Implementing an Endocarditis Interdisciplinary Pathway in a Large Academic Medical Center: A Quality Improvement Project

Infective endocarditis (IE) is an infection and or inflammation of the heart valves and endocardium and a potentially life threatening illness. Dependent on the infecting organism, the cardiac damage caused by IE can be indolent or very aggressive. Hospitalized patients with IE require management by an interdisciplinary team, including cardiologists, cardiac surgeons, infectious disease specialists, registered nurses, nurse practitioners, physician assistants, pharmacists, and social workers. Treatment is complex and patients often present with various comorbidities. Standardized interdisciplinary care protocols have been shown to reduce patient mortality and hospital length of stay. The development of the pathway guidelines was informed by stakeholder meetings and recommendations from the American Heart Association, American Association for Thoracic Surgery, and European Society of Cardiology. One IE-related pathway was published in the institution’s intranet with two subsections: IE Diagnosis and IE Management and Discharge Processes. Education sessions on pathway access were conducted for interdisciplinary staff across three cardiac care units. The frequency of pathway online views was measured over three months, accumulating a total of 191 views. The median number of daily views was 2.5 [IQR 2, 4]. Analysis of these initial measures will help guide future efforts to streamline and enhance interdisciplinary collaboration amongst staff that care for patients with IE

Characteristics of Patients with Late-Stage Parkinsonism who are Nursing Home Residents Compared with those Living at Home

OBJECTIVES: To determine clinical characteristics and treatment complications of patients with late-stage Parkinsonism living in nursing homes compared with those living at home. DESIGN: Cross-sectional analysis. SETTING AND PARTICIPANTS: This study is an analysis of 692 patients with late stage Parkinsonism recruited to an in-depth international study, Care of Late-Stage Parkinsonism (CLaSP). MEASURES: Sociodemographic characteristics were compared between patients who were living in a nursing home (n = 194) and those living at home (n = 498). Clinical assessments included the Unified Parkinson's Disease Rating Scale (UPDRS), the nonmotor symptom scale, the neuropsychiatric inventory, and a structured interview of patients and carers. Predictors of nursing home status were determined in a multivariate analysis. RESULTS: Nursing home placement was strongly associated with more severe cognitive impairment, worse UPDRS motor scores and disability, and with being unmarried and older. Although nursing home residents had significantly higher axial scores, falls were less common. Despite similar levodopa equivalence doses, they had less dyskinesia. Nonmotor symptom burden, particularly delusion, hallucination, and depression scores were higher in nursing home residents, and they were more frequently on psychotropic medication. They had lower rates of dopamine agonist use and lower rates of impulse control disorders. In multivariate analysis, being unmarried, presence of cognitive impairment, worse disease severity as assessed on the UPDRS parts II and III, severity of delusions, and lower rate of dyskinesia were associated with nursing home placement. CONCLUSIONS AND IMPLICATIONS: These clinical characteristics suggest that in patients with Parkinsonsim who are nursing home residents, presence of cognitive impairment and delusions particularly add to the higher overall symptom burden, and more often require specific treatments, including clozapine. Despite similar levodopa equivalent daily dose, motor severity is higher, and dyskinesias, indicative of a response to levodopa, are less common. Falls, however, also occur less commonly, and dopamine agonists are less frequently used, with lower rates of impulse control disorder

The Arecibo Galaxy Environment Survey III: Observations Toward the Galaxy Pair NGC 7332/7339 and the Isolated Galaxy NGC 1156

Two 5 square degree regions around the NGC 7332/9 galaxy pair and the isolated galaxy NGC 1156 have been mapped in the 21-cm line of neutral hydrogen (HI) with the Arecibo L-band Feed Array out to a redshift of ~0.065$(~20,000$ km/s) as part of the Arecibo Galaxy Environment Survey. One of the aims of this survey is to investigate the environment of galaxies by identifying dwarf companions and interaction remnants; both of these areas provide the potential for such discoveries. The neutral hydrogen observations were complemented by optical and radio follow-up observations with a number of telescopes. A total of 87 galaxies were found, of which 39 (45 per cent) were previously cataloged and 15 (17 per cent) have prior redshifts. Two dwarf galaxies have been discovered in the NGC 7332 group and a single dwarf galaxy in the vicinity NGC 1156 . A parallel optical search of the area revealed one further possible dwarf galaxy near NGC 7332.Comment: 18 pages, 17 figures, uses emulateap

An Analysis of Collegiate Club-Sport Female Lacrosse Players: Sport-Specific Field Test Performance and the Influence of Lacrosse Stick Carrying

International Journal of Exercise Science 11(4): 269-280, 2018. Lacrosse is a field-based, intermittent sport that requires players to use a stick with a shaft and mesh pocket to manipulate the ball. However, there has been limited analysis of the characteristics of collegiate club-sport players, and whether stick carry influences the sprinting speed of lacrosse players. As a result, this study investigated the field test characteristics of collegiate club-sport female lacrosse players, and the effects of stick carry on linear and change-of-direction speed. Nine players (seven field players, two goalkeepers) volunteered for this study and completed: vertical jump and standing broad jump; 30-meter (m) sprint (0-5, 0-10, and 0-30 m intervals) and modified T-test without and with a stick; and the Yo-Yo Intermittent Recovery Test. Magnitude-based inference analyses via effect sizes (d) compared the field players and goalkeepers. Data was pooled for the 30-m sprint and modified T-test to examine the effect of stick carry via paired samples t-tests (p\u3c0.05) and effect sizes. Field players performed better in most field tests (d=0.93-2.45), although goalkeepers generated greater vertical jump power (d=2.01). With regards to the effects of stick carry, there was a significant difference between the faster 0-5 m sprint interval without a stick compared to with a stick (p=0.02), but this had a small effect (d=0.25). There were no differences between the other sprint intervals and modified T-test (p=0.08-0.39; d=0.06-0.19). When contextualized with comparisons to other female collegiate athletes, the results indicated limitations in training exposure for collegiate club-sport lacrosse players. Furthermore, stick carry generally did not affect speed

An investigation of the mechanics and sticking region of a one-repetition maximum close-grip bench press versus the traditional bench press

The close-grip bench press (CGBP) is a variation of the traditional bench press (TBP) that uses a narrower grip (~95% of biacromial distance (BAD)) and has potential application for athletes performing explosive arm actions from positions where the hands are held close to the torso. Limited research has investigated CGBP mechanics compared to the TBP. Twenty-seven resistance-trained individuals completed a one-repetition maximum TBP and CGBP. The TBP was performed with the preferred grip; the CGBP with a grip width of 95% BAD. A linear position transducer measured lift distance and duration; peak and mean power, velocity, and force; distance and time when peak power occurred; and work. Pre-sticking region (PrSR), sticking region, and post-sticking region distance and duration for each lift was measured. A repeated measures ANOVA was used to derive differences between TBP and CGBP mechanics (p \u3c 0.01); effect sizes (d) were also calculated. A greater load was lifted in the TBP, thus mean force was greater (d = 0.16–0.17). Peak power and velocity were higher in the CGBP, which had a longer PrSR distance (d = 0.49–1.32). The CGBP could emphasize power for athletes that initiate explosive upper-body actions with the hands positioned close to the torso

Pharmacokinetics of metformin in patients with gastrointestinal intolerance

Skin affections after sulfur mustard (SM) exposure include erythema, blister formation and severe inflammation. An antidote or specific therapy does not exist. Anti-inflammatory compounds as well as substances counteracting SM-induced cell death are under investigation. In this study, we investigated the benzylisoquinoline alkaloide berberine (BER), a metabolite in plants like berberis vulgaris, which is used as herbal pharmaceutical in Asian countries, against SM toxicity using a well-established in vitro approach. Keratinocyte (HaCaT) mono-cultures (MoC) or HaCaT/THP-1 co-cultures (CoC) were challenged with 100, 200 or 300 mM SM for 1 h. Post-exposure, both MoC and CoC were treated with 10, 30 or 50 mu M BER for 24 h. At that time, supernatants were collected and analyzed both for interleukine (IL) 6 and 8 levels and for content of adenylate-kinase (AK) as surrogate marker for cell necrosis. Cells were lysed and nucleosome formation as marker for late apoptosis was assessed. In parallel, AK in cells was determined for normalization purposes. BER treatment did not influence necrosis, but significantly decreased apoptosis. Anti-inflammatory effects were moderate, but also significant, primarily in CoC. Overall, BER has protective effects against SM toxicity in vitro. Whether this holds true should be evaluated in future in vivo studies

Cosmic ray diffusion near the Bohm limit in the Cassiopeia A supernova remnant

Supernova remnants (SNRs) are believed to be the primary location of the acceleration of Galactic cosmic rays, via diffusive shock (Fermi) acceleration. Despite considerable theoretical work the precise details are still unknown, in part because of the difficulty in directly observing nucleons that are accelerated to TeV energies in, and affect the structure of, the SNR shocks. However, for the last ten years, X-ray observatories ASCA, and more recently Chandra, XMM-Newton, and Suzaku have made it possible to image the synchrotron emission at keV energies produced by cosmic-ray electrons accelerated in the SNR shocks. In this article, we describe a spatially-resolved spectroscopic analysis of Chandra observations of the Galactic SNR Cassiopeia A to map the cutoff frequencies of electrons accelerated in the forward shock. We set upper limits on the electron diffusion coefficient and find locations where particles appear to be accelerated nearly as fast as theoretically possible (the Bohm limit).Comment: 18 pages, 5 figures. Accepted for publication in Nature Physics (DOI below), final version available week of August 28, 2006 at http://www.nature.com/nphy

Seminar on Securities Law

Materials from the UK/CLE Seminar on Securities Law held February 14-15, 1986

Short-term costs of conventional vs laparoscopic assisted surgery in patients with colorectal cancer (MRC CLASICC trial)

The short-term clinical results of the CLASICC trial indicated that clinical outcomes were similar between laparoscopic and open approaches. This study presents the short-term (3 month) cost analysis undertaken on a subset of patients entered into the CLASICC trial (682 of 794 patients). As expected the costs associated with the operation were higher in the 452 patients randomised to laparoscopic surgery (lap) compared with the 230 randomised to open procedure (open), £1703 vs £1386. This was partially offset by the other hospital (nontheatre) costs, which were lower in the lap group (£2930 vs £3176). The average cost to individuals for reoperations was higher in the lap group (£762 vs £553). Overall costs were slightly higher in the lap group (£6899 vs £6631), with mean difference of £268 (95%CI −689 to 1457). Sensitivity analysis made little difference to these results. The cost of rectal surgery was higher than for colon, for lap (£8259 vs £5586) and open procedures (£7820 vs £5503). The short-term cost analysis for the CLASICC trial indicates that the costs of either laparoscopic or open procedure were similar, lap surgery costing marginally more on average than open surgery