The Frequency of Withdrawal from Acute Care Is Impacted by Severe Acute Renal Failure

Introduction: In the general intensive care setting, decisions to withdraw life support when patients deteriorate despite aggressive treatment are estimated to occur in 10% of all patients and in 40% of the patients who die. Acute renal failure (ARF) severe enough to necessitate renal replacement therapy (RRT) is associated with in-hospital mortality approximating 50%. Yet the impact of severe ARF on decisions to withdraw treatment has not been previously described. In chronic renal failure patients, voluntary withdrawal from maintenance dialysis occurs in 10%–20% of patients when increasing complications and poor quality of life ensue, and knowing these data facilitates discussions with patients and families. Having similar data for complicated ARF would facilitate decision making for families and caregivers when these difficult situations arise. Methods: All cases of ARF requiring RRT during 2000–2001 at University of Michigan Hospital (n = 383) were entered prospectively into an outcome study at the time RRT was initiated. Comprehensive data collection included demographic and clinical characteristics, outcome and complications, and severity of illness. Additional information for patients who died included cause of death, life-support withdrawal decisions, and the presence of prior advance directives. Results: Overall mortality in severe ARF (i.e., severe enough to require RRT) was 53%. Lifesupport withdrawal occurred in 72% of deaths (compared to 40%–50% reported among general intensive care cases) and was associated with intensive care stay well beyond 2 weeks. Severity of illness, as indicated by modified APACHE III scores, was higher in patients who died than in survivors, but severity of illness was not higher for withdrawal from treatment than death without withdrawal decisions. Life-support withdrawal was not associated with other demographic or clinical characteristics (hospital service, primary admitting diagnosis, ventilator or pressor dependence, sepsis, or initial type of RRT chosen). Prior advance directives were available in 29% of patients overall, but having advance directives did not predict withdrawal from acute treatment. Death occurred within 2 days of withdrawal in more than 90% of cases, emphasizing the severity of underlying illness. Conclusions: Severe ARF reflects the severity of underlying illness, impacts overall survival, and is associated with more frequent withdrawal from aggressive treatment. High severity of illness and prolonged intensive care without improvement beyond 2 weeks presage decisions to withdraw treatment and signal patients and caregivers that death is imminent and that further aggressive care should be reconsidered or limited.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63219/1/jpm.2004.7.676.pd

ADAPTATION OF LEAN METHODOLOGIES FOR HEALTHCARE APPLICATIONS

Lean and Six Sigma quality concepts and terminology have been applied in the manufacturing arena since the late 1980’s and early 1990’s. It has only been in recent years that healthcare administrators have identified these methods as being adaptable to their organizations so that they may realize organizational improvements for continuing success and delighting customers. Unfortunately, this is not an application that is widely taught in typical Industrial Engineering curriculum and therefore there are few educated professionals coming right out of college that are able to apply these principles to healthcare. There are however, many experienced professionals knowledgeable in the basic Lean and Six Sigma principles as applied to manufacturing. This paper presents research conducted by the IUPUI School of Engineering and Technology in partnership with Sister of St. Francis Health Services (SSFHS) which was focused on the development and implementation of a Lean Six Sigma Training Program specifically for healthcare. Through the development of this training program, Purdue faculty have adapted traditional manufacturing Lean methodologies for healthcare specific applications. This paper will present multiple examples of successfully adapted Lean manufacturing training for Healthcare organizations. The authors will then present their findings and recommendations concerning Lean training specifically for Healthcare professionals. They will also present in-depth explanations of hands-on exercises used to demonstrate application of lean tools such as value stream mapping, 5S and visual controls that can be used to effectively train employees in most any healthcare organization

Advance consent in acute stroke trials: survey of Canadian Research Ethics Board chairs

dvance consent could allow individuals at high risk of stroke to provide consent before they might become eligible for enrollment in acute stroke trials. This survey explores the acceptability of this novel technique to Canadian Research Ethics Board (REB) chairs that review acute stroke trials. Responses from 15 REB chairs showed that majority of respondents expressed comfort approving studies that adopt advance consent. There was no clear preference for advance consent over deferral of consent, although respondents expressed significant concern with broad rather than trial-specific advance consent. These findings shed light on the acceptability of advance consent to Canadian ethics regulators

The IXPE View of GRB 221009A

We present the IXPE observation of GRB 221009A, which includes upper limits on the linear polarization degree of both prompt and afterglow emission in the soft X-ray energy band. GRB 221009A is an exceptionally bright gamma-ray burst (GRB) that reached Earth on 2022 October 9 after traveling through the dust of the Milky Way. The Imaging X-ray Polarimetry Explorer (IXPE) pointed at GRB 221009A on October 11 to observe, for the first time, the 2–8 keV X-ray polarization of a GRB afterglow. We set an upper limit to the polarization degree of the afterglow emission of 13.8% at a 99% confidence level. This result provides constraints on the jet opening angle and the viewing angle of the GRB, or alternatively, other properties of the emission region. Additionally, IXPE captured halo-rings of dust-scattered photons that are echoes of the GRB prompt emission. The 99% confidence level upper limit to the prompt polarization degree depends on the background model assumption, and it ranges between ∼55% and ∼82%. This single IXPE pointing provides both the first assessment of X-ray polarization of a GRB afterglow and the first GRB study with polarization observations of both the prompt and afterglow phases

Discutindo a educação ambiental no cotidiano escolar: desenvolvimento de projetos na escola formação inicial e continuada de professores

A presente pesquisa buscou discutir como a Educação Ambiental (EA) vem sendo trabalhada, no Ensino Fundamental e como os docentes desta escola compreendem e vem inserindo a EA no cotidiano escolar., em uma escola estadual do município de Tangará da Serra/MT, Brasil. Para tanto, realizou-se entrevistas com os professores que fazem parte de um projeto interdisciplinar de EA na escola pesquisada. Verificou-se que o projeto da escola não vem conseguindo alcançar os objetivos propostos por: desconhecimento do mesmo, pelos professores; formação deficiente dos professores, não entendimento da EA como processo de ensino-aprendizagem, falta de recursos didáticos, planejamento inadequado das atividades. A partir dessa constatação, procurou-se debater a impossibilidade de tratar do tema fora do trabalho interdisciplinar, bem como, e principalmente, a importância de um estudo mais aprofundado de EA, vinculando teoria e prática, tanto na formação docente, como em projetos escolares, a fim de fugir do tradicional vínculo “EA e ecologia, lixo e horta”.Facultad de Humanidades y Ciencias de la Educació

15 Photographs 15 Curators

The museum invited fifteen individuals from the university community—faculty, students, staff, administrators—to each choose a photograph from Sheldon’s permanent collection and write a brief reflection on or response to the work. The selected images span history, genres, and styles, just as the participants represent diverse intellectual and creative interests on campus. Equally varied are the reflections themselves. Some participants describe qualities that have drawn them to particular images; others consider the ways art provides a fresh lens for their specialized work in other disciplines. Photographs: Monte Gerlach Rising Form Sarah Charlesworth Candle Stanley Truman Joinery, Coloma, California Carrie Mae Weems Kitchen Table Series Ansel Adams Ranch House Near Carson City, Nevada, Winter Harold Edgerton Wes Fesler Kicking a Football Dorothea Lange Migrant Mother, Nipomo, California Frank Gohlke Landscape—Grain Elevator and Lightning Flash, Lamesa, Texas Mark Ruwedel Virginia and Truckee #1 Robert Adams Colorado Springs, Colorado Alan Cohen Robert Morris 134-7 Henry Holmes Smith Death of Punch Gordon Parks Willie Causey and Family, Shady Grove, Alabama, 1956 Dorothea Lange Pathan Warrior Tribesman, Khyber Pass Judy Dater Kathleen Kell