Optimizing the nutrition support care model: Analysis of survey data.

BACKGROUND: Malnutrition is underrecognized and underdiagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models. METHODS: This survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth. RESULTS: Of 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p < .0001). Most responding physicians (46/57; 80.7%) reported being a member of NSTs, compared with 56.5% (88/156) of dietitians. Of those not practicing in NSTs (N = 81/235, 34.4%), 12.3% (10/81) reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (115/235; 48.9%), followed by leadership (72/235; 30.6%), and healthcare professional (HCP) interest (55/235; 23.4%). A majority (173/235; 73.6%) of all respondents wanted additional training in nutrition but reported insufficient protected time, ability to travel, or support from administrators or other HCPs. CONCLUSION: Core actions resulting from this survey focused on formalizing physician roles, increasing interdisciplinary nutrition support expertise, utilizing cost-effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models.

The first juvenile dromaeosaurid (Dinosauria: Theropoda) from Arctic Alaska.

Compared to the osteological record of herbivorous dinosaurs from the Late Cretaceous Prince Creek Formation of northern Alaska, there are relatively fewer remains of theropods. The theropod record from this unit is mostly comprised of isolated teeth, and the only non-dental remains known can be attributed to the troodontid cf. Troodon and the tyrannosaurid Nanuqsaurus. Thus far, the presence of members of Dromaeosauridae has been limited to isolated teeth. Here we describe a symphyseal portion of a small dentary with two ziphodont teeth. Based on tooth shape, denticle morphology, and the position of the Meckelian groove, we attribute this partial dentary to a saurornitholestine dromaeosaurid. The fibrous bone surface, small size, and higher number of mesial denticles compared to distal ones point to a juvenile growth stage for this individual. Multivariate comparison of theropod teeth morphospace by means of principal component analysis reveals an overlap between this dentary and Saurornitholestinae dromaeosaurid morphospace, a result supported by phylogenetic analyses. This is the first confirmed non-dental fossil specimen from a member of Dromaeosauridae in the Arctic, expanding on the role of Beringia as a dispersal route for this clade between Asia and North America. Furthermore, the juvenile nature of this individual adds to a growing body of data that suggests Cretaceous Arctic dinosaurs of Alaska did not undergo long-distance migration, but rather they were year-round residents of these paleopolar latitudes.

Data supporting Maastrichtian paleoclimate variables applying a multi proxy approach to a paleosol profile, Arctic Alaska.

We provide the dataset of climate variables related to the research article "Paleoclimate reconstruction of the Prince Creek Formation, Arctic Alaska, during Maastrichtian global warming" [1]. The dataset includes mean annual precipitation (MAP) values determined using two independent proxies, estimates of the oxygen isotope composition of meteoric water (δ18Ow) obtained from smectites and a comparison with previously published siderite data. We also provide the data used to calculate the total flux of CO2 required for the weathering of silicates. This dataset is an example of a multi proxy approach that could add further insight for researchers in the selection of suitable proxies for paleoclimatic interpretations.

Dinosaur ichnology and sedimentology of the Chignik Formation (Upper Cretaceous), Aniakchak National Monument, southwestern Alaska; Further insights on habitat preferences of high-latitude hadrosaurs.

While there are now numerous records of dinosaurs from Cretaceous rocks around the state of Alaska, very few fossil records of terrestrial vertebrates are known from the Mesozoic rocks of the southwestern part of the state. Here we report the new discovery of extensive occurrences of dinosaur tracks from Aniakchak National Monument of the Alaska Peninsula. These tracks are in the Late Cretaceous (Maastrichtian) Chignik Formation, a cyclic sequence of rocks, approximately 500-600 m thick, representing shallow marine to nearshore marine environments in the lower part and continental alluvial coastal plain environments in the upper part of the section. These rocks are part of the Peninsular Terrane and paleomagnetic reconstructions based on the volcanic rocks of this terrane suggest that the Chignik Formation was deposited at approximately its current latitude which is almost 57° N. Recent field work in Aniakchak National Monument has revealed over 75 new track sites, dramatically increasing the dinosaur record from the Alaska Peninsula. Most of the combined record of tracks can be attributed to hadrosaurs, the plant-eating duck-billed dinosaurs. Tracks range in size from those made by full-grown adults to juveniles. Other tracks can be attributed to armored dinosaurs, meat-eating dinosaurs, and two kinds of fossil birds. The track size of the predatory dinosaur suggests a body approximately 6-7 m long, about the estimated size of the North Slope tyrannosaurid Nanuqsaurus. The larger bird tracks resemble Magnoavipes denaliensis previously described from Denali National Park, while the smaller bird tracks were made by a bird about the size of a modern Willet. Previous interdisciplinary sedimentologic and paleontologic work in the correlative and well-known dinosaur bonebeds of the Prince Creek Formation 1400km-1500km further north in Alaska suggested that high-latitude hadrosaurs preferred distal coastal plain or lower delta plain habitats. The ichnological record being uncovered in the Chignik Formation of southwestern Alaska is showing that the hadrosaur tracks here were also made in distal coastal and delta plain conditions. This similarity may corroborate the habitat preference model for Cretaceous high-latitude dinosaurs proposed for the data gathered from the Prince Creek Formation, and may indicate that at least Beringian hadrosaurids had similar habitat preferences regardless of latitude.

The First Definite Lambeosaurine Bone From the Liscomb Bonebed of the Upper Cretaceous Prince Creek Formation, Alaska, United States.

The Prince Creek Formation of Alaska, a rock unit that represents lower coastal plain and delta deposits, is one of the most important formations in the world for understanding vertebrate ecology in the Arctic during the Cretaceous. Here we report on an isolated cranial material, supraoccipital, of a lambeosaurine hadrosaurid from the Liscomb Bonebed of the Prince Creek Formation. The lambeosaurine supraoccipital has well-developed squamosal bosses and a short sutural surface with the exoccipital-opisthotic complex, and is similar to lambeosaurine supraoccipitals from the Dinosaur Park Formation in having anteriorly positioned squamosal bosses. Affinities with Canadian lambeosaurines elucidate more extensive faunal exchange between the Arctic and lower paleolatitudes which was previously suggested by the presence of Edmontosaurus, Pachyrhinosaurus, tyrannosaurids, and troodontids in both regions. The presence of one lambeosaurine and nine hadrosaurine supraoccipitals in the Liscomb Bonebed suggests hadrosaurine dominated faunal structure as in the Careless Creek Quarry of the USA that was also deposited under a near-shore environment. It differs from the lambeosaurine dominant structures of localities in Russia and China interpreted as inland environments. This may suggest that lambeosaurines had less preference for near-shore environments than hadrosaurines in both Arctic and lower paleolatitudes.

An unusual association of hadrosaur and therizinosaur tracks within Late Cretaceous rocks of Denali National Park, Alaska.

We report details of a unique association of hadrosaur and therizinosaur tracks found in the Late Cretaceous lower Cantwell Formation, Denali National Park, central Alaska Range, Alaska. This rock unit is now well-documented as a source of thousands of fossil footprints of vertebrates such as fishes, pterosaurs, and avialan and non-avialan dinosaurs. The lower Cantwell Formation in this area consists of numerous fining-upward successions of conglomerates and pebbly sandstones, cross-stratified and massive sandstones, interbedded sandstones and siltstones, organic-rich siltstones and shales, and rare, thin, bentonites, typically bounded by thin coal seams, and it contains a diverse fossil flora. We report the first North American co-occurrence of tracks attributable to hadrosaurs and therizinosaurs in the lower Cantwell Formation. Although previously un-reported in North America, this association of hadrosaur and therizinosaur tracks is more characteristic of the correlative Nemegt Formation in central Asia, perhaps suggesting that parameters defining the continental ecosystem of central Asia were also present in this part of Alaska during the Latest Cretaceous.

Lacosamide Pharmacokinetics in a Critically Ill Patient Receiving Continuous Venovenous Hemofiltration.

Lacosamide is a new-generation antiepileptic drug (AED) that is eliminated by both hepatic and renal mechanisms. Lacosamide elimination by continuous renal replacement therapy (CRRT) has never been studied. The objective of this case report was to describe lacosamide pharmacokinetics in the setting of CRRT. We describe a single patient admitted to the study center with status epilepticus and multiorgan failure. The patient required both continuous venovenous hemofiltration (CVVH) and several AEDs. He was receiving intravenous lacosamide 200 mg twice/day at steady state prior to sampling. Plasma lacosamide concentrations were derived using a validated high-performance liquid chromatography method. Parameters were calculated using Phoenix WinNonlin 7.1 software. The peak concentration at steady state was 7.7 mg/L, the trough concentration was 5.9 mg/L (goal 5-12 mg/L). The volume of distribution was 0.7 L/kg, the elimination half-life was 21 hours, and the sieving coefficient was 0.8 (± 0.06). Lacosamide was cleared by CVVH as demonstrated by the sieving coefficient, but plasma concentrations remained within goal range throughout the dosing interval. These results may suggest that lacosamide 200 mg twice/day is a useful dosing strategy for critically ill patients who require CVVH.

Emotions correlate with perceived mental effort and concentration disruption in adult sport performers.

Two studies explored the relationship between emotions, perceived mental effort and concentration disruption in adult sport performers. In Study 1, semi-professional association football players completed questionnaire measures before and after a competitive match. In Study 2, student athletes completed questionnaire measures for two performance scenarios: one in which they were performing above their normal level and one in which they were performing below their normal level. Findings demonstrated that cognitive trait anxiety was associated with greater disruptions in concentration but was unrelated to mental effort. For state measures, athletes reported greater levels of concentration disruption when experiencing high levels of anxiety or high levels of happiness, and fewer disruptions in concentration when experiencing high levels of excitement. Findings also showed that excitement was associated with low levels of mental effort during good performances and high levels of mental effort during poor performances; anxiety and happiness were associated with high levels of mental effort during good performances and low levels of mental effort during poor performances. Taken together, these studies point towards potential benefits accompanying high levels of excitement and potential disadvantages accompanying high levels of anxiety and happiness.

Emotions, cognitive interference, and concentration disruption in youth sport.

We explored the relationship between emotions, cognitive interference, concentration disruption and performance in youth sport. In study 1, 150 youth sport athletes (Mage = 13.13 years, s = 1.79) completed measures of emotion, cognitive interference, and concentration disruption for their most recently completed competition. In Study 2, 46 female rhythmic gymnasts (Mage = 10.30 years, s = 1.74) completed measures of emotion immediately before competition, and measures of cognitive interference and concentration disruption immediately after competition. Study 1 showed that anxiety and dejection were associated with more interfering thoughts and greater disruptions in concentration, whereas the effects of anger and happiness on interfering thoughts differed relative to the age of participants. Specifically, anger was associated with more interfering thoughts only in younger athletes and happiness was associated with fewer interfering thoughts only in older athletes. Study 2 showed that emotions experienced before competition were not strongly associated with cognitive interference or concentration disruption, but athletes reporting more thoughts of escape in competition were less successful in the competition as measured by objective performance scores. These findings demonstrate that emotions are important for cognitive interference and concentration disruption, and provide some initial evidence that cognitive interference is important for performance in youth sport.

Cognitive and affective components of challenge and threat states.

We explored the cognitive and affective components of the Theory of Challenge and Threat States in Athletes (TCTSA) using a cross-sectional design. One hundred and seventy-seven collegiate athletes indicated how they typically approached an important competition on measures of self-efficacy, perceived control, achievement goals, emotional states and interpretation of emotional states. Participants also indicated to what extent they typically perceived the important competition as a challenge and/or a threat. The results suggest that a perception of challenge was not predicted by any of the cognitive components. A perception of threat was positively predicted by avoidance goals and negatively predicted by self-efficacy and approach goals. Both challenge and threat had a positive relationship with anxiety. Practical implications of this study are that an avoidance orientation appeared to be related to potentially negative constructs such as anxiety, threat and dejection. The findings may suggest that practitioners and researchers should focus on reducing an avoidance orientation, however the results should be treated with caution in applied settings, as this study did not examine how the combination of constructs exactly influences sport performance. The results provided partial support for the TCTSA with stronger support for proposed relationships with threat rather than challenge states.

Continuous renal replacement therapies: a brief primer for the neurointensivist.

Continuous renal replacement therapy (CRRT) is a renal replacement modality that is often used in the ICU setting, including the neuro-ICU. This form of renal replacement therapy has been used classically for acute renal failure in patients with hemodynamic compromise, but is gaining acceptance as a method to control vascular and extra-vascular volume and mediate cytokines in non-renal diseases. Although these uses are briefly discussed, this review concentrates on the different forms of continuous renal replacement, mainly focusing on the technology of convective versus diffusive modalities and briefly on filter technology. There is also discussion on the various anticoagulation regimes used in CRRT including data on performing CRRT without anticoagulation. This review is not meant to be a discussion on the pros and cons of CRRT versus intermittent dialysis, but rather a primer on the technology of CRRT and how this therapy may affect general care of the ICU patient.

International and specialty trends in the use of prophylactic antibiotics to prevent infectious complications after insertion of external ventricular drainage devices.

BACKGROUND: External ventricular drains (EVD) are used as a method of diverting cerebral spinal fluid out of the cranium. After placement of these drains, it has been customary to initiate antibiotics to prevent drain-related infections. Prophylactic regimes include peri-operative and prolonged administration of antibiotics. Little evidence exists to support either regime. To determine current practices or to determine if an unintended consensus has developed, a survey was taken concerning antibiotic prophylaxis with EVD insertion. METHODS: E-mail survey from a membership database of the Neurocritical Care Society, a database of neurosurgeons maintained by the LSU Department of Neurosurgery and infectious diseases practitioners from a Department of Medicine database. RESULTS: There was an approximate 781 responses. Of the responders, 77% (599) were neurosurgeons, 10.5% (82) neurocritical care, 5.0% (41) intensivists, 6.5% (50) infectious diseases specialist, and 1% (9) others. The majority of responders (64%) have been in practice > 10 years. Most respondents from outside Europe recommended use of prophylactic antibiotics. Of those that did use antibiotics prophylaxis, the majority (56%) recommend use for the duration the catheter is in place. The exception is European responders used peri-operative prophylaxis most frequently. The majority of responders (78%) support a prospective trial to address this issue. CONCLUSION: The use of antibiotics prophylaxis after EVD placement is disparate among specialties that deal with EVD placement and complications. There is no consistent practice pattern based on specialty, locale, and years of practice. The majority of all responders felt a prospective trial was warranted.

Agitation and/or aggression after traumatic brain injury in the pediatric population treated with ziprasidone. Clinical article.

OBJECT: Agitation and aggression are common after traumatic brain injury (TBI) and can hamper recovery and rehabilitative efforts. To date, there is no consensus on pharmaceutical intervention for these conditions after TBI. Ziprasidone has been reported efficacious in this population but the evidence is limited. The authors report their experience of using ziprasidone to treat posttraumatic brain injury agitation in 20 consecutive pediatric patients. A secondary objective of this case series was to attempt to establish an age-specific dosage and identify possible side effects of this medication. METHODS: This case series study was performed at a university hospital and pediatric trauma center. Over an 18-month period, all patients who presented to the pediatric intensive care unit with TBI and later developed agitation and/or aggression were treated with ziprasidone as the sole intervention. Pre- and posttreatment scores on the Riker Sedation-Agitation Scale (SAS) were recorded along with demographic data. RESULTS: Twenty children received ziprasidone for agitation and/or aggression during the immediate recovery period from TBI. The median patient age was 8 years (range 9 months-17 years). Children were stratified into 4 age groups: <2 years old (Group 1), 2-6 years old (Group 2), 7-12 years old (Group 3), and >or=13 years old (Group 4). The SAS score, before and 24 hours after the initiation of ziprasidone, demonstrated a significant reduction after initiation of the medication (p<0.001). The initial dose for Groups 1-4 was 1.7, 0.9, 0.7, and 0.6 mg/kg, respectively, with final doses of 1.8, 1.5, 1.7, and 0.07 mg/kg, respectively. The duration of therapy for Groups 1-4 was 5, 8, 6, and 3 days, respectively. All patients received continuous cardiac and blood-pressure monitoring. No adverse events were reported in any of the age groups. CONCLUSIONS: Based on this limited patient series, ziprasidone appears to be safe and effective in pediatric patients with closed head injuries who develop agitation and/or aggression in the immediate postinjury period. Ziprasidone consistently lowered SAS scores and did so in all age groups. There were minimal dose adjustments and the duration of therapy was relatively brief. No adverse events were reported. A prospective trial of ziprasidone in this population appears warranted.

Survivin in glioblastomas. Protein and messenger RNA expression and comparison with telomerase levels.

CONTEXT: Survivin is a novel inhibitor of apoptosis that acts via a pathway independent of bcl-2. Little is known about its distribution in brain tumors or how it correlates with other biomarkers of malignancy, such as telomerase, an enzyme that plays a critical role in cellular immortalization and cancer biology. OBJECTIVES: To assess survivin protein expression in gliomas and to compare expression with that of telomerase. DESIGN: Immunohistochemical staining for survivin protein expression was performed using an antibody developed in our laboratory. Quantitative survivin messenger RNA (mRNA) levels were assessed by reverse transcriptase-polymerase chain reaction. In selected cases, survivin results were compared with quantitative telomerase values analyzed by polymerase chain reaction-based telomerase repeat amplification protocol (TRAP) assay. Twenty-five tumor tissue samples from 16 cases of glioblastoma multiforme (GBM; including multiple tissue samples in 6 patients), 2 grade II gliomas, 4 grade III gliomas, and 3 control temporal lobectomy specimens were studied. RESULTS: Nuclear immunoreactivity for survivin protein and survivin mRNA were detectable in most glioma samples, regardless of grade. Glioblastoma multiforme demonstrated moderate protein expression and survivin mRNA levels compared to epithelial malignancies previously tested in our laboratory. Although the association of survivin mRNA with the levels of telomerase within the GBM cases did not reach statistical significance, most GBMs also expressed survivin. The quantitative score for survivin mRNA was higher in GBMs than in grade II and III gliomas (P =.02), after accounting for multiple specimens per patient. CONCLUSIONS: Quantitative survivin mRNA analysis, but not immunohistochemistry, distinguished GBMs from lower grade gliomas. Mechanisms that promote both cell proliferation (telomerase expression) and cell survival (survivin expression) are often activated in GBMs.