Brain Pro-TCT:Quality improvement of delirium detection on a cardiothoracic surgical ward

1) Please declare any conflicts of interest below: The authors declare a potential conflict of interest but not a personal conflict of interest. Part of the costs for this study are covered by Heartcentre Twente Foundation. Prolira provided training and the DeltaScans during the study period free of charge and applied a discount to the disposable patch costs. 2) Ethics Approval: Ethical approval was waived by the Advisory committee Medisch Spectrum Twente at Enschede. The Institutional Review Board of Medisch Spectrum Twente has concluded that this study does not fall under the remit of the Medical Research Involving Human Subjects. 3) Context: The study was done on the cardiothoracic surgery ward at Thoraxcentrum Twente (Medisch Spectrum Twente, Enschede, the Netherlands), a tertiary teaching hospital. Patients 70 years or older who underwent cardiac surgery were included. The quality improvement team included nurse practitioners in cardiac surgery and psychiatry, a cardiac surgeon, nurses, a technical physician, and an epidemiologist. 4) Problem: Delirium is a common syndrome of acute brain failure, which often occurs in hospitalized older patients following cardiac surgery. Delirium after cardiac surgery is related to adverse long-term outcomes, more readmissions to hospital, and decreased cognitive and functional outcomes. Early detection of delirium allows early treatment of underlying causes. In standard care, we use a delirium observation scale score (DOSS). Recently, a single-channel electroencephalography (EEG) medical device was developed to screen delirium based on detection of delta waves (DeltaScan). Using DeltaScan in routine care may improve delirium detection and clinical outcomes. 5) Assessment of problem and analysis of its causes: Previous delirium studies in Thoraxcentrum Twente using DOSS as standard care reported an incidence of delirium of 13 to 17% in elective patients aged ≥45 years. Published and unpublished research data for cardiothoracic surgery wards show an increase of delirium detection by &gt;15% (absolute percentage growth), when DeltaScan was used in clinical studies. Nurses, nurse practitioners, and medical doctors were informed  about the aims of the study and importance of delirium screening. A nurse improvement project, including a workgroup, was started, where the importance of screening was emphasized. Before the implementation of the DeltaScan, nurses on the surgical ward received education and training. Medical doctors, residents, and nurse practitioners were trained on how to interpret the DeltaScan scores. 6) Intervention: First, we continued the DOSS as regular care for delirium screening; three measurements a day for the first three postoperative days. Second, DeltaScan was implemented as new regular care. DeltaScan measurements took place twice a day for at least three consecutive days. 7) Strategy for change: In February 2021 additional training of the DOSS for delirium screening began, and from April 2021 onwards, prospective data collection of the first group continued till May 2022. Training with DeltaScan started in March/April 2022. The DeltaScan data collection started in May 2022, and is still ongoing. 8) Measurement of improvement: The primary endpoints to measure improvement were incidence of delirium, and length of hospital stay. Secondary endpoints included delirium duration, adherence to delirium protocol, and costs related to the innovation. The innovation was deemed successful with an incidence increase from 15 to 30%, and a length of stay reduction with at least 1.5 days. This abstract is based on preliminary data until October 2022. 9) Effects of changes: In total 612 patients were included, with 450 patients in the DOSS group and 162 patients (interim results) in the DeltaScan group. Incidence of finding delirium increased from 15% to 25% (p = 0.008). Median length of hospital stay for delirium patients was reduced from 9 hospital nights to 5.5 nights (p = 0.002). Median duration of delirium decreased (not significantly) from 77 hours to 65 hours (p = 0.12). 10) Lessons learned: Involving all stakeholders early in the project helped to gain commitment to the innovation. The change was measured in a scientific study, as no formal results on effectivity are known at the moment. Introducing a new device for delirium screening arouses resistance. Reducing or removing this resistance remains difficult. 11) Messages for others: Involving all stakeholders in a working group for delirium screening helped to start an innovation, monitor benefits, and motivated colleagues to actually commit to the innovation. Screening for delirium with DeltaScan in our study leads to an increase of finding delirium, and reduced hospital stay (interim results) for patients after cardiothoracic surgery. It is unknown yet, whether this is cost-effective. We hypothesize that these results are expected to be similar for other patient groups such as geriatric or general surgical patients. 12) Please describe how you have involved patients, carers, or family members in the project: Patients and their relatives are informed about the risk of delirium and the impact of delirium before hospital admission. Relatives and patients are often informed during measurements on the importance of adequate delirium screening, where positive responses are often heard. No formal co-creation by patients was done, but informal feedback will be collected in the near future. </p

Breaking Traditions:An Isotopic Study on the Changing Funerary Practices in the Dutch Iron Age (800-12 bc)

Urnfields in the Dutch river area were replaced by cemeteries with a mixture of cremation and inhumation graves around the sixth century bc. This study provides the first biogeochemical evidence that the Iron Age communities were heterogeneous in terms of geological origins. The high percentage of non-locally born individuals (~48%) supports the hypothesis that the change in burial practice was the result of the influx of foreign people, who were being allowed to keep their own burial customs, whereas some of the local inhabitants adapted the burial rites of foreign cultures, leading to a heterogeneous burial rite for some centuries

Trends in Antarctic Peninsula surface melting conditions from observations and regional climate modeling

Multidecadal meteorological station records and microwave backscatter time-series from the SeaWinds scatterometer onboard QuikSCAT (QSCAT) were used to calculate temporal and spatial trends in surface melting conditions on the Antarctic Peninsula (AP). Four of six long-term station records showed strongly positive and statistically significant trends in duration of melting conditions, including a 95% increase in the average annual positive degree day sum (PDD) at Faraday/Vernadsky, since 1948. A validated, threshold-based melt detection method was employed to derive detailed melt season onset, extent, and duration climatologies on the AP from enhanced resolution QSCAT data during 1999–2009. Austral summer melt on the AP was linked to regional- and synoptic-scale atmospheric variability by respectively correlating melt season onset and extent with November near-surface air temperatures and the October–January averaged index of the Southern Hemisphere Annular Mode (SAM). The spatial pattern, magnitude, and interannual variability of AP melt from observations was closely reproduced by simulations of the regional model RACMO2. Local discrepancies between observations and model simulations were likely a result of the QSCAT response to, and RACMO2 treatment of, ponded surface water, and the relatively crude representation of coastal climate in the 27 km RACMO2 grid

Century-scale simulations of the response of the West Antarctic Ice Sheet to a warming climate

We use the BISICLES adaptive mesh ice sheet model to carry out one, two, and three century simulations of the fast-flowing ice streams of the West Antarctic Ice Sheet, deploying sub-kilometer resolution around the grounding line since coarser resolution results in substantial underestimation of the response. Each of the simulations begins with a geometry and velocity close to present-day observations, and evolves according to variation in meteoric ice accumulation rates and oceanic ice shelf melt rates. Future changes in accumulation and melt rates range from no change, through anomalies computed by atmosphere and ocean models driven by the E1 and A1B emissions scenarios, to spatially uniform melt rate anomalies that remove most of the ice shelves over a few centuries. We find that variation in the resulting ice dynamics is dominated by the choice of initial conditions and ice shelf melt rate and mesh resolution, although ice accumulation affects the net change in volume above flotation to a similar degree. Given sufficient melt rates, we compute grounding line retreat over hundreds of kilometers in every major ice stream, but the ocean models do not predict such melt rates outside of the Amundsen Sea Embayment until after 2100. Within the Amundsen Sea Embayment the largest single source of variability is the onset of sustained retreat in Thwaites Glacier, which can triple the rate of eustatic sea level rise

Sensitivity of the Atlantic meridional overturning circulation to South Atlantic freshwater anomalies

The sensitivity of the Atlantic Meridional Overturning Circulation (AMOC) to changes in basin integrated net evaporation is highly dependent on the zonal salinity contrast at the southern border of the Atlantic. Biases in the freshwater budget strongly affect the stability of the AMOC in numerical models. The impact of these biases is investigated, by adding local anomaly patterns in the South Atlantic to the freshwater fluxes at the surface. These anomalies impact the freshwater and salt transport by the different components of the ocean circulation, in particular the basin-scale salt-advection feedback, completely changing the response of the AMOC to arbitrary perturbations. It is found that an appropriate dipole anomaly pattern at the southern border of the Atlantic Ocean can collapse the AMOC entirely even without a further hosing. The results suggest a new view on the stability of the AMOC, controlled by processes in the South Atlantic. <br/

Семантические барьеры в деловой коммуникации

Статья из специализированного выпуска научного журнала "Культура народов Причерноморья", материалы которого объединены общей темой "Язык и Мир" и посвящены общим вопросам Языкознания и приурочены к 80-летию со дня рождения Николая Александровича Рудякова.Стаття із спеціалізованого випуску наукового журналу "Культура народов Причерноморья", матеріали якого поєднані загальною темою "Мова і Світ" і присвячені загальним питанням мовознавства і приурочені до 80-річчя з дня народження Миколи Олександровича Рудякова

Serum methylarginines and spirometry-measured lung function in older adults

Rationale: Methylarginines are endogenous nitric oxide synthase inhibitors that have been implicated in animal models of lung disease but have not previously been examined for their association with spirometric measures of lung function in humans. Objectives: This study measured serum concentrations of asymmetric and symmetric dimethylarginine in a representative sample of older community-dwelling adults and determined their association with spirometric lung function measures. Methods: Data on clinical, lifestyle, and demographic characteristics, methylated arginines, and L-arginine (measured using LC-MS/MS) were collected from a population-based sample of older Australian adults from the Hunter Community Study. The five key lung function measures included as outcomes were Forced Expiratory Volume in 1 second, Forced Vital Capacity, Forced Expiratory Volume in 1 second to Forced Vital Capacity ratio, Percent Predicted Forced Expiratory Volume in 1 second, and Percent Predicted Forced Vital Capacity. Measurements and Main Results: In adjusted analyses there were statistically significant independent associations between a) higher asymmetric dimethylarginine, lower Forced Expiratory Volume in 1 second and lower Forced Vital Capacity; and b) lower L-arginine/asymmetric dimethylarginine ratio, lower Forced Expiratory Volume in 1 second, lower Percent Predicted Forced Expiratory Volume in 1 second and lower Percent Predicted Forced Vital Capacity. By contrast, no significant associations were observed between symmetric dimethylarginine and lung function. Conclusions: After adjusting for clinical, demographic, biochemical, and pharmacological confounders, higher serum asymmetric dimethylarginine was independently associated with a reduction in key measures of lung function. Further research is needed to determine if methylarginines predict the decline in lung function

A new albedo parameterization for use in climate models over the Antarctic ice sheet

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/95255/1/jgrd16889.pd

Extent of Low-accumulation 'Wind Glaze' Areas on the East Antarctic Plateau: Implications for Continental Ice Mass Balance

Persistent katabatic winds form widely distributed localized areas of near-zero net surface accumulation on the East Antarctic ice sheet (EAIS) plateau. These areas have been called 'glaze' surfaces due to their polished appearance. They are typically 2-200 square kilometers in area and are found on leeward slopes of ice-sheet undulations and megadunes. Adjacent, leeward high-accumulation regions (isolated dunes) are generally smaller and do not compensate for the local low in surface mass balance (SMB). We use a combination of satellite remote sensing and field-gathered datasets to map the extent of wind glaze in the EAIS above 1500m elevation. Mapping criteria are derived from distinctive surface and subsurface characteristics of glaze areas resulting from many years of intense annual temperature cycling without significant burial. Our results show that 11.2 plus or minus 1.7%, or 950 plus or minus 143 x 10(exp 3) square kilometers, of the EAIS above 1500m is wind glaze. Studies of SMB interpolate values across glaze regions, leading to overestimates of net mass input. Using our derived wind-glaze extent, we estimate this excess in three recent models of Antarctic SMB at 46-82 Gt. The lowest-input model appears to best match the mean in regions of extensive wind glaze