Screening and Early Recognition of Sepsis in Home Hospital and Home Care Patients

Problem Statement: In 2018, septicemia was the number one diagnosis for hospital inpatient stays for ages 65-74 in the United States (Agency for Healthcare Research and Quality, 2018). Most hospital admissions due to sepsis come from the community- as many as 87% (Rhee et al., 2017). People over 65 are 13 times more likely to end up hospitalized due to sepsis (Sepsis Alliance, n.d.). Sepsis in Home Hospital Care (HHC) and Home Care (HC) patients is prevalent because these patients are typically over 65. HC and the HHC program within the project site have noted a rise in hospital readmissions due to sepsis. HC nurses do not always identify early sepsis signs and symptoms due to a gap in sepsis knowledge. Early recognition and prompt action can improve outcomes and decrease unnecessary hospitalizations in HHC patients. Purpose: This quality improvement (QI) project aimed to provide sepsis education and sepsis screening tool training to HC nurses. The training was intended to increase HC nurses’ ability to identify early sepsis signs and symptoms, improve patient outcomes, and decrease hospital readmissions related to sepsis. Methods: A QI project provided sepsis education to 114 HC nurses who completed pre, post, and 5-week follow-up questionnaires that measured staff knowledge of sepsis\u27s early signs and symptoms. Education occurred over two mandatory HC nursing staff quarterly meetings, and data collection occurred before and after the meetings. Results: Due to various intervening factors, only three HC nurses completed the pre-sepsis knowledge assessment; only 1 (33%) completed the post-sepsis assessment. This participant did not complete the 5-week knowledge retention assessment. The post-sepsis knowledge assessment score (10 out of 16) was one point lower than the pre-sepsis knowledge assessment score (11 out of 16). 5 HC nurses completed the 5-week sepsis knowledge retention assessment. The average score ranged from 10 to 15 (62.5% to 93.7%) out of 16. Conclusion: The implementation of sepsis education for HC nurses successfully educated 114 HC nurses; however, participation in the sepsis knowledge assessments was very poor. As a result of poor participation, a conclusion cannot be drawn as to whether or not sepsis education was directly related to increasing HC nursing sepsis knowledge

Why do doctors in Norway choose general practice and remain there? A qualitative study about motivational experiences

Objective: To explore experiences motivating doctors to become and remain GPs. Design and contributors: Qualitative analysis of written responses from an open-ended question about motivational experiences posted on an internet discussion list for GPs in Norway. Texts from 25 contributors were analysed with Systematic Text Condensation, supported by theories about calling as motivation. Results: Analysis revealed numerous aspects of motivation to become and remain a general practitioner. Inspirations from early experiences and skilled role models had conveyed values and offered insight into a fascinating world of care, gratitude and respect. Close and continuous relationships with patients provided GPs with humbling experiences and learning moments. Contributors described how these encounters became rewarding sources of insight and mutual trust, improving interpersonal skills. Also, the extensive variety of tasks during the workday and the space for autonomy and independence was emphasised. Implications: Understanding motivational experiences influencing GPs’ choice of medical career is necessary to develop strategies for recruitment and stability and contribute to prevention of burn-out and improper work-life balance. GPs’ professional identities and commitments should be recognized and developed in dialogues between authorities and GPs to enhance communication, improve the structural frames of work environment and thereby sustainable recruitment. Key points GPs regard their choice of medical career as strongly influenced by motivational experiences in childhood, adolescence and as medical students Role models, diversity of work, feelings of being able to contribute and rewarding and continuous relationships with patients were mentioned to activate and maintain general practice commitment Knowledge about motivational influences, professional identities and commitment for GPs is crucial for medical education and dialogue to promote general practice as a career choice and prevent dangers of work overload and burnoutpublishedVersio

Climate Underground: The Effects of Climate Variability on Groundwater Irrigation

This study addresses the question of groundwater use sensitivity to changes in climate. We use county fixed effects models to empirically estimate the effect of climatic changes during the growing season on groundwater use for irrigation. This study uses data from USGS reports on industry water use and weather data from NOAA. We find both precipitation and temperature have a significant effect on groundwater irrigation, with particular prominence in areas with lower annual precipitation on average. These effect estimates are then used to model the effects of climate change on groundwater irrigation by the end of the century. We conclude that groundwater users are more responsive in their groundwater use to changes in precipitation than to changes in temperature, and that increased groundwater demand will be particularly prominent in Texas, the states overlying the High Plains Aquifer, and in parts of the Northwestern United States

The Role of Astrocytes in Tumor Growth and Progression

Current research is continually implicating the importance of astrocytes as active participants in neurological injury, disease, and tumor progression. This chapter will discuss some of these emerging concepts, especially as they relate to tumor biology. Astrocytes themselves can become tumorigenic, such as the case in gliomas, which often have aberrant signaling in key regulating genes of astrocyte development. Astrocytes secrete factors that maintain the tight junctions of the blood brain barrier (BBB), which in turn regulates the success or failure of metastatic cells extravasating into the brain. This astrocytic association with the brain vasculature also promotes brain tumor stem cell characteristics, which are known to be necessary for tumor initiation. Tumor cells within the brain make direct contacts with astrocytes through gap junctions, which subsequently lead to increased chemoresistance of the tumor cells. Astrocytes have also been shown to effect tumors cells via secretion of degradative enzymes, cytokines, chemokines, and growth factors, all of which have been shown to promote tumor cell proliferation, survival, and invasion. Thus, research in astrocyte biology and the role of astrocytes in the tumor microenvironment has and will likely continue to reveal novel targets for cancer intervention

Effects of Exercise on Glycemic Response after Consumption of Monster Energy

Energy drinks have been anecdotally associated with deleterious cardiovascular health outcomes. These drinks contain ingredients, including but not limited to caffeine, which could affect glycemic response to the carbohydrate ingredients in the drink. Exercise alters insulin sensitivity and could be a factor related to the response to acute energy drink response. The aim of this study was to determine if acute exercise would alter the glycemic and physiological response to the consumption of Monster Energy ©. Following an overnight fast, human subjects (age 19.11±1.39; 30 female; 5 male) were randomized to exercise on a stationary bike at 33% of their predicted VO2 max for 10 minutes with a five minute sitting rest after, or sitting (control) for five minutes prior to ingestion of Monster Energy. Blood glucose, heart rate, and blood pressure were measured 0-, 30-, 60- , and 90-minutes postprandially. Data is represented as LSM ± SE with significance analyzed using a t-test, or multiple comparison test. Significance is assumed when P\u3c 0.05. Blood glucose (mg/dL) for control at 0-, 30-, 60-, and 90-minutes 91.58±1.2, 133.7±4.29, 96.3±4.17, and 82.4±1.82 mg/dL, respectively. For those receiving bike exercise prior to ingestion blood glucose was 92.2±1.2, 126.6±3.79, 92.5±2.27, 84.0±1.77 mg/dL. There were no significant blood glucose differences observed between groups across time, within group significance in both groups was observed between 0 and 30, 30 and 60, and 60 and 90, for control only. Heart rate for control at 0-, 30-, 60-, and 90-minutes was 78.0±3.06, 78.2±2.55, 78.6±2.6, and 74.4±1.85 respectively. For those receiving bike exercise prior to ingestion heart rate was 88.7±3.71, 85.5±2.69, 83.1±2.35, and 80.3±2.89. There were no significant heart rate differences observed between groups across time, within group significance in both groups was observed between 0 and 30, 30 and 60, and 60 and 90, for control only. Blood pressure for control at 0-, 30-, 60-, and 90-minutes was 86.8±2.05, 89.2±2.05, 89.2±2.5, and 87.6±2.6. For those receiving bike exercise prior to ingestion blood pressure was 90.6±3.07, 88.98±2.3, 88.2±1.97, and 86.98±2.08. There were no significant blood pressure differences observed between groups across time, within group significance in both groups was observed between 0 and 30, 30 and 60, and 60 and 90, for control only. In conclusion exercise probably does not alter the glycemic and physiological response to energy drinks.https://openriver.winona.edu/urc2019/1092/thumbnail.jp

Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Use Disorders in Title X Facilities: Assessing Barriers, Change of Provider Behavior, and Patient Outcomes

Introduction: Substance use disorders, specifically opioids, are an increasing problem in the US. Screening, brief intervention, and referral to treatment (SBIRT) is a method to identify and treat patients at risk, or currently using illicit substances. Integrating SBIRT into Title X facilities, which provide reproductive healthcare to lower income populations, may allow identification and treatment of individuals that do not seek healthcare elsewhere. Objective: We aim to assess the efficacy of a longitudinal training program in Title X facilities. The program provides a structured approach to implementing new protocols, including an educational session on SBIRT and motivational interviewing (MI). Methods: We conducted a trial of assessments during the first of two cohorts to determine their value as assessments for learner outcomes based on SBIRT/MI training. One assessment measured SBIRT/MI knowledge, while the other measured attitudes about substance users. Data was collected using electronic forms with personalized and de-identified codes. Results: 3 of 35 providers responded, representing 3 of 5 facilities. All respondents thought the assessments were ‘Very relevant’ to their training, the knowledge assessment was ‘Appropriately difficult’ (mean score of 8/10 ± 1), and the training program improved their skills to identify and address patients with concerns of substance use. Conclusion: Despite limitations, results suggest the knowledge and attitude assessments were appropriate for our population. In the second cohort, we will conduct pre- and post-testing. These measures will be used to assess the efficacy of training, as well as compare the attitude outcomes with values in the literature

A Randomized, Double-Blinded, Placebo-Controlled, Cross Over Study Evaluating the Efficacy and Safety of Timolol Ophthalmic Solution as an Acute Treatment of Migraine

Introduction. Daily oral beta-adrenoreceptor antagonist has been shown to be effective in preventing migraine headaches. Timolol 0.5% ophthalmic solution is a non-selective beta-adrenoreceptor antago- nist, where the primary use is for glaucoma. There have been case reports that timolol is effective in aborting or improving an acute migraine headache. The objective of this study was to assess the efficacy (decrease of ≥ 50% in pain scale at 120 minutes) of timolol 0.5% ophthalmic solution compared to placebo in acute treatment of migraine headache. Methods.We performed a randomized, double-blind, crossover, placebo-controlled, study. Study entry criteria required subjects to have one to eight migraine episodes per month. The primary outcome was comparison of the change in a visual analog pain scale (VAS) at 120 minutes after taking the study medication. Study subjects were given a pain scale with a range of 1 (no pain) to 10 (most severe pain) to complete after onset of migraine but before administration of study drops and 120 minutes after administration of study drops. Improve- ment was defined as a ≥ 50% decrease in pain scale. Results. Nineteen subjects completed the study and were used for analysis. The primary outcome changes in pain scale, 120 minutes after dose, showed a similar decrease for placebo and drug with a slightly wider 95% CI for placebo. Six subjects in each arm experi- enced a ≥ 50% decrease in pain scale. Conclusion. These results support that timolol 0.5% ophthalmic solution is not an efficacious treatment for acute migraine headache

Thymectomy through lateralized partial sternotomy

A young woman with nonthymomic myasthenia gravis with failure of medical treatment was offered thymectomy through partial sternotomy. Shifting of vertical arm of “L” incision laterally avoids fracture of opposite sternal flange and provides better sternal stability postoperatively