Clinical Decision Making by Critical Care Mid-Level Practitioners Working within an Interdisciplinary Team: A Dissertation

To improve patient safety a major change in health care reduced medical resident work hours to limit provider fatigue, in 2002 (Philibert, Friedmann, Williams, & Hours, 2002). This resulted in mid-level practitioners filling this provider void in health care teams, including critical care units (Buchanan, 1996; Christmas et al., 2005; Hoffman, Tasota, Scharfenberg, Zullo, & Donahoe, 2003; Hoffman, Tasota, Zullo, Scharfenberg, & Donahoe, 2005; Hooker & McCaig, 1996, 2001; Kaups, Parks, & Morris, 1998; Miller, Riehl, Napier, Barber, & Dabideen, 1998; Yeager, Shaw, Casavant, & Burns, 2006). In order to make appropriate clinical decisions for patients in critical care settings, mid-level practitioners are required to interpret data from multiple sources and to assimilate this information in a timely manner (Bernard, Corwin, & MacIntyre, 2000). Although these practitioners are actively involved in decision making individually and among interdisciplinary teams in critical care units, their decision making has not been described in the literature to date (Shortell et al., 1994). Therefore, the purpose of this qualitative study was to describe how critical care mid-level practitioners (N= 17) make decisions within an interdisciplinary team, undergirded by the cognitive continuum theory. A qualitative research design using focus groups guided by naturalistic inquiry enabled data collection. An interview guide, developed from the literature review and undergirded by the cognitive continuum theory, was used to structure discussion in the focus groups. Additionally, a demographic questionnaire and vignette were used to aid in description of findings. Data was managed by note based analysis and summarized on a Microsoft Excel document. Qualitative description was used to illustrate the findings. Prior to this study, there was a paucity of empirical literature describing the clinical decision making of critical care mid-level practitioners. The findings revealed a web of complexity in mid-level practitioner decision making on an interdisciplinary team. This included an overarching theme of quality of care, with central overlapping themes of judgment, resources, and negotiation interwoven with sub-themes of trust, communication, experience, and team structure. This study’s findings have direct implications for mid-level practitioner training courses, mid-level training, critical care orientation programs, theory development, and health policy

Expression of the Integrin Beta 8 Gene (ITGB8) in Epicardial Adipose Tissue is Highly and Directly Correlated with the Degree of Coronary Atherosclerosis

Background: In patients with coronary artery disease (CAD), epicardial adipose tissue (EAT) expression of inflammatory genes is high while expression of anti-inflammatory genes is low. We hypothesized that expression of certain genes in EAT would correlate directly with the degree of adjacent CAD. Methods: EAT and paired subcutaneous adipose tissue (SAT) samples were collected from cardiac surgery patients (n=9) with and without CAD. RNA was isolated and hybridized to Affymetrix 1.0 ST chips. Genes differentially expressed in EAT vs. SAT were identified. Probe intensities were correlated with the severity of CAD in each patient using the Gensini score. Results: 35 genes were differentially expressed in EAT at \u3e3.0 fold change (p Conclusions: Expression of ITGB8 is directly correlated with CAD severity. ITGB8 has been previously shown to be expressed by fibroblasts and functions to activate TGFβ. TGFβ signaling has also been correlated with advanced atherosclerosis. We speculate that EAT expression of ITGB8 may have pro-inflammatory effects, possibly by activating TGFβ, and stimulating recruitment of dendritic cells or T cells to secondary lymphoid organs in EAT. Whether or not this is the case is a goal of future studies

Expression of ITGB8 in Epicardial Adipose Tissue is Highly and Directly Correlated with the Severity of Coronary Atherosclerosis

Background: In patients with coronary artery disease (CAD), epicardial adipose tissue (EAT) has been shown to express increased levels of inflammatory cytokines (IL-1β, IL-6, MCP-1, TNFα) and decreased levels of anti-inflammatory and cardioprotective adipokines. However, it is not known whether or not inflammation in EAT is a primary cause or a secondary response to atherosclerosis. In order to better understand this pathophysiology, we tested the hypothesis that expression of certain genes in EAT would correlate with the degree of coronary atherosclerosis. Purpose: The purpose of this study was to determine whether there is a difference in gene expression in epicardial fat of patients with and without coronary artery disease and if there is a difference, whether these differentially expressed genes participate in the inflammatory pathways. Methods: EAT and paired subcutaneous adipose tissue (SAT) samples collected from cardiac surgery patients with and without coronary disease were fixed for microscopy and frozen for RNA extraction. RNA was hybridized to Affymetrix Human Gene 1.0 ST chips. We used an unbiased approach to identify genes highly and differentially expressed in EAT vs. SAT (FC\u3e3.0). The probe intensities for these resultant genes were then correlated with the severity of atherosclerosis in each patient as determined by the Gensini score. Results:35 genes were differentially expressed in EAT at \u3e3.0 fold change (p Conclusions: Using an unbiased whole genome approach, we identified ITGB8 and TG2 as genes whose expression is correlated with CAD severity. ITGB8 has been previously shown to be expressed by fibroblasts and functions to activate TGFβ. TGFβ signaling has also been correlated with advanced atherosclerosis. We speculate that EAT expression of ITGB8 may have pro-inflammatory effects, possibly by activating TGFβ, and stimulating recruitment of dendritic cells or T cells to secondary lymphoid organs in EAT. Whether or not this is the case is a goal of future studies