Emergency Department Provider Satisfaction with EMS Turnover Reports in Critical Trauma Patients

Introduction: Trauma accounts for 23% of all emergency department (ED) visits and is a leading cause of morbidity and mortality.1,2 Many critical trauma patients arrive to the ED by emergency medical services (EMS). EMS-ED handoff quality affects patient safety and quality of care.3-6 However, there is a scarcity of literature examining trauma patient handoffs and hospital staff satisfaction. The goal of this study was to investigate the relationship of specific information given during EMS handoffs with hospital staff satisfaction. Methods: This study observed handoffs of patients sustaining major trauma at the University of New Mexico (UNM) Hospital, the state’s only level I trauma center. UNM Hospital has a trauma alert protocol (TAP) to notify emergency medicine and surgery teams of incoming patients; these patients are assessed, stabilized, and treated by these teams. Data were collected from January 1, 2017 to December 31, 2017. This study included handoffs for TAP patients who were brought in by EMS. ED research assistants directly observed handoffs and recorded information using electronic data capture. Data points included vital signs (blood pressure, pulse, blood glucose, and mental status) and medical factors (allergies, IV access, injury mechanism, medications given by EMS, and home medications). Subjective factors included numerical satisfaction scores of EMS and various hospital providers for the handoff and the initial treatment/resuscitation after the handoff (both used 10-point Likert scales).
 Stata™ 14 was used for all analyses, with significance determined using t-tests and a type 1 error rate of 0.05. Results: We observed 180 handoffs and recorded satisfaction scores for 142 ED physicians, 53 surgeons, 68 nurses, and 163 EMS providers. Median satisfaction scores and interquartile ranges were: ED physicians 8 (8-9), surgeons 8 (7-9), nurses 9 (7-10), and EMS providers 9 (8-10). Provider satisfaction was unrelated to the number of vital signs reported, or to whether any individual vital sign was reported. Conversely, most medical factors were related to satisfaction by at least one type of provider (Table). The total number of medical factors reported was associated with satisfaction among ED physicians and nurses. Among physicians, handoff satisfaction and satisfaction with the resuscitation were associated. Conclusion: The quantity of medical factors transferred during EMS-ED handoffs provides a target for improving ED physician satisfaction. Medical factors, individually and in sum, varied in how they influenced receiving provider satisfaction. Emphasis of individual pertinent medical factors may need to be tailored based on audience. A limitation of this study is the use of ED provider satisfaction as a proxy for handoff quality. Of note, ED physician satisfaction was associated with resuscitation satisfaction. This may indicate that using satisfaction as a proxy for handoff quality is confounded by patient outcome. Transfer of vital signs was not correlated to increased satisfaction; this suggests the need for further research on redundancies between handoffs and initial ED assessment

Flow cytometry quantitation of dopamine receptor D2 loss as a sensitive measure of Huntington's Disease progression in mouse neurons

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Biology, 2013.This electronic version was submitted by the student author. The certified thesis is available in the Institute Archives and Special Collections.Cataloged from student-submitted PDF version of thesis.Includes bibliographical references.Mouse models of Huntington's Disease (HD) are often used for testing potential therapeutic compounds. These experiments require substantial investments in time and resources, and have yet to produce any intervention that has made a significant impact on disease progression in the clinic. In evaluating potential therapeutics, there is an unmet need for a rapid, highly quantitative measure of disease progression in the HD mouse model brain. Such an assay would help make preclinical trials more efficient. To address this need, I have developed a novel technique for measuring the progression of transcriptional dysregulation, a phenotype with substantial similarities between mouse models and patients. Specifically, utilizing mice that drive GFP expression under the control of one such dysregulated gene (Drd2), I have improved on previous protocols for the isolation and characterization of adult neurons by flow cytometry. Drd2 is a well-studied marker of a particularly vulnerable population in HD patients, the indirect medium spiny neurons of the striatum. Using this technique, I have demonstrated the ability to accurately and rapidly quantitate Drd2 transcript levels, as measured by Drd2 GFP (D2GFP) fluorescence, in several strains of HD model mice. This D2GFP loss is particularly robust, with sufficient power to allow subtle, statistically significant alterations to be observed with very small cohorts. Furthermore, the introduction of this D2GFP transgene does not alter the classic HD pathology in these mice. Finally, I show that D2GFP dysregulation can be either induced or ameliorated genetically by delivering transgenes via adeno associated viral vectors, and that a small molecule with only subtle transcriptional effects (cystamine) fails to rescue D2GFP loss. I hope that this system can be of great utility in the validation of effective therapeutic interventions for HD.by Zachary R. Crook.Ph.D

Sparse Gamma Rhythms Arising through Clustering in Adapting Neuronal Networks

Gamma rhythms (30–100 Hz) are an extensively studied synchronous brain state responsible for a number of sensory, memory, and motor processes. Experimental evidence suggests that fast-spiking interneurons are responsible for carrying the high frequency components of the rhythm, while regular-spiking pyramidal neurons fire sparsely. We propose that a combination of spike frequency adaptation and global inhibition may be responsible for this behavior. Excitatory neurons form several clusters that fire every few cycles of the fast oscillation. This is first shown in a detailed biophysical network model and then analyzed thoroughly in an idealized model. We exploit the fact that the timescale of adaptation is much slower than that of the other variables. Singular perturbation theory is used to derive an approximate periodic solution for a single spiking unit. This is then used to predict the relationship between the number of clusters arising spontaneously in the network as it relates to the adaptation time constant. We compare this to a complementary analysis that employs a weak coupling assumption to predict the first Fourier mode to destabilize from the incoherent state of an associated phase model as the external noise is reduced. Both approaches predict the same scaling of cluster number with respect to the adaptation time constant, which is corroborated in numerical simulations of the full system. Thus, we develop several testable predictions regarding the formation and characteristics of gamma rhythms with sparsely firing excitatory neurons

Association of MAPT haplotypes with Alzheimer’s disease risk and MAPT brain gene expression levels

Introduction: MAPT encodes for tau, the predominant component of neurofibrillary tangles that are neuropathological hallmarks of Alzheimer’s disease (AD). Genetic association of MAPT variants with late-onset AD (LOAD) risk has been inconsistent, although insufficient power and incomplete assessment of MAPT haplotypes may account for this. Methods: We examined the association of MAPT haplotypes with LOAD risk in more than 20,000 subjects (n-cases = 9,814, n-controls = 11,550) from Mayo Clinic (n-cases = 2,052, n-controls = 3,406) and the Alzheimer’s Disease Genetics Consortium (ADGC, n-cases = 7,762, n-controls = 8,144). We also assessed associations with brain MAPT gene expression levels measured in the cerebellum (n = 197) and temporal cortex (n = 202) of LOAD subjects. Six single nucleotide polymorphisms (SNPs) which tag MAPT haplotypes with frequencies greater than 1% were evaluated. Results: H2-haplotype tagging rs8070723-G allele associated with reduced risk of LOAD (odds ratio, OR = 0.90, 95% confidence interval, CI = 0.85-0.95, p = 5.2E-05) with consistent results in the Mayo (OR = 0.81, p = 7.0E-04) and ADGC (OR = 0.89, p = 1.26E-04) cohorts. rs3785883-A allele was also nominally significantly associated with LOAD risk (OR = 1.06, 95% CI = 1.01-1.13, p = 0.034). Haplotype analysis revealed significant global association with LOAD risk in the combined cohort (p = 0.033), with significant association of the H2 haplotype with reduced risk of LOAD as expected (p = 1.53E-04) and suggestive association with additional haplotypes. MAPT SNPs and haplotypes also associated with brain MAPT levels in the cerebellum and temporal cortex of AD subjects with the strongest associations observed for the H2 haplotype and reduced brain MAPT levels (β = -0.16 to -0.20, p = 1.0E-03 to 3.0E-03). Conclusions: These results confirm the previously reported MAPT H2 associations with LOAD risk in two large series, that this haplotype has the strongest effect on brain MAPT expression amongst those tested and identify additional haplotypes with suggestive associations, which require replication in independent series. These biologically congruent results provide compelling evidence to screen the MAPT region for regulatory variants which confer LOAD risk by influencing its brain gene expression

25th annual computational neuroscience meeting: CNS-2016

The same neuron may play different functional roles in the neural circuits to which it belongs. For example, neurons in the Tritonia pedal ganglia may participate in variable phases of the swim motor rhythms [1]. While such neuronal functional variability is likely to play a major role the delivery of the functionality of neural systems, it is difficult to study it in most nervous systems. We work on the pyloric rhythm network of the crustacean stomatogastric ganglion (STG) [2]. Typically network models of the STG treat neurons of the same functional type as a single model neuron (e.g. PD neurons), assuming the same conductance parameters for these neurons and implying their synchronous firing [3, 4]. However, simultaneous recording of PD neurons shows differences between the timings of spikes of these neurons. This may indicate functional variability of these neurons. Here we modelled separately the two PD neurons of the STG in a multi-neuron model of the pyloric network. Our neuron models comply with known correlations between conductance parameters of ionic currents. Our results reproduce the experimental finding of increasing spike time distance between spikes originating from the two model PD neurons during their synchronised burst phase. The PD neuron with the larger calcium conductance generates its spikes before the other PD neuron. Larger potassium conductance values in the follower neuron imply longer delays between spikes, see Fig. 17.Neuromodulators change the conductance parameters of neurons and maintain the ratios of these parameters [5]. Our results show that such changes may shift the individual contribution of two PD neurons to the PD-phase of the pyloric rhythm altering their functionality within this rhythm. Our work paves the way towards an accessible experimental and computational framework for the analysis of the mechanisms and impact of functional variability of neurons within the neural circuits to which they belong

Huntington's Disease: Can Mice Lead the Way to Treatment?

Mouse models for Huntington's Disease (HD) and HD patients demonstrate motor and behavioral dysfunctions, such as progressive loss of coordination and memory, and share similar transcriptional profiles and striatal neuron atrophy. Clear differences between the mouse and human diseases include almost complete striatal degeneration and rarity of intranuclear inclusions in HD, and the fact that mice expressing full-length mutant huntingtin do not demonstrate a shortened life span characteritstic of HD. While no clinical interventions tested in mouse models to date have delayed disease progression, the mouse models provide an invaluable tool for both investigating the underlying pathogenic processes and developing new effective therapies. Inherent differences between humans and mice must be considered in the search for efficacious treatments for HD, but the striking similarities between human HD and mouse models support the view that these models are a biologically relevant system to support the identification and testing of potential clinical therapies

Effects of sex and APOE on Parkinson’s Disease-related cognitive decline

Introduction. Cognitive impairment is common in Parkinson’s Disease, but the impact of predictive factors on incidence and rate of cognitive decline is incompletely understood. We aimed to determine the effects of sex and APOE allele status on cognitive performance in patients with Parkinson’s Disease (PD).Material and methods. We conducted a retrospective analysis of 325 clinically diagnosed PD patients who underwent one or more cognitive screenings with a Mini-Mental Status Examination (MMSE) or Mattis Dementia Rating Scale (DRS-2). We used proportional odds regression models to estimate odds ratios for higher versus lower cognitive scores in association with age, sex, education, disease duration, and APOE allele status.Results. Higher cognitive scores were independently associated with female sex on the MMSE (OR 2.43; 95% CI 1.14, 5.14) and DRS-2 total (OR 4.14; 95% CI 2.01, 8.53). APOE ε4 dose was associated with lower DRS-2 totals (OR 0.42; 95% CI 0.22, 0.81), but there was no evidence of association with MMSE. Higher education level was also associated with higher scores on the MMSE (OR 1.22; 95% CI 1.07, 1.38) and DRS-2 total (OR 1.31; 95% CI 1.15, 1.50). Disease duration was not associated with cognitive performance on any measure when adjusting for age.Conclusion. Male sex and APOE ε4, along with age and lower education level, were associated with poorer cognitive performance among a population of predominantly non-demented PD patients

Vegetation Response to Piñon and Juniper Tree Shredding

Piñon (Pinus spp.) and juniper (Juniperus spp.) expansion and infilling in sagebrush (Artemisia L.) steppe communities can lead to high-severity fire and annual weed dominance. To determine vegetation response to fuel reduction by tree mastication (shredding) or seeding and then shredding, we measured cover for shrub and herbaceous functional groups on shredded and adjacent untreated areas on 44 sites in Utah. We used mixed model analysis of covariance to determine significant differences among ecological site type (expansion and tree climax) and treatments across a range of pretreatment tree cover as the covariate. Although expansion and tree climax sites differed in cover values for some functional groups, decreasing understory cover with increasing tree cover and increased understory cover with tree reduction was similar for both ecological site types. Shrub cover decreased by 50% when tree cover exceeded 20%. Shredding trees at ≤ 20% cover maintained a mixed shrub (18.6% cover)−perennial herbaceous (17.6% cover) community. Perennial herbaceous cover decreased by 50% when tree cover exceeded 40% but exceeded untreated cover by 11% (20.1% cover) when trees were shredded at 15−90% tree cover. Cheatgrass (Bromus tectorum L.) cover also increased after tree shredding or seeding and then shredding but was much less dominant (\u3c 10% cover) where perennial herbaceous cover exceeded 42%. Sites with high cheatgrass cover on untreated plots had high cheatgrass cover on shredded and seeded-shredded plots. Seeding and then shredding decreased cheatgrass cover compared with shredding alone when implemented at tree cover ≥ 50%. Vegetation responses to shredding on expansion sites were generally similar to those for tree cutting treatments in the SageSTEP study. Shredding or seeding and then shredding should facilitate wildfire suppression, increase resistance to weed dominance, and lead toward greater resilience to disturbance by increasing perennial herbaceous cover