Improving Discharge Planning Using the Re-Engineered Discharge (RED) Program

The 12-actionable items of the Re-Engineered Discharge Program (RED) are equipped to address essential areas to prevent hospital re-visits. Evidence supports the use of nurses to complete these essential components of hospital interventions. The aims of this project were to: 1) assess nurses’ readiness to learn prior to receiving education on the RED Program, and 2) measure the utilization of the RED discharge process from patient chart reviews following an educational intervention focused on the RED 12-actionable items. Participants (N = 69) scored high M = 219.8 (SD 23.7) on the Self-Directed Learning Readiness – Adult Scale, indicating the nurses had high self-directed readiness to learn prior to the educational intervention. Chart reviews found that utilization of the 12-actionable items pre-intervention, (n = 60) M = 6.55 (SD 1.478) compared to post-intervention (n = 60) M = 10.08 (SD 1.544) indicated a statistically significant improvement in discharge planning (t = 17.730, p = .000 (CI 3.13 – 3.93). The study supports that RED discharge program focused education sessions for nurses with higher levels of self-directed readiness to learn are effective in promoting improvement in discharge planning

Data related to cyclic deformation and fatigue behavior of direct laser deposited Ti–6Al–4V with and without heat treatment

AbstractData is presented describing the strain-controlled, fully-reversed uniaxial cyclic deformation and fatigue behavior of Ti–6Al–4V specimens additively manufactured via Laser Engineered Net Shaping (LENS) – a Direct Laser Deposition (DLD) process. The data was collected by performing multiple fatigue tests on specimens with various microstructural states/conditions, i.e. in their ‘as-built’, annealed (below the beta transus temperature), or heat treated (above the beta transus temperature) condition. Such data aids in characterizing the mechanical integrity and fatigue resistance of DLD parts. Data presented herein also allows for elucidating the strong microstructure coupling of the fatigue behavior of DLD Ti–6Al–4V, as the data trends were found to vary with material condition (i.e. as-built, annealed or heat treated) [1]. This data is of interest to the additive manufacturing and fatigue scientific communities, as well as the aerospace and biomedical industries, since additively-manufactured parts cannot be reliably deployed for public use, until their mechanical properties are understood with high certainty

Episodic X-ray Emission Accompanying the Activation of an Eruptive Prominence: Evidence of Episodic Magnetic Reconnection

We present an X-ray imaging and spectroscopic study of a partially occulted C7.7 flare on 2003 April 24 observed by RHESSI that accompanied a prominence eruption observed by TRACE. (1) The activation and rise of the prominence occurs during the preheating phase of the flare. The initial X-ray emission appears as a single coronal source at one leg of the prominence and it then splits into a double source. Such a source splitting happens three times, each coinciding with an increased X-ray flux and plasma temperature, suggestive of fast reconnection in a localized current sheet and an enhanced energy release rate. In the late stage of this phase, the prominence displays a helical structure. These observations are consistent with the tether-cutting and/or kink instability model for triggering solar eruptions. (2) The eruption of the prominence takes place during the flare impulsive phase. Since then, there appear signatures predicted by the classical CSHKP model of two-ribbon flares occurring in a vertical current sheet trailing an eruption. These signatures include an EUV cusp and current-sheet-like feature (or ridge) above it. There is also X-ray emission along the EUV ridge both below and above the cusp, which in both regions appears closer to the cusp at higher energies in the thermal regime. This trend is reversed in the nonthermal regime. (3) Spectral analysis indicates thermal X-rays from all sources throughout the flare, while during the impulsive phase there is additional nonthermal emission which primarily comes from the coronal source below the cusp. This source also has a lower temperature, a higher emission measure, and a much harder nonthermal spectrum than the upper sources.Comment: 8 pages, 5 figures, submitted to Ap

A new short-faced archosauriform from the Upper Triassic Placerias/Downs’ quarry complex, Arizona, USA, expands the morphological diversity of the Triassic archosauriform radiation

The Placerias/Downs’ Quarry complex in eastern Arizona, USA, is the most diverse Upper Triassic vertebrate locality known. We report a new short-faced archosauriform, Syntomiprosopus sucherorum gen. et sp. nov., represented by four incomplete mandibles, that expands that diversity with a morphology unique among Late Triassic archosauriforms. The most distinctive feature of Syntomiprosopus gen. nov. is its anteroposteriorly short, robust mandible with 3–4 anterior, a larger caniniform, and 1–3 “postcanine” alveoli. The size and shape of the alveoli and the preserved tips of replacement teeth preclude assignment to any taxon known only from teeth. Additional autapomorphies of S. sucherorum gen. et sp. nov. include a large fossa associated with the mandibular fenestra, an interdigitating suture of the surangular with the dentary, fine texture ornamenting the medial surface of the splenial, and a surangular ridge that completes a 90° arc. The external surfaces of the mandibles bear shallow, densely packed, irregular, fine pits and narrow, arcuate grooves. This combination of character states allows an archosauriform assignment; however, an associated and similarly sized braincase indicates that Syntomiprosopus n. gen. may represent previously unsampled disparity in early-diverging crocodylomorphs. The Placerias Quarry is Adamanian (Norian, maximum depositional age ~219 Ma), and this specimen appears to be an early example of shortening of the skull, which occurs later in diverse archosaur lineages, including the Late Cretaceous crocodyliform Simosuchus. This is another case where Triassic archosauriforms occupied morphospace converged upon by other archosaurs later in the Mesozoic and further demonstrates that even well-sampled localities can yield new taxa

Internally-Developed Teen Smoking Cessation Programs: Characterizing the Unique Features of Programs Developed by Community-Based Organizations

We have compared the unique features of teen tobacco cessation programs developed internally by community-based organizations (N=75) to prepackaged programs disseminated nationally (N=234) to expand our knowledge of treatment options for teen smokers. Internally-developed programs were more likely offered in response to the sponsoring organization’s initiative (OR=2.16, p<0.05); had fewer trained cessation counselors (OR=0.31, p<0.01); and were more likely found in urban areas (OR=2.89, p=0.01). Internally-developed programs more often provided other substance-abuse treatment services than prepackaged programs and addressed other youth-specific problem behaviors (p≤0.05). Studies that examine the effectiveness of internally-developed programs in reducing smoking and maintaining cessation for teen smokers are warranted

Challenges of Population-based Measurement of Suicide Prevention Activities Across Multiple Health Systems

Suicide is a preventable public health problem. Zero Suicide (ZS) is a suicide prevention framework currently being evaluated by Mental Health Research Network investigators embedded in six Health Care Systems Research Network (HCSRN) member health systems implementing ZS. This paper describes ongoing collaboration to develop population-based process improvement metrics for use in, and comparison across, these and other health systems. Robust process improvement metrics are sorely needed by the hundreds of health systems across the country preparing to implement their own best practices in suicide care. Here we articulate three examples of challenges in using health system data to assess suicide prevention activities, each in ascending order of complexity: 1) Mapping and reconciling different versions of suicide risk assessment instruments across health systems; 2) Deciding what should count as adequate suicide prevention follow-up care and how to count it in different health systems with different care processes; and 3) Trying to determine whether a safety planning discussion took place between a clinician and a patient, and if so, what actually happened. To develop broadly applicable metrics, we have advocated for standardization of care processes and their documentation, encouraged standardized screening tools and urged they be recorded as discrete electronic health record (EHR) variables, and engaged with our clinical partners and health system data architects to identify all relevant care processes and the ways they are recorded in the EHR so we are not systematically missing important data. Serving as embedded research partners in our local ZS implementation teams has facilitated this work

Medication use, renin-angiotensin system inhibitors, and acute care utilization after hospitalization in patients with chronic kidney disease.

OBJECTIVES: The aims of this secondary analysis were to: (a) characterize medication use following hospital discharge for patients with chronic kidney disease (CKD), and (b) investigate relationships of medication use with the primary composite outcome of acute care utilization 90 days after hospitalization. METHODS: The CKD-Medication Intervention Trial (CKD-MIT) enrolled acutely ill hospitalized patients with CKD stages 3-5 not dialyzed (CKD 3-5 ND). In this post hoc analysis, data for medication use were characterized, and the relationship of medication use with the primary outcome was evaluated using Cox proportional hazards models. RESULTS: Participants were taking a mean of 12.6 (standard deviation=5.1) medications, including medications from a wide variety of medication classes. Nearly half of study participants were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB). ACE inhibitor/ARB use was associated with decreased risk of the primary outcome (hazard ratio=0.51; 95% confidence interval 0.28-0.95; CONCLUSIONS: A large number, variety, and complexity of medications were used by hospitalized patients with CKD 3-5 ND. ACE inhibitor or ARB use at hospital discharge was associated with a decreased risk of 90-day acute care utilization

Effect of Levocarnitine vs Placebo as an Adjunctive Treatment for Septic Shock: The Rapid Administration of Carnitine in Sepsis (RACE) Randomized Clinical Trial

Importance: Sepsis induces profound metabolic derangements, while exogenous levocarnitine mitigates metabolic dysfunction by enhancing glucose and lactate oxidation and increasing fatty acid shuttling. Previous trials in sepsis suggest beneficial effects of levocarnitine on patient-centered outcomes. Objectives: To test the hypothesis that levocarnitine reduces cumulative organ failure in patients with septic shock at 48 hours and, if present, to estimate the probability that the most efficacious dose will decrease 28-day mortality in a pivotal phase 3 clinical trial. Design, Setting, and Participants: Multicenter adaptive, randomized, blinded, dose-finding, phase 2 clinical trial (Rapid Administration of Carnitine in Sepsis [RACE]). The setting was 16 urban US medical centers. Participants were patients aged 18 years or older admitted from March 5, 2013, to February 5, 2018, with septic shock and moderate organ dysfunction. Interventions: Within 24 hours of identification, patients were assigned to 1 of the following 4 treatments: low (6 g), medium (12 g), or high (18 g) doses of levocarnitine or an equivalent volume of saline placebo administered as a 12-hour infusion. Main Outcomes and Measures: The primary outcome required, first, a greater than 90% posterior probability that the most promising levocarnitine dose decreases the Sequential Organ Failure Assessment (SOFA) score at 48 hours and, second (given having met the first condition), at least a 30% predictive probability of success in reducing 28-day mortality in a subsequent traditional superiority trial to test efficacy. Results: Of the 250 enrolled participants (mean [SD] age, 61.7 [14.8] years; 56.8% male), 35, 34, and 106 patients were adaptively randomized to the low, medium, and high levocarnitine doses, respectively, while 75 patients were randomized to placebo. In the intent-to-treat analysis, the fitted mean (SD) changes in the SOFA score for the low, medium, and high levocarnitine groups were -1.27 (0.49), -1.66 (0.38), and -1.97 (0.32), respectively, vs -1.63 (0.35) in the placebo group. The posterior probability that the 18-g dose is superior to placebo was 0.78, which did not meet the a priori threshold of 0.90. Mortality at 28 days was 45.9% (34 of 74) in the placebo group compared with 43.3% (45 of 104) for the most promising levocarnitine dose (18 g). Similar findings were noted in the per-protocol analysis. Conclusions and Relevance: In this dose-finding, phase 2 adaptive randomized trial, the most efficacious dose of levocarnitine (18 g) did not meaningfully reduce cumulative organ failure at 48 hours

The genetics of adaptive shape shift in stickleback: pleiotropy and effect size.

The distribution of effect sizes of genes underlying adaptation is unknown (Orr 2005

Alzheimer’s disease genetic risk and cognitive reserve in relationship to long-term cognitive trajectories among cognitively normal individuals

Background: Both Alzheimer’s disease (AD) genetic risk factors and indices of cognitive reserve (CR) influence risk of cognitive decline, but it remains unclear whether they interact. This study examined whether a CR index score modifies the relationship between AD genetic risk factors and long-term cognitive trajectories in a large sample of individuals with normal cognition. Methods: Analyses used data from the Preclinical AD Consortium, including harmonized data from 5 longitudinal cohort studies. Participants were cognitively normal at baseline (M baseline age = 64 years, 59% female) and underwent 10 years of follow-up, on average. AD genetic risk was measured by (i) apolipoprotein-E (APOE) genetic status (APOE-ε2 and APOE-ε4 vs. APOE-ε3; N = 1819) and (ii) AD polygenic risk scores (AD-PRS; N = 1175). A CR index was calculated by combining years of education and literacy scores. Longitudinal cognitive performance was measured by harmonized factor scores for global cognition, episodic memory, and executive function. Results: In mixed-effects models, higher CR index scores were associated with better baseline cognitive performance for all cognitive outcomes. APOE-ε4 genotype and AD-PRS that included the APOE region (AD-PRSAPOE) were associated with declines in all cognitive domains, whereas AD-PRS that excluded the APOE region (AD-PRSw/oAPOE) was associated with declines in executive function and global cognition, but not memory. There were significant 3-way CR index score × APOE-ε4 × time interactions for the global (p = 0.04, effect size = 0.16) and memory scores (p = 0.01, effect size = 0.22), indicating the negative effect of APOE-ε4 genotype on global and episodic memory score change was attenuated among individuals with higher CR index scores. In contrast, levels of CR did not attenuate APOE-ε4-related declines in executive function or declines associated with higher AD-PRS. APOE-ε2 genotype was unrelated to cognition. Conclusions: These results suggest that APOE-ε4 and non-APOE-ε4 AD polygenic risk are independently associated with global cognitive and executive function declines among individuals with normal cognition at baseline, but only APOE-ε4 is associated with declines in episodic memory. Importantly, higher levels of CR may mitigate APOE-ε4-related declines in some cognitive domains. Future research is needed to address study limitations, including generalizability due to cohort demographic characteristics