Implementing a Digital Deteriorating Patient Pathway to improve the safety and effectiveness of care of the adult deteriorating patient.

Identification, escalation and clinical review of the deteriorating patient is essential for a safe and effective hospital. We present a deteriorating patient pathway developed within our electronic patient record, including implementation of a digital escalation and senior review process, triggered from a logic algorithm and vital signs. The pathway is activated by an average 43 patients per day with median mortality of 13.3%. Our Trust has seen a significant improvement in escalation and senior review and increased use of treatment escalation plans. The pathway has facilitated a cultural shift in the Trust towards the deteriorating patient. The new pathway is transferrable to both other digital Trusts as well as maternity and paediatric practice.

Living Without Temporal Cues: A Case Study.

Isolation from external time cues allows endogenous circadian rhythmicity to be demonstrated. In this study, also filmed as a television documentary, we assessed rhythmic changes in a healthy man time isolated in a bunker for 9 days/nights. During this period the lighting conditions were varied between: (1) self-selected light/dark cycle, (2) constant dim light, and (3) light/dark cycle with early wake up. A range of variables was assessed and related to the sleep-wake cycle, psychomotor and physical performance and clock-time estimation. This case study using modern non-invasive monitoring techniques emphasizes how different physiological circadian rhythms persist in temporal isolation under constant dim light conditions with different waveforms, free-running with a period (τ) between 24 and 25 h. In addition, a significant correlation between time estimation and mid-sleep time, a proxy for circadian phase, was demonstrated.

Low-Income Residents' Perceptions of Medication Availability.

Access to medications is a critical determinant of health which often mediates the effects of diseases and leads to healthier lifestyles. With limited access to pharmacies, neighborhoods become pharmacy deserts. The purpose of this study was to explore the medication needs and perceptions of low-income community residents. A purposive sample of 40 low-income community residents participated in focus groups. Content analysis revealed four themes: transitioning to the present, stereotyping, feelings of disconnectedness, and ideal pharmacy. These findings reiterate the difficulties of living in pharmacy deserts, and decrease the gaps of limited qualitative research in this area.

The effect of image alterations on identification using palmar flexion creases.

Palmprints are identified using matching of minutia points, which can be time consuming for fingerprint experts and in database searches. This article analyzes the operational characteristics of a palmar flexion crease (PFC) identification software tool, using a dataset of 10 replicates of 100 palms, where the user can label and match palmar line features. Results show that 100 palmprint images modified 10 times each using rotation, translation, and additive noise, mimicking some of the characteristics found in crime scene palmar marks, can be identified with a 99.2% genuine acceptance rate and 0% false acceptance rate when labeled within 3.5 mm of the PFC. Partial palmprint images can also be identified using the same method to filter the dataset prior to traditional matching, while maintaining an effective genuine acceptance rate. The work shows that identification using PFCs can improve palmprint identification through integration with existing systems, and through dedicated palmprint identification applications.

Extensive autolytic fragmentation of membranous versus cytosolic calpain following myocardial ischemia-reperfusion.

We investigated calpain activation in the heart during ischemia-reperfusion (I-R) by immunologically mapping the fragmentation patterns of calpain and selected calpain substrates. Western blots showed the intact 78 kDa large subunit of membrane-associated calpain was autolytically fragmented to 56 and 43 kDa signature immunopeptides following I-R. Under these conditions, the 78 kDa calpain large subunit from crude cytosolic fractions was markedly less fragmented, with only weakly stained autolytic peptides detected at higher molecular weights (70 and 64 kDa). Western blots also showed corresponding calpain-like degradation products (150 and 145 kDa) of membrane-associated alpha-fodrin (240 kDa) following I-R, but in crude myofibrils alpha-fodrin degradation occurred in a manner uncharacteristic of calpain. For control hearts perfused in the absence of ischemia, autolytic fragmentation of calpain and calpain-like alpha-fodrin degradation were completely absent from most subcellular fractions. The exception was sarcolemma-enriched membranes, where significant calpain autolysis and calpain-like alpha-fodrin degradation were detected. In purified sarcoplasmic reticulum membranes, RyR2 and SERCA2 proteins were also highly degraded, but for RyR2 this did not occur in a manner characteristic of calpain. When I-R-treated hearts were perfused with peptidyl calpain inhibitors (ALLN or ALLM; 25 micromol/L), calpain autolysis and calpain-like degradation of alpha-fodrin were equally attenuated by each inhibitor. However, only ALLN protected against early loss of developed pressure in hearts following I-R, with no functionally protective effect of ALLM observed. Our studies suggest calpain is preferentially activated at membranes following I-R, possibly contributing to impaired ion channel function implicated by others in I-R injury.

Impact of neurohormonal blockade on association between body mass index and mortality.

BACKGROUND: The prognostic impact of body mass index (BMI) in patients following acute myocardial infarction (AMI) may be altered by neurohormonal blockade. METHODS: The impact of neurohormonal blockade on the association between BMI and mortality was examined in 5548 patients following AMI (CONSENSUS II), 50% receiving enalapril and 7% beta-blockade, and in 4367 patients with coronary artery disease (CAD) (4S), 79% with prior AMI, 12% receiving ACEi and 67% beta-blockade. Median follow-up was 0.4 and 5.2 years, respectively. Patients were categorized into 4 BMI groups: Underweight, < 22.00; normal-weight, 22.00-24.99; overweight, 25.00-29.99; obese, > or = 30.00 kg/m2. Multivariable analysis adjusted for demographics, patient history, physical examination, biochemistry and medication. RESULTS: CONSENSUS II: Overall, adjusted mortality (n=301) risk was similar across BMI groups. Comparing overweight with normal-weight patients, the hazard ratios (HRs) for mortality differed significantly (P=0.028) between patients randomized to placebo (HR 1.41) and enalapril (HR 0.75). 4S: Overall, adjusted mortality (n=421) risk was similar for normal-weight, overweight and obese patients. In a time-dependent analysis for drug use, comparing obese with normal-weight patients, the HRs for mortality differed significantly (P=0.047) between patients without (HR 1.86) and those with (HR 0.97) neurohormonal blockade. CONCLUSION: In patients after AMI or with CAD, high BMI was associated with increased mortality risk among patients not receiving neurohormonal blockade, but with decreased or neutral mortality risk among those receiving neurohormonal blockade. Tests for interaction indicate that neurohormonal blockade may attenuate the relationship between high BMI and increased mortality risk. Neurohormonal blockade may thus partly explain the so-called obesity paradox.

Computational Science and Engineering Online (CSE-Online): a cyber-infrastructure for scientific computing.

With the expansion of the Internet and World Wide Web (or the Web), research environments have changed dramatically. As a result, the need to be able to efficiently and securely access information and resources from remote computer systems is becoming even more critical. This paper describes the development of an extendable integrated Web-accessible simulation environment for computational science and engineering called Computational Science and Engineering Online (CSE-Online; http://cse-online.net). CSE-Online is based on a unique client-server software architecture that can distribute the workload between the client and server computers in such a way as to minimize the communication between the client and server, thus making the environment less-sensitive to network instability. Furthermore, the new software architecture allows the user to access data and resources on one or more remote servers as well as on the computing grid while having the full capability of the Web-services collaborative environment. It can be accessed anytime and anywhere from a Web browser connected to the network by either a wired or wireless connection. It has different modes of operations to support different working environments and styles. CSE-Online is evolving into middleware that can provide a framework for accessing and managing remote data and resources including the computing grid for any domain, not necessarily just within computational science and engineering.

Beginning students' definitions of nursing: an inductive framework of professional identity.

Nursing identity is a developmental process that evolves throughout professional nurses' careers. Educational systems that prepare nurses include experiences that are important in the early development of nursing identity. Therefore, faculty in nursing programs are interested in understanding how their students perceive and define professional identity. For this study, a qualitative design was selected to explore students' early beliefs and concepts about nursing. Data were collected on the students' first day of the nursing program using the open-ended question, "What is your definition of nursing?" Using a qualitative descriptive approach, thematic analyses of the data are provided. Results revealed an inductive framework of professional nursing identity based on students' descriptions and definitions of nursing. These results demonstrate that nursing students come to an educational program with more than a rudimentary conception of professional identity. Use of these data may lead to opportunities to improve nursing students' educational experiences and foster the development of professional identity. Faculty can use knowledge of students' definitions of nursing to enrich student learning.

RyR1/SERCA1 cross-talk regulation of calcium transport in heavy sarcoplasmic reticulum vesicles.

We investigated the functional interdependence of sarco-endoplasmic reticulum Ca2+ ATPase isoform 1 and ryanodine receptor isoform 1 in heavy sarcoplasmic reticulum membranes by synchronous fluorescence determination of extravesicular Ca2+ transients and catalytic activity. Under conditions of dynamic Ca2+ exchange ATPase catalytic activity was well coordinated to ryanodine receptor activation/inactivation states. Ryanodine-induced activation of Ca2+ release channel leaks also produced marked ATPase activation in the absence of measurable increases in bulk free extravesicular Ca2+. This suggested that Ca2+ pumps are highly sensitive to Ca2+ release channel leak status and potently buffer Ca2+ ions exiting cytoplasmic openings of ryanodine receptors. Conversely, ryanodine receptor activation was dependent on Ca2+-ATPase pump activity. Ryanodine receptor activation by cytosolic Ca2+ was (i) inversely proportional to luminal Ca2+ load and (ii) dependent upon the rate of presentation of cytosolic Ca2+. Progressive Ca2+ filling coincided with progressive loss of Ca2+ sequestration rates and at a threshold loading, ryanodine-induced Ca2+ release produced small transient reversals of catalytic activity. These data indicate that attainment of threshold luminal Ca2+ loads coordinates sensitization of Ca2+ release channels with autogenic inhibition of Ca2+ pumping. This suggests that Ca2+-dependent control of Ca2+ release in intact heavy sarcoplasmic reticulum membranes involves a Ca2+-mediated "cross-talk" between sarco-endoplasmic reticulum Ca2+ ATPase isoform 1 and ryanodine receptor isoform 1.

Test-retest reliability of a self-administered musculoskeletal symptoms and job factors questionnaire used in ergonomics research.

The purpose of this study was to investigate the test-retest reliability of questionnaire items related to musculoskeletal symptoms and the reliability of specific job factors. The type of questionnaire items described in the present study have been used by several investigators to assess symptoms of musculoskeletal disorders and problematic job factors among workers from a variety of occupations. Employees at a plastics molding facility were asked to complete an initial symptom and jobs factors questionnaire and then complete an identical questionnaire either two or four weeks later. Of the 216 employees participating in the initial round, 99 (45.8%) agreed to participate in the retest portion of the study. The kappa coefficient was used to determine repeatability for categorical outcomes. The majority of the kappa coefficients for the 58 questionnaire items were above 0.50 but ranged between 0.13 and 1.00. The section of the questionnaire having the highest kappa coefficients was the section related to hand symptoms. Interval lengths of two and four weeks between the initial test and retest were found to be equally sufficient in terms of reliability. The results indicated that the symptom and job factors questionnaire is reliable for use in epidemiologic studies. Like all measurement instruments, the reliability of musculoskeletal questionnaires must be established before drawing conclusions from studies that employ the instrument.