Small Patients but a Heavy Lift: Workload and Burnout of Advanced Practice Providers and Physicians in a Level IV Neonatal Intensive Care Unit.

OBJECTIVE: This study explored the association between workload and the level of burnout reported by clinicians in our neonatal intensive care unit (NICU). A qualitative analysis was used to identify specific factors that contributed to workload and modulated clinician workload in the NICU. STUDY DESIGN: We conducted a study utilizing postshift surveys to explore workload of 42 NICU advanced practice providers and physicians over a 6-month period. We used multinomial logistic regression models to determine associations between workload and burnout. We used a descriptive qualitative design with an inductive thematic analysis to analyze qualitative data. RESULTS: Clinicians reported feelings of burnout on nearly half of their shifts (44%), and higher levels of workload during a shift were associated with report of a burnout symptom. Our study identified 7 themes related to workload in the NICU. Two themes focused on contributors to workload, 3 themes focused on modulators of workload, and the final 2 themes represented mixed experiences of clinicians' workload. CONCLUSION: We found an association between burnout and increased workload. Clinicians in our study described common contributors to workload and actions to reduce workload. Decreasing workload and burnout along with improving clinician well-being requires a multifaceted approach on unit and systems levels.

Workload In Neonatology (WORKLINE): Validation and feasibility of a system for measuring clinician workload integrated into the electronic health record.

OBJECTIVE: The purpose of the study was to validate WORKLINE, a NICU specific clinician workload model and to evaluate the feasibility of integrating WORKLINE into our EHR. STUDY DESIGN: This was a prospective, observational study of the workload of 42 APPs and physicians in a large academic medical center NICU over a 6-month period. We used regression models with robust clustered standard errors to test associations of WORKLINE values with NASA Task Load Index (NASA-TLX) scores. RESULTS: We found significant correlations between WORKLINE and NASA-TLX scores. APP caseload was not significantly associated with WORKLINE scores. We successfully integrated the WORKLINE model into our EHR to automatically generate workload scores. CONCLUSION: WORKLINE provides an objective method to quantify the workload of clinicians in the NICU, and for APPs, performed better than caseload numbers to reflect workload. Integrating the WORKLINE model into the EHR was feasible and enabled automated workload scores.

Developing a Unit-Based Quality Improvement Program in a Large Neonatal ICU.

BACKGROUND: Quality improvement (QI) methods have been widely adopted in health care. Although theoretical frameworks and models for organizing successful QI programs have been described, few reports have provided practical examples to link existing QI theory to building a unit-based QI program. The purpose of this report is to describe the authors' experience in building QI infrastructure in a large neonatal ICU (NICU). METHODS: A unit-based QI program was developed with the goal of fostering the growth of high-functioning QI teams. This program was based on six pillars: shared vision for QI, QI team capacity, QI team capability, actionable data for improvement, culture of improvement, and QI team integration with external collaboratives. Multiple interventions were developed, including a QI dashboard to align NICU metrics with unit and hospital quality goals, formal training for QI leaders, QI coaches imbedded in project teams, a day-long QI educational workshop to introduce QI methodology to unit staff, and a secure, Web-based QI data infrastructure. RESULTS: Over a five-year period, this QI infrastructure brought organization and support for individual QI project teams and improved patient outcomes in the unit. Two case studies are presented, describing teams that used support from the QI infrastructure. The Infection Prevention team reduced central line-associated bloodstream infections from 0.89 to 0.36 infections per 1,000 central line-days. The Nutrition team decreased the percentage of very low birth weight infants discharged with weights less than the 10th percentile from 51% to 40%. CONCLUSION: The clinicians provide a pragmatic example of incorporating QI organizational and contextual theory into practice to support the development of high-functioning QI teams and build a unit-based QI program.

Investigation of infectious reproductive pathogens of large ruminants: Are neosporosis, brucellosis, leptospirosis and BVDV of relevance in Lao PDR?

N. caninum, bovine viral diarrhoea virus, Brucella abortus and Leptospira interrogans serovar Hardjo are globally significant reproductive pathogens that cause abortion and reproductive loss in large ruminants. Prevalence information is lacking in Lao People's Democratic Republic (Laos) despite the poor reproductive performance of cattle and buffalo. Serological examination of frozen cattle (n=90) and buffalo (n=61) sera by commercially available enzyme-linked immunosorbent assays provided the first reported screening of some of these pathogens in Laos. Seroprevalence differed amongst these large ruminant species, with N. caninum, BVDV and L. interrogans serovar Hardjo antibodies found in 68.9% (95% CI±11.6), 4.9% (95% CI±5.4) and 3.3% (95% CI±4.5) of buffalo sera, respectively, and in 7.8% (95% CI±5.5), 10.0% (95% CI±6.2) and 22.2% (95% CI±8.6) of cattle sera, respectively. Buffalo sera had a significantly higher seroprevalence of N. caninum compared to cattle (p<0.001) and cattle sera had a significantly higher seroprevalence of L. interrogans serovar Hardjo compared to buffalo (p=0.003). Variability was also observed across provinces for N. caninum in buffalo (p=0.007) and for L. interrogans serovar Hardjo in cattle (p=0.071), suggesting provincial risk factors conducive to pathogen transmission. BVDV and N. caninum seropositivity were negatively associated in buffalo (p=0.018) and cattle (p=0.003). In buffalo, L. interrogans serovar Hardjo and BVDV seropositivity were associated (p=0.035, p=0.039). The identification of antibodies against three major abortifacient pathogens in Laos prompts further research to determine if infection is associated with low reproductive efficiency and the risk factors for infection. This is needed for the development of evidence based prevention strategies for improved large ruminant reproductive management among smallholders in Laos.

The development of attention skills in action video game players.

Previous research suggests that action video game play improves attentional resources, allowing gamers to better allocate their attention across both space and time. In order to further characterize the plastic changes resulting from playing these video games, we administered the Attentional Network Test (ANT) to action game players and non-playing controls aged between 7 and 22 years. By employing a mixture of cues and flankers, the ANT provides measures of how well attention is allocated to targets as a function of alerting and orienting cues, and to what extent observers are able to filter out the influence of task irrelevant information flanking those targets. The data suggest that action video game players of all ages have enhanced attentional skills that allow them to make faster correct responses to targets, and leaves additional processing resources that spill over to process distractors flanking the targets.

Turnover and function of noncoding RNA polymerase II transcripts.

In the past few years, especially since the discovery of RNA interference (RNAi), our understanding of the role of RNA in gene expression has undergone a significant transformation. This change has been brought about by growing evidence that RNA is more complex and transcription more promiscuous than has previously been thought. Many of the new transcripts are of so-called noncoding RNA (ncRNA); i.e., RNA that does not code for proteins such as mRNA, or intrinsic parts of the cellular machinery such as the highly structured RNA components of ribosomes (rRNA) and the small nuclear RNA (snRNA) components of the splicing machinery. It is becoming increasingly apparent that ncRNAs have very important roles in gene expression. This paper focuses on work from our laboratory in which we have investigated the roles and turnover of ncRNA located within the gene pre-mRNA, which we refer to as intragenic ncRNA. Also discussed are some investigations of intergenic ncRNA transcription and how these two classes of ncRNA may interrelate.

Multiple transcript cleavage precedes polymerase release in termination by RNA polymerase II.

The requirement of poly(A) signals to elicit transcription termination of RNA polymerase II (pol II) is firmly established. However, little else is known about the actual process of pol II transcription termination. Evidence presented in this paper, based on analysis of nascent transcripts of the human beta- and epsilon-globin genes, demonstrates that pol II transcription termination involves two distinct and temporally separate events. The first event, termed pretermination cleavage (PTC), is mediated by sequence tracts located downstream of the poly(A) site which appear to promote heterogeneous cleavage of the nascent transcript. The second event, in which pol II disengages from the DNA template, requires that polymerase has transcribed both a PTC sequence tract and a functional poly(A) site.

Patterns of telephone use among nursing home residents.

There is convincing evidence that nursing home residents who have more visitors fare better than those who have fewer visitors. However, as many as one third of all individuals living in nursing homes have virtually no visitors. The purpose of this study was to address this concern by examining telephone use in older adults living in nursing homes, and evaluating the potential of telephone communications as a means of social support for this at-risk group. Using a recording device activated each time the receiver was picked up, the research team "listened in" on the telephone conversations of three nursing home residents (aged 76, 79, and 92) for a period of 1 week. The transcripts revealed 56 minutes of actual conversation during the week (10, 21, and 25 minutes, respectively), most often with family or longtime friends living out of town. Each resident laughed aloud more than once per minute. The telephone conversations provided the residents with vivid glimpses of life outside the walls of their facility and appeared to help them stay connected with their family and friends. The findings support further study of the telephone as a way to sustain authentic social support in long-term care populations.

Anger, irrational beliefs, and dysfunctional attitudes in violent dating relationships.

The purpose of the present investigation was to evaluate whether perpetrators of dating violence could be differentiated from their nonviolent counterparts on measures of anger and cognitive distortion, specifically Ellis's (1994) irrational beliefs and Beck's (1976) dysfunctional attitudes. Of the 95 male and 152 female undergraduates surveyed, 27% (24 males and 43 females) reported using some form of physical aggression against their current dating partner in the past year. On a self-report measure of anger (State-Trait Anger Expression Inventory), violent individuals reported higher levels of Anger Out and lower levels of Anger Control compared to nonviolent participants. While there were no differences between violent and nonviolent participants' levels of Trait Anger, the results suggest that violent individuals have difficulty controlling angry feelings when they arise, which may increase the likelihood of externally directed forms of anger expression. No significant group differences emerged on questionnaire measures of irrational beliefs and dysfunctional attitudes. Within the violent sample, there was no differential pattern of correlations between measures of anger and cognition relative to the nonviolent sample. The present data suggest that while trait-based measures of cognitive distortion explain little variance in self-reported acts of dating violence, future research should investigate whether (a) cognitive distortions are present during affect-inducing partner conflict situations, or (b) vary with violence severity.

Transcription of the human U2 snRNA genes continues beyond the 3' box in vivo.

The 3' box of the human class II snRNA genes is required for proper 3' processing of transcripts, but how it functions is unclear. Several lines of evidence suggest that termination of transcription occurs at the 3' box and the terminated transcript is then a substrate for processing. However, using nuclear run-on analysis of endogenous genes, we demonstrate that transcription continues for at least 250 nucleotides beyond the 3' box of the U2 genes. Although in vivo footprinting analysis of both the U1 and U2 genes detects no protein-DNA contacts directly over the 3' box, a series of G residues immediately downstream from the 3' box of the U1 gene are clearly protected from methylation by dimethylsulfate. In conjunction with the 3' box of the U1 gene, this in vivo footprinted region causes termination of transcription of transiently transfected U2 constructs, whereas a 3' box alone does not. Taken together, these results indicate that the 3' box is not an efficient transcriptional terminator but may act as a processing element that is functional in the nascent RNA.

Terminal exon definition occurs cotranscriptionally and promotes termination of RNA polymerase II.

Analysis of nascent transcription from the human epsilon- and beta-globin genes shows that transcriptional termination occurs within 1.5 kb of the poly(A) site and is dependent on the presence of functional poly(A) signals. Even so, transcripts that have not been cleaved at the poly(A) site are detected up to the termination region, suggesting that there is a kinetic lag between transcription over the poly(A) signal and its effect on transcriptional termination. Surprisingly, mutation of the splice acceptor (SA) of the beta-globin IVS2 also abolishes transcriptional termination. Our results emphasize the interconnection of transcription and RNA processing by showing that the enhancement of 3' end processing by the terminal splice acceptor occurs cotranscriptionally.

Phylogenetic grouping and identification of Rhizobium isolates on the basis of random amplified polymorphic DNA profiles.

Through the use of a single, random 15mer as a primer, between 1 and 12 DNA amplification products were obtained per strain from a selection of 84 Rhizobium and Bradyrhizobium isolates. A principal-coordinate analysis was used to analyse the resulting amplified DNA profiles and it was possible to assign isolates to specific groupings. Within the species Rhizobium leguminosarum, the biovar phaseoli formed a distinct group from the other biovars of the species, viciae and trifolii, which grouped together. Isolates of Rhizobium meliloti and Bradyrhizobium species formed their own clear, specific groups. Although it was possible to identify individual isolates on the basis of differences in their amplified DNA profiles, there was evidence that some amplified segments were conserved among individuals at the biovar and species levels.

Characterisation of Rhizobium isolates by amplification of DNA polymorphisms using random primers.

The use of single random primers, selected in the absence of target sequence information, has been shown to be effective in producing DNA amplifications that provide fingerprints which are unique to individual organisms. DNA amplification by random priming was applied to the DNA from isolates of Rhizobium leguminosarum biovar trifolii. Amplification products were produced using a number of primers, and the resulting fingerprints allowed strain differentiation. However, the effectiveness of primers was dependent upon length and GC content. It was also possible to amplify DNA directly from cells in culture and in nodule tissue. Lysis of these cells was achieved simply through heat applied in the initial DNA denaturation stage of the thermal reaction. The ability to produce varied amplification patterns from different Rhizobium isolates, especially directly from nodules, gives this method potential for use in examining genetic structures and relationships in Rhizobium populations.

Prognosis after surgical excision of canine fibrous connective tissue sarcomas.

One hundred eighty seven dogs from which fibrous connective tissue sarcomas had been excised were studied until death or for at least 3 years after surgery. Dogs with a skin fibrosarcoma had a median survival time of 80 weeks, compared with 140 weeks for animals with haemangiopericytoma in similar sites, this difference being statistically significant. However, the difference in survival time between the two histologic types disappeared when tumours with a similar mitotic index were compared. Dogs with a tumour of mitotic index 9 or more had a median survival time of 49 weeks, compared with 118 weeks for those with a tumour of mitotic index less than 9, regardless of tumour morphology. Tumour recurrence rates of 62% and 25% respectively for the two groups were also significantly different.

Prognosis after surgical excision of fibrosarcomas in cats.

Forty-four cats from which fibrosarcomas had been excised were studied for a minimum of 3 years, of until death. Two factors, tumor site and mitotic index, were found to be of prognostic significance, but tumor size, duration of growth, and histologic appearance were not. Following removal of fibrosarcomas from the pinna or flank in 6 cats, none died as a result of the tumor but 24 of 35 (70%) cats with fibrosarcoma in the skin of the head, back, or limbs were euthanatized because of local recurrence, usually within 9 months of surgery. The median survival time of cats with a tumor of mitotic index 6 or more in the head, back, or limbs was 16 weeks, compared with 128 weeks when the mitotic index was less than 6. Eleven percent of cats developed pulmonary metastases.