Geriatric Hip Fracture Quality Initiative

Introduction: Multiple studies demonstrate increased morbidity, mortality, and loss of independence after hip fractures in geriatric patients. The 1-year mortality rate after a hip fracture has been estimated at anywhere from 14% to 58%. Hip fractures are one of the most common injuries evaluated by the UNM Orthopedic department. Geriatric hip fracture protocols have shown improved outcomes at many other centers with regard to improved functionality and decreased morbidity. The goal of this initiative is to improve outcomes with regard to length of hospital stay, functionality after surgery, and as a result, decreased morbidity and mortality. Materials/methods: All deaths in the orthopedic department were reviewed and analyzed from June 2009 to July 2019. Deaths were identified from morbidity and mortality submissions and NSQIP data. The geriatric hip fracture protocol was developed and implemented in Fall 2019, with non-critical care patients being primarily admitted to orthopedics, with hospitalist co-management. Specific post-operative and pain order sets were developed for efficiency and improved standard of care. Results: Early results of the newly developed geriatric hip fracture protocol demonstrate decreased length of stay in the hospital and earlier time to surgical intervention. It is too early to determine if morbidity and mortality has seen any decrease, however this can be anticipated with earlier time to surgery and decreased time in the hospital. Conclusions: We identified a need and successfully developed an initiative to improve care for geriatric patients with hip fractures. Implementation of this protocol decreased length of hospital stay as well as time to surgery. The analysis of the effect of this protocol on overall morbidity and mortality is ongoing

An improved constraint satisfaction adaptive neural network for job-shop scheduling

Copyright @ Springer Science + Business Media, LLC 2009This paper presents an improved constraint satisfaction adaptive neural network for job-shop scheduling problems. The neural network is constructed based on the constraint conditions of a job-shop scheduling problem. Its structure and neuron connections can change adaptively according to the real-time constraint satisfaction situations that arise during the solving process. Several heuristics are also integrated within the neural network to enhance its convergence, accelerate its convergence, and improve the quality of the solutions produced. An experimental study based on a set of benchmark job-shop scheduling problems shows that the improved constraint satisfaction adaptive neural network outperforms the original constraint satisfaction adaptive neural network in terms of computational time and the quality of schedules it produces. The neural network approach is also experimentally validated to outperform three classical heuristic algorithms that are widely used as the basis of many state-of-the-art scheduling systems. Hence, it may also be used to construct advanced job-shop scheduling systems.This work was supported in part by the Engineering and Physical Sciences Research Council (EPSRC) of UK under Grant EP/E060722/01 and in part by the National Nature Science Fundation of China under Grant 60821063 and National Basic Research Program of China under Grant 2009CB320601

Pretransplant gastroesophageal reflux compromises early outcomes after lung transplantation

ObjectivesGastroesophageal reflux disease (GERD) is implicated as a risk factor for bronchiolitis obliterans syndrome after lung transplantation, but its effects on acute rejection, early allograft function, and survival are unclear. Therefore, we sought to systematically understand the time-related impact of pretransplant GERD on graft function (spirometry), mortality, and acute rejection early after lung transplantation.MethodsFrom January 2005 to July 2008, 215 patients underwent lung transplantation; 114 had preoperative pH testing, and 32 (28%) had objective evidence of GERD. Lung function was assessed by forced 1-second expiratory volume (FEV1; percent of predicted) in 97 patients, mortality by follow-up (median, 2.2 years), and acute rejection by transbronchial biopsy.ResultsPretransplant GERD was associated with decreased FEV1 early after lung transplantation (P = .01) such that by 18 months, FEV1 was 70% of predicted in double lung transplant patients with GERD versus 83% among non-GERD patients (P = .05). A similar decrease was observed in single lung transplantation (50% vs 60%, respectively; P = .09). GERD patients had lower survival early after transplant ( P = .02)—75% versus 90%. Presence of GERD did not affect acute rejection (P = .6).ConclusionsFor lung transplant recipients, pretransplant GERD is associated with worse early allograft function and survival, but not increased acute rejection. The compromise in lung function is substantial, such that FEV1 after double lung transplant in GERD patients approaches that of single lung transplant in non-GERD patients. We advocate thorough testing for GERD before lung transplantation; if identified, aggressive therapy early after transplant, including fundoplication, may prove efficacious

Ethical issues in implementation research: a discussion of the problems in achieving informed consent

Background: Improved quality of care is a policy objective of health care systems around the world. Implementation research is the scientific study of methods to promote the systematic uptake of clinical research findings into routine clinical practice, and hence to reduce inappropriate care. It includes the study of influences on healthcare professionals' behaviour and methods to enable them to use research findings more effectively. Cluster randomized trials represent the optimal design for evaluating the effectiveness of implementation strategies. Various codes of medical ethics, such as the Nuremberg Code and the Declaration of Helsinki inform medical research, but their relevance to cluster randomised trials in implementation research is unclear. This paper discusses the applicability of various ethical codes to obtaining consent in cluster trials in implementation research. Discussion: The appropriate application of biomedical codes to implementation research is not obvious. Discussion of the nature and practice of informed consent in implementation research cluster trials must consider the levels at which consent can be sought, and for what purpose it can be sought. The level at which an intervention is delivered can render the idea of patient level consent meaningless. Careful consideration of the ownership of information, and rights of access to and exploitation of data is required. For health care professionals and organizations, there is a balance between clinical freedom and responsibility to participate in research. Summary: While ethical justification for clinical trials relies heavily on individual consent, for implementation research aspects of distributive justice, economics, and political philosophy underlie the debate. Societies may need to trade off decisions on the choice between individualized consent and valid implementation research. We suggest that social sciences codes could usefully inform the consideration of implementation research by members of Research Ethics Committees

17 ways to say yes:Toward nuanced tone of voice in AAC and speech technology

People with complex communication needs who use speech-generating devices have very little expressive control over their tone of voice. Despite its importance in human interaction, the issue of tone of voice remains all but absent from AAC research and development however. In this paper, we describe three interdisciplinary projects, past, present and future: The critical design collection Six Speaking Chairs has provoked deeper discussion and inspired a social model of tone of voice; the speculative concept Speech Hedge illustrates challenges and opportunities in designing more expressive user interfaces; the pilot project Tonetable could enable participatory research and seed a research network around tone of voice. We speculate that more radical interactions might expand frontiers of AAC and disrupt speech technology as a whole

HIF-1 and SKN-1 Coordinate the Transcriptional Response to Hydrogen Sulfide in Caenorhabditis elegans

Hydrogen sulfide (H2S) has dramatic physiological effects on animals that are associated with improved survival. C. elegans grown in H2S are long-lived and thermotolerant. To identify mechanisms by which adaptation to H2S effects physiological functions, we have measured transcriptional responses to H2S exposure. Using microarray analysis we observe rapid changes in the abundance of specific mRNAs. The number and magnitude of transcriptional changes increased with the duration of H2S exposure. Functional annotation suggests that genes associated with protein homeostasis are upregulated upon prolonged exposure to H2S. Previous work has shown that the hypoxia-inducible transcription factor, HIF-1, is required for survival in H2S. In fact, we show that hif-1 is required for most, if not all, early transcriptional changes in H2S. Moreover, our data demonstrate that SKN-1, the C. elegans homologue of NRF2, also contributes to H2S-dependent changes in transcription. We show that these results are functionally important, as skn-1 is essential to survive exposure to H2S. Our results suggest a model in which HIF-1 and SKN-1 coordinate a broad transcriptional response to H2S that culminates in a global reorganization of protein homeostasis networks

On equal temperament

In this article, I use Stengers’ (2010) concepts of ‘factish’, ‘requirements’ and ‘obligations’, as well as Latour’s (1993) critique of modernity, to interrogate the rise of Equal Temperament as the dominant system of tuning for western music. I argue that Equal Temperament is founded on an unacknowledged compromise which undermines its claims to rationality and universality. This compromise rests on the standardization which is the hallmark of the tuning system of Equal Temperament, and, in this way, it is emblematic of Latour’s definition of modernity. I further argue that the problem of the tuning of musical instruments is one which epitomizes the modern distinction between the natural and the social. In turn, this bears witness to what Whitehead calls the ‘bifurcation of nature’. Throughout this article, using the work of Stengers and Latour, I seek to use tuning as a case study which allows social research to talk both of the natural and of the social aspects of music and tuning, without recourse to essentialism or simple social construction. In this way, my argument seeks to avoid bifurcating nature

Complicated spastic paraplegia in patients with AP5Z1 mutations (SPG48)

Objective: Biallelic mutations in the AP5Z1 gene encoding the AP-5 ζ subunit have been described in a small number of patients with hereditary spastic paraplegia (HSP) (SPG48); we sought to define genotype–phenotype correlations in patients with homozygous or compound heterozygous sequence variants predicted to be deleterious. Methods: We performed clinical, radiologic, and pathologic studies in 6 patients with biallelic mutations in AP5Z1. Results: In 4 of the 6 patients, there was complete loss of AP-5 ζ protein. Clinical features encompassed not only prominent spastic paraparesis but also sensory and motor neuropathy, ataxia, dystonia, myoclonus, and parkinsonism. Skin fibroblasts from affected patients tested positive for periodic acid Schiff and autofluorescent storage material, while electron microscopic analysis demonstrated lamellar storage material consistent with abnormal storage of lysosomal material. Conclusions: Our findings expand the spectrum of AP5Z1-associated neurodegenerative disorders and point to clinical and pathophysiologic overlap between autosomal recessive forms of HSP and lysosomal storage disorders

Complicated spastic paraplegia in patients with AP5Z1 mutations (SPG48).

OBJECTIVE: Biallelic mutations in the AP5Z1 gene encoding the AP-5 ζ subunit have been described in a small number of patients with hereditary spastic paraplegia (HSP) (SPG48); we sought to define genotype-phenotype correlations in patients with homozygous or compound heterozygous sequence variants predicted to be deleterious. METHODS: We performed clinical, radiologic, and pathologic studies in 6 patients with biallelic mutations in AP5Z1. RESULTS: In 4 of the 6 patients, there was complete loss of AP-5 ζ protein. Clinical features encompassed not only prominent spastic paraparesis but also sensory and motor neuropathy, ataxia, dystonia, myoclonus, and parkinsonism. Skin fibroblasts from affected patients tested positive for periodic acid Schiff and autofluorescent storage material, while electron microscopic analysis demonstrated lamellar storage material consistent with abnormal storage of lysosomal material. CONCLUSIONS: Our findings expand the spectrum of AP5Z1-associated neurodegenerative disorders and point to clinical and pathophysiologic overlap between autosomal recessive forms of HSP and lysosomal storage disorders