Improving Early Discharge Using a Team-Based Structure for Discharge Multidisciplinary Rounds.

PURPOSE OF STUDY: Miscommunications during the complex process of discharging patients from acute care facilities can lead to adverse events, patient dissatisfaction, and delays in discharge. Brief multidisciplinary discharge rounds (MDRs) can increase communication between stakeholders and shorten a patient's length of stay (LOS). At our tertiary academic medical center, case managers (CMs) have historically been assigned patients by physical unit location rather than by provider teams caring for patients. As a result, medicine teams often interact with several unit-based CMs due to lack of geographically cohorted patients, leading to inefficiency and fragmentation in discharge planning communication. Our aim was to implement and evaluate the impact of multidisciplinary, team-based discharge planning rounds (MDR) for general medicine patients. PRIMARY PRACTICE SETTING: A tertiary academic medical center. METHODOLOGY AND SAMPLE: Using the model for continuous improvement, we implemented and optimized MDR on 2 of 4 internal medicine resident ward teams that care for general internal medicine patients, including creation of a multidisciplinary team, improving physician continuity. RESULTS: During the pilot, 1,584 patients were discharged from all medicine teams-825 from pilot teams and 759 from control teams. The proportion of patients with discharge before noon (DBN) orders was 41.2% on pilot versus 29.6% on control teams. Length of stay was 92.2 hr versus 97.2 hr, and 30-day readmission rate was 16.0% versus 18.3% for the pilot versus control teams, respectively. After the pilot concluded, we continued to have resident continuity on pilot teams but returned to the unit-based CM model. During this time, the proportion of DBN orders and LOS were similar between the pilot and control teams (29.0% vs. 24.3% and 95.8 hr vs. 96.6 hr, respectively). The 30-day readmission rate was 12.6% compared with 18.9% for the pilot versus control teams. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Our team-based MDR pilot improved interdisciplinary relationships and communication and resulted in shorter LOS, earlier discharge times, and lower 30-day readmissions.

Novel integrative virtual rehabilitation reduces symptomatology of primary progressive aphasia--a case report.

PURPOSE: BrightBrainer™ integrative cognitive rehabilitation system evaluation in an Adult Day Program by a subject with Primary Progressive Aphasia (PPA) assumed to be of the mixed nonfluent/logopenic variant, and for determination of potential benefits. METHODS: The subject was a 51-year-old Caucasian male diagnosed with PPA who had attended an Adult Day Program for 18 months prior to BrightBrainer training. The subject interacted with therapeutic games using a controller that measured 3D hand movements and flexion of both index fingers. The computer simulations adapted difficulty level based on task performance; results were stored on a remote server. The clinical trial consisted of 16 sessions, twice/week for 8 weeks. The subject was evaluated through neuropsychological measures, therapy notes and caregiver feedback forms. RESULTS: Neuropsychological testing indicated no depression (BDI 0) and severe dementia (BIMS 1 and MMSE 3). The 6.5 h of therapy consisted of games targeting Language comprehension; Executive functions; Focusing; Short-term memory; and Immediate/working memory. The subject attained the highest difficulty level in all-but-one game, while averaging 1300-arm task-oriented active movement repetitions and 320 index finger flexion movements per session. While neuropsychological testing showed no benefits, the caregiver reported strong improvements in verbal responses, vocabulary use, speaking in complete sentences, following one-step directions and participating in daily activities. This corroborated well with therapy notes. CONCLUSIONS: Preliminary findings demonstrate a meaningful reduction of PPA symptoms for the subject, suggesting follow-up imaging studies to detail neuronal changes induced by BrightBrainer system and controlled studies with a sufficiently large number of PPA subjects.

Thermomechanical Synergisms from Ionic Liquid Doping of Poly(methyl methacrylate).

A synergism between methyl methacrylate and an amphiphilic ionic liquid acrylate 1-(11-acryloyloxyundecyl)-3-methyl imidazolium bromide (IL) not only increases the apparent thermal stability (kinetic retardation of thermal decomposition) of poly(MMA-co-IL) copolymers by 50 °C at relatively low doping levels of 0.5 mol %, but also increases the storage (∼10%) and loss (15-25%) moduli over 0-75 °C (increasing the elasticity). Moderate to high doping levels provide plasticization without the risk of leaching or plasticizer contamination.

Triblock copolymer based on poly(propylene oxide) and poly(1-[11-acryloylundecyl]-3-methyl-imidazolium bromide).

The controlled atom transfer radical polymerization of an ionic liquid, 1-(11-acryloylundecyl)-3-methyl imidazolium bromide (ILBr), from both ends of a telechelic poly(propylene oxide) (PPO) macroinitiator, end-functionalized with bromoisobutyryloyl is reported. The resulting highly water-soluble triblock, poly(ILBr-b-PO-b-ILBr) is multistimuli responsive. This new class of triblocks exhibits classical surface activity in lowering surface tension at the air-water interface and in modifying wetting in waterborne coatings. It also immunizes model colloids against coagulation induced by Debye-Hückel (indifferent electrolyte) electrostatic screening. Further, sol-gel thermoreversibility is unexpectedly found as an additional form of stimuli responsiveness.

Polymer dewetting via stimuli responsive structural relaxation-contact angle analysis.

Thin films of a stimuli-responsive homopolymer dewet as a stimulus response after anion exchange of the imidazolium's counter anion. Contact angle analysis and interfacial energy considerations indicate dewetting goes counter to increasing spreading coefficient. Intrafilm stress arising from structural relaxation drives the dewetting.

Stimuli responsive poly(1-[11-acryloylundecyl]-3-methyl-imidazolium bromide): dewetting and nanoparticle condensation phenomena.

A stimuli-responsive homopolymer poly(ILBr) is fabricated via a "two-phase" atom transfer radical polymerization (ATRP) process, where ILBr stands for the reactive ionic liquid surfactant, 1-[11-acryloylundecyl]-3-methyl-imidazolium bromide. An extraordinarily wide molecular weight distribution (PDI = 6.0) was obtained by introducing the initiator (4-bromomethyl methyl benzoate) in a heterogeneous two-phase process. The molecular weight distribution of poly(ILBr) was characterized by size-exclusion chromatography (SEC). The resulting homopolymer was found to be surface active and stimuli responsive. Poly(ILBr) films coated on quartz exhibit stimuli-responsive dewetting after ion exchange of Br(-) by PF(6)(-). This dewetting phenomenon can be understood in chain segmental terms as a stimuli-induced structural relaxation and appears to be the first such reported stimuli-responsive polymeric dewetting. Titrating aqueous poly(ILBr) with aqueous bis(2-ethylhexyl)sulfosuccinate induces nanophase separation and results in the condensation of nanoparticles 30-60 nm in diameter.

Organic solvent-dispersed TiO(2) nanoparticle characterization.

Anatase titanium dioxide nanoparticles are derivatized with the polymerizable reagent (3-methacryloxypropyl)trimethoxysilane to provide dispersions in organic solvent. The titania core particles are characterized by transmission electron microscopy (TEM) and X-ray diffraction (XRD). The organic component structures and thickness are elucidated using nuclear magnetic resonance (NMR), quasielastic light scattering (QELS), and size-exclusion chromatography (SEC). Thin, high-refractive-index coatings prepared from the organic dispersions are characterized by atomic force microscopy (AFM). The combination of microscopies, spectroscopy, light scattering, and separation techniques provides unique information on the structure, thickness, morphology, and size distributions of the surface-treated nanoparticles that is difficult to obtain by any single technique. The findings indicate titania platelets with a modal diameter of 9.8 nm and a thickness of approximately 1.5 nm. The particles are coated with a 1.5-1.9 nm thick organic ligand layer, and a substantial population of 2 nm siloxane oligomers is detected. The analytical methodology presented may also be useful for characterizing other anisotropic organic-inorganic nanoparticles and their dispersions.

Characterizing property distributions of polymeric nanogels by size-exclusion chromatography.

Nanogels are highly branched, swellable polymer structures with average diameters between 1 and 100nm. Size-exclusion chromatography (SEC) fractionates materials in this size range, and it is commonly used to measure nanogel molar mass distributions. For many nanogel applications, it may be more important to calculate the particle size distribution from the SEC data than it is to calculate the molar mass distribution. Other useful nanogel property distributions include particle shape, area, and volume, as well as polymer volume fraction per particle. All can be obtained from multi-detector SEC data with proper calibration and data analysis methods. This work develops the basic equations for calculating several of these differential and cumulative property distributions and applies them to SEC data from the analysis of polymeric nanogels. The methods are analogous to those used to calculate the more familiar SEC molar mass distributions. Calibration methods and characteristics of the distributions are discussed, and the effects of detector noise and mismatched concentration and molar mass sensitive detector signals are examined.