocysteine, ADMA, fasting blood glucose, cholesterol HDL and triglyceride.RESULTS: In later stage of CKD there was significantly higher tHcy concentration as compared with the earlier stage of CKD (p=0.0000). In CKD stage 2 to 4 there was a tendency for ADMA concentration to increase to a significant average (p=0.210), but ADMA concentration was lower at stage 5. There was increased ADMA along with increased tHcy concentration of around 20μ mol/L, and this then decreased. The inverse correlation between tHcy and ADMA concentrations started to appear in CKD stage 4, but this correlation was statistically insignificant (r2 =0.19; p=0.499).CONCLUSIONS: This study showed there was a correlation between homocysteine and ADMA concentrations in patients with CKD stage 2 to 5, although statistically not significant

Evaluation of the Spinoffs Criteria: a Lesson From the Indonesian Islamic Banking Industry

Spin-off policy is one of the crucial issues in the Indonesian Islamic Banking Act (The Act of 21/2008). This paper is going to evaluate the spinoffs criteria that are inherent in the Act of 21/2008. The method that has been used in this paper to evaluate the spinoffs criteria is ARIMA and simulation. This ARIMA method is used to forecast that the Islamic banking unit can achieve the fifty percent asset after fifteen years after this act. The object that is used in this paper is four Islamic spin-off's banks, five Islamic banking units, and two Islamic full-fledged banks. The ARIMA result shows that from all of the objects in fifteen years or the year of 2023, there are no Islamic banks either Islamic full-fledged banks or Islamic banking unit can achieve the fifty percent asset. Besides that, based on the simulation it needs high growth asset to achieve the market share asset of its parent's banks. According to these results, this study suggests the regulator should revise the spinoffs criteria using the strict criteria that based on either nominal assets, capital, financial ratio or the others

Neutron interferometric measurement of the scattering length difference between the triplet and singlet states of n-3^3He

We report a determination of the n-$^3$He scattering length difference $\Delta b^{\prime} = b_{1}^{\prime}-b_{0}^{\prime} =$ ($-5.411$ $\pm$ $0.031$ (statistical) $\pm$ $0.039$ (systematic)) fm between the triplet and singlet states using a neutron interferometer. This revises our previous result $\Delta b^{\prime} =$ (-5.610 $\pm$ $0.027$ (statistical) $\pm$ $0.032$ (systematic) fm obtained using the same technique in 2008. This revision is due to a re-analysis of the 2008 experiment that includes a more robust treatment of the phase shift caused by magnetic field gradients near the $^3$He cell. Furthermore, we more than doubled our original data set from 2008 by acquiring six months of additional data in 2013. Both the new data set and a re-analysis of the older data are in good agreement. Scattering lengths of low Z isotopes are valued for use in few-body nuclear effective field theories, provide important tests of modern nuclear potential models and in the case of $^3$He aid in the interpretation of neutron scattering from quantum liquids. The difference $\Delta b^{\prime}$ was determined by measuring the relative phase shift between two incident neutron polarizations caused by the spin-dependent interaction with a polarized $^3$He target. The target $^3$He gas was sealed inside a small, flat windowed glass cell that was placed in one beam path of the interferometer. The relaxation of $^3$He polarization was monitored continuously with neutron transmission measurements. The neutron polarization and spin flipper efficiency were determined separately using $^3$He analyzers and two different polarimetry analysis methods. A summary of the measured scattering lengths for n-$^3$He with a comparison to nucleon interaction models is given

Integration of renewable energy resources into the distribution network : a review on required power quality

Power quality is the critical element of modern power system network where more and more distributed energy resources (DER) can be found. Distributed generation, generates electricity from many small DER particularly from renewable sources. Distributed generator (DG) within the network from renewable energy resources (RER) like solar and wind, bring significant challenges to maintain acceptable power quality (PQ) at the consumer end. This paper investigates PQ issues associated with RER. It reviews existing PQ standards for distribution network (DN) and also summarized the experiences of several Distributed Network Service Provider (DNSP) while integrating DGs into the grid. It was found that few PQ parameter ranges varies in different standards due to lack of harmonization and that may hinder to accept bulk renewable energy into the grid