Development and Pilot of a Checklist for Management of Acute Liver Failure in the Intensive Care Unit

Introduction Acute liver failure (ALF) is an ideal condition for use of a checklist. Our aims were to develop a checklist for the management of ALF in the intensive care unit (ICU) and assess the usability of the checklist among multiple providers. Methods The initial checklist was developed from published guidelines and expert opinion. The checklist underwent pilot testing at 11 academic liver transplant centers in the US and Canada. An anonymous, written survey was used to assess the usability and quality of the checklist. Written comments were used to improve the checklist following the pilot testing period. Results We received 81 surveys involving the management of 116 patients during the pilot testing period. The overall quality of the checklist was judged to be above average to excellent by 94% of users. On a 5-point Likert scale, the majority of survey respondents agreed or agreed strongly with the following checklist characteristics: the checklist was easy to read (99% agreed/agreed strongly), easy to use (97%), items are categorized logically (98%), time to complete the checklist did not interfere with delivery of appropriate and safe patient care (94%) and was not excessively burdensome (92%), the checklist allowed the user the freedom to use his or her clinical judgment (80%), it is a useful tool in the management of acute liver failure (98%). Web-based and mobile apps were developed for use of the checklist at the point of care. Conclusion The checklist for the management of ALF in the ICU was shown in this pilot study to be easy to use, helpful and accepted by a wide variety of practitioners at multiple sites in the US and Canada

White Blood, Black Gold: The Commodification of Wild Rubber in the Bolivian Amazon, 1870-1920

The Bolivian rubber boom thrived during the 1880 and 1920 decades throughout the Amazonian fluvial network (Madre de Dios, Beni, Purús, Madeira and Beni rivers). The economic potential of rubber quickly became a decisive phenomenon in the social history of Eastern Bolivia, linked with the definitive ocupation of marginal territories, new interethnic relations, national and international migration, taxation, property entitlement, the foundation of cities, the rise of nationalism, the struggle to settle republican frontiers and a novel regional opening to global economy. The boom also encouraged substantial developments in cartography, hidrography, botanics and ethnology. Our goal is to describe the singularities of the rubber-tapping industry in Bolivia and to analyse the representations of “nature” held by rubber tappers of the period: there was indeed a modernist discourse based on the usual ideas of "progress" and "civilization" of the industry opposed to the "wildness", "savagery" and "barbarism" massively attributed to Amazonia, and also a generalized notion of the jungle as a "desert land" open to opportunities for the self-made man. In retrospect, these discourses can certainly reveal a lack of “ecological awareness”. However, a closer analysis of historical sources also shows the existence of voices that were more nuanced and reflexive, and in some cases even dared to point out the limits of extractivism –not only in "ecological" terms but also in reference to the life of the indigenous and creole populations involved in the rubber boom

Towards bounded wait-free PASIS

The PASIS read/write protocol implements a Byzantine fault-tolerant erasure-coded atomic register. The prototype PASIS storage system implementation provides excellent best-case performance. Writes require two round trips and contention- and failure-free reads require one. Unfortunately, even though writes and reads are wait-free in PASIS, Byzantine components can induce correct clients to perform an unbounded amount of work. In this extended abstract, we enumerate the avenues by which Byzantine servers and clients can induce correct clients to perform an unbounded amount of work in PASIS. We sketch extensions to the PASIS protocol and Lazy Verification that bound the amount of work Byzantine components can induce correct clients to perform. We believe that the extensions provide bounded wait-free reads and writes. We also believe that an implementation that incorporates these extensions will preserve the excellent best-case performance of the original PASIS prototype

Evaluating CollaboRATE in a Clinical Setting: Analysis of Mode Effects on Scores, Response Rates and Costs of Data Collection

Shared decision-making (SDM) has become a policy priority, yet its implementation is not routinely assessed. To address this gap we tested the delivery of CollaboRATE, a 3-item patient reported experience measure of SDM, via multiple survey modes.To assess CollaboRATE response rates and respondent characteristics across different modes of administration, impact of mode and patient characteristics on SDM performance and cost of administration per response in a real-world primary care practice.Observational study design, with repeated assessment of SDM performance using CollaboRATE in a primary care clinic over 15 months of data collection. Different modes of administration were introduced sequentially including paper, patient portal, interactive voice response (IVR) call, text message and tablet computer.Consecutive patients ≥18 years, or parents/guardians of patients \u3c18 years, visiting participating primary care clinicians.CollaboRATE assesses three core SDM tasks: (1) explanation about health issues, (2) elicitation of patient preferences and (3) integration of patient preferences into decisions. Responses to each item range from 0 (no effort was made) to 9 (every effort was made). CollaboRATE scores are calculated as the proportion of participants who report a score of nine on each of the three CollaboRATE questions.Scores were sensitive to mode effects: the paper mode had the highest average score (81%) and IVR had the lowest (61%). However, relative clinician performance rankings were stable across the different data collection modes used. Tablet computers administered by research staff had the highest response rate (41%), although this approach was costly. Clinic staff giving paper surveys to patients as they left the clinic had the lowest response rate (12%).CollaboRATE can be introduced using multiple modes of survey delivery while producing consistent clinician rankings. This may allow routine assessment and benchmarking of clinician and clinic SDM performance

Density Perturbations of Quantum Mechanical Origin and Anisotropy of the Microwave Background

If the large-angular-scale anisotropy in the cosmic microwave background radiation is caused by the long-wavelength cosmological perturbations of quantum mechanical origin, they are, most likely, gravitational waves, rather than density perturbations or rotational perturbations.Comment: 53 pages, RevTeX, WUGRAV-94-4, (Received by Phys. Rev. D on March 17, 1994

Defining language impairments in a subgroup of children with autism spectrum disorder

Autism spectrum disorder (ASD) is diagnosed on the basis of core impairments in pragmatic language skills, which are found across all ages and subtypes. In contrast, there is significant heterogeneity in language phenotypes, ranging from nonverbal to superior linguistic abilities, as defined on standardized tests of vocabulary and grammatical knowledge. The majority of children are verbal but impaired in language, relative to age-matched peers. One hypothesis is that this subgroup has ASD and co-morbid specific language impairment (SLI). An experiment was conducted comparing children with ASD to children with SLI and typically developing controls on aspects of language processing that have been shown to be impaired in children with SLI: repetition of nonsense words. Patterns of performance among the children with ASD and language impairment were similar to those with SLI, and contrasted with the children with ASD and no language impairment and typical controls, providing further evidence for the hypothesis that a subgroup of children with ASD has co-morbid SLI. The findings are discussed in the context of brain imaging studies that have explored the neural bases of language impairment in ASD and SLI, and overlap in the genes associated with elevated risk for these disorders.M01 RR00533 - NCRR NIH HHS; R01 DC10290 - NIDCD NIH HHS; U19 DC03610 - NIDCD NIH HH

Achondroplasia manifesting as enchondromatosis and ossification of the spinal ligaments: a case report

<p>Abstract</p> <p>Introduction</p> <p>A girl presented with achondroplasia manifested as mild knee pain associated with stiffness of her back. A skeletal survey showed enchondroma-like metaphyseal dysplasia and ossification of the spinal ligaments. Magnetic resonance imaging of the spine further clarified the pathological composites.</p> <p>Case presentation</p> <p>A 7-year-old girl presented with the classical phenotypic features of achondroplasia. Radiographic documentation showed the co-existence of metaphyseal enchondromatosis and development of spinal bony ankylosis. Magnetic resonance imaging showed extensive ossification of the anterior and posterior spinal ligaments. Additional features revealed by magnetic resonance imaging included calcification of the peripheral vertebral bodies associated with anterior end-plate irregularities.</p> <p>Conclusion</p> <p>Enchondromas are metabolically active and may continue to grow and evolve throughout the patient's lifetime; thus, progressive calcification over a period of years is not unusual. Ossification of the spinal ligaments has a specific site of predilection and often occurs in combination with senile ankylosing vertebral hyperostosis. Nevertheless, ossification of the spinal ligaments has been encountered in children with syndromic malformation complex. It is a multifactorial disease in which complex genetic and environmental factors interact, potentially leading to chronic pressure on the spinal cord and nerve roots with subsequent development of myeloradiculopathy. Our patient presented with a combination of achondroplasia, enchondroma-like metaphyseal dysplasia and calcification of the spinal ligaments. We suggest that the development of heterotopic bone formation along the spinal ligaments had occurred through an abnormal ossified enchondral mechanism. We postulate that ossification of the spinal ligaments and metaphyseal enchondromatous changes are related to each other and represent impaired terminal differentiation of chondrocytes in this particular case. Standard radiographic examination showed spinal bony ankylosis only. The pathological composites of the vertebrae have been clarified using scanning technology. Extensive spinal ligament ossification associated with calcification of the peripheral vertebral bodies and anterior end-plate irregularities were notable. We report what may be a novel spinal and extraspinal malformation complex in a girl with achondroplasia.</p

A proteomic approach for the identification of novel lysine methyltransferase substrates

<p>Abstract</p> <p>Background</p> <p>Signaling via protein lysine methylation has been proposed to play a central role in the regulation of many physiologic and pathologic programs. In contrast to other post-translational modifications such as phosphorylation, proteome-wide approaches to investigate lysine methylation networks do not exist.</p> <p>Results</p> <p>In the current study, we used the ProtoArray^®platform, containing over 9,500 human proteins, and developed and optimized a system for proteome-wide identification of novel methylation events catalyzed by the protein lysine methyltransferase (PKMT) SETD6. This enzyme had previously been shown to methylate the transcription factor RelA, but it was not known whether SETD6 had other substrates. By using two independent detection approaches, we identified novel candidate substrates for SETD6, and verified that all targets tested <it>in vitro </it>and in cells were genuine substrates.</p> <p>Conclusions</p> <p>We describe a novel proteome-wide methodology for the identification of new PKMT substrates. This technological advance may lead to a better understanding of the enzymatic activity and substrate specificity of the large number (more than 50) PKMTs present in the human proteome, most of which are uncharacterized.</p

Safety, tolerability, and pharmacokinetics of l‐ornithine phenylacetate in patients with acute liver injury/failure and hyperammonemia

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142428/1/hep29621.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142428/2/hep29621-sup-0001-suppinfo1.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142428/3/hep29621_am.pd