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Interprofessional teams in the pediatric cardiac ICU consolidate their management plans in pre-family meeting huddles, a process that affects the course of family meetings but often lacks optimal communication and teamwork.
Methods:
Cardiac ICU clinicians participated in an interprofessional intervention to improve how they prepared for and conducted family meetings. We conducted a pretest–posttest study with clinicians participating in huddles before family meetings. We assessed feasibility of clinician enrollment, assessed clinician perception of acceptability of the intervention via questionnaire and semi-structured interviews, and impact on team performance using a validated tool. Wilcoxon rank sum test assessed intervention impact on team performance at meeting level comparing pre- and post-intervention data.
Results:
Totally, 24 clinicians enrolled in the intervention (92% retention) with 100% completion of training. All participants recommend cardiac ICU Teams and Loved ones Communicating to others and 96% believe it improved their participation in family meetings. We exceeded an acceptable level of protocol fidelity (>75%). Team performance was significantly (p < 0.001) higher in post-intervention huddles (n = 30) than in pre-intervention (n = 28) in all domains. Median comparisons: Team structure [2 vs. 5], Leadership [3 vs. 5], Situation Monitoring [3 vs. 5], Mutual Support [ 3 vs. 5], and Communication [3 vs. 5].
Conclusion:
Implementing an interprofessional team intervention to improve team performance in pre-family meeting huddles is feasible, acceptable, and improves team function. Future research should further assess impact on clinicians, patients, and families.
Inference is considered for the marginal distribution of X, when (X, Y) has a truncated bivariate normal distribution. The Y variable is truncated, but only the X values are observed. The relationship of this distribution to Azzalini's “skew-normal” distribution is obtained. Method of moments and maximum likelihood estimation are compared for the three-parameter Azzalini distribution. Samples that are uniformative about the skewness of this distribution may occur, even for large n. Profile likelihood methods are employed to describe the uncertainty involved in parameter estimation. A sample of 87 Otis test scores is shown to be well-described by this model.
Debate surrounds the early peopling of the Arabian Peninsula. The first evidence of the Levallois lithic technology in the Huqf area of south-eastern Arabia now extends the Middle Palaeolithic record of hominin activity into central Oman and helps to diversify the picture of Arabian prehistory.
Radiotherapy for pediatric brain tumor has been associated with late cognitive effects. Compared to conventional photon radiotherapy (XRT), proton radiotherapy (PRT) delivers less radiation to healthy brain tissue. PRT has been associated with improved long term cognitive outcomes compared to XRT. However, there is limited research comparing the effects of XRT and PRT on verbal memory outcomes.
Participants and Methods:
Survivors of pediatric brain tumor treated with either XRT (n = 29) or PRT (n = 51) completed neuropsychological testing > 1 year following radiotherapy. XRT and PRT groups were similar with respect to sex, handedness, race, age at diagnosis, age at evaluation, tumor characteristics, and treatment history (i.e., craniospinal irradiation, craniotomy, shunting, chemotherapy, radiation dose). Verbal learning and memory were assessed using the age-appropriate version of the California Verbal Learning Test (CVLT-II/CVLT-C). Measures of intellectual functioning, executive functioning, attention and adaptive behavior were also collected. Performance on neuropsychological measures was compared between treatment groups (XRT vs. PRT) using analysis of covariance (ANCOVA). On the CVLT, each participant was classified as having an encoding deficit profile (i.e., impaired learning, recall, and recognition), retrieval deficit profile (i.e., impaired recall but intact recognition), intact profile, or other profile. Chi-squared tests of independence were used to compare the probability of each memory profile between treatment groups. Pearson correlation was used to examine associations between memory performance and strategy use, intellectual functioning, adaptive behavior, attention, and executive functioning.
Results:
Overall, patients receiving PRT demonstrated superior verbal learning (CVLT Trials 1-5; t(76) = 2.61, p = .011), recall (CVLT Long Delay Free; t(76) = 3.57, p = .001) and strategy use (CVLT Semantic Clustering; t(76) = 2.29, p = .025) compared to those treated with XRT. Intact performance was more likely in the PRT group than the XRT group (71% PRT, 38% XRT; X2 = 8.14, p = .004). Encoding and retrieval deficits were both more common in the XRT group, with encoding problems being most prevalent (Encoding Deficits: 31% XRT, 12% PRT, X2 = 4.51, p = .034; Retrieval Deficits: 17% XRT, 4% PRT, X2 = 4.11, p = .043). Across all participants, semantic clustering predicted better encoding (r = .28, p = .011) and retrieval (r = .26, p = .022). Better encoding predicted higher intellectual (r = .56, p < .001) and adaptive functioning (r = .30, p = .011), and fewer parent-reported concerns about day-today attention (r = -.36, p = .002), and cognitive regulation (r = -.35, p = .002).
Conclusions:
Results suggest that PRT is associated with superior verbal memory outcomes compared to XRT, which may be driven by encoding skills and use of learning strategies. Moreover, encoding ability predicted general intellectual ability and day-to-day functioning. Future work may help to clarify underlying neural mechanisms associated with verbal memory decline following radiotherapy, which will better inform treatment approaches for survivors of pediatric brain tumor.
Bloodstream infections (BSIs) are a frequent cause of morbidity in patients with acute myeloid leukemia (AML), due in part to the presence of central venous access devices (CVADs) required to deliver therapy.
Objective:
To determine the differential risk of bacterial BSI during neutropenia by CVAD type in pediatric patients with AML.
Methods:
We performed a secondary analysis in a cohort of 560 pediatric patients (1,828 chemotherapy courses) receiving frontline AML chemotherapy at 17 US centers. The exposure was CVAD type at course start: tunneled externalized catheter (TEC), peripherally inserted central catheter (PICC), or totally implanted catheter (TIC). The primary outcome was course-specific incident bacterial BSI; secondary outcomes included mucosal barrier injury (MBI)-BSI and non-MBI BSI. Poisson regression was used to compute adjusted rate ratios comparing BSI occurrence during neutropenia by line type, controlling for demographic, clinical, and hospital-level characteristics.
Results:
The rate of BSI did not differ by CVAD type: 11 BSIs per 1,000 neutropenic days for TECs, 13.7 for PICCs, and 10.7 for TICs. After adjustment, there was no statistically significant association between CVAD type and BSI: PICC incident rate ratio [IRR] = 1.00 (95% confidence interval [CI], 0.75–1.32) and TIC IRR = 0.83 (95% CI, 0.49–1.41) compared to TEC. When MBI and non-MBI were examined separately, results were similar.
Conclusions:
In this large, multicenter cohort of pediatric AML patients, we found no difference in the rate of BSI during neutropenia by CVAD type. This may be due to a risk-profile for BSI that is unique to AML patients.
Given the rising numbers of older adults in Canada experiencing falls, evidence-based identification of fall risks and plans for prevention across the continuum of care is a significant priority for health care providers. A scoping review was conducted to synthesize published international clinical practice guidelines (CPGs) and recommendations for fall risk screening and assessment in older adults (defined as 65 years of age and older). Of the 22 CPGs, 6 pertained to multiple settings, 9 pertained to community-dwelling older adults only, 2 each pertained to acute care and long-term care settings only, and 3 did not specify setting. Two criteria, prior fall history and gait and balance abnormalities, were applied either independently or sequentially in 19 CPG fall risk screening algorithms. Fall risk assessment components were more varied across CPGs but commonly included: detailed fall history; detailed evaluation of gait, balance, and/or mobility; medication review; vision; and environmental hazards assessment. Despite these similarities, more work is needed to streamline assessment approaches for heterogeneous and complex older adult populations across the care continuum. Support is also needed for sustainable implementation of CPGs in order to improve health outcomes.
Greenhouse and growth chamber studies were conducted to investigate effects of herbicide placement in soil on toxicity to emerging seedlings. The use of a technique involving a plastic bag over the plants for 3 to 4 weeks to reduce soil moisture loss did not change the apparent site of 2-chloro-4-(ethylamino)-6-(isopropylamino)-s-triazine (atrazine) uptake by green foxtail (Setaria viridis (L.) Beauv.) or oats (Avena sativa L.). Atrazine was more effective on oats through root exposure and more effective on green foxtail through shoot exposure when an untreated buffer zone around the seed was used. But in subsequent studies without the buffer zone, atrazine was most active when placed immediately below the seed of both oats and green foxtail. Proximity to the seed increased effectiveness of atrazine, S-ethyl dipropylthiocarbamate (EPTC), and 3-(3,4-dichlorophenyl)-1,1-dimethylurea (diuron). Also, a narrow concentrated layer of these three herbicides adjacent to the seed was more effective than a wider dilute layer above or below the seed. A diurnal fluctuating temperature regime with a low night temperature increased toxicity of EPTC to oats through root exposure, when compared to a constant temperature regime.
Increased summer ice velocities on the Greenland ice sheet are driven by meltwater input to the subglacial environment. However, spatial patterns of surface input and partitioning of meltwater between different pathways to the base remain poorly understood. To further our understanding of surface drainage, we apply a supraglacial hydrology model to the Paakitsoq region, West Greenland for three contrasting melt seasons. During an average melt season, crevasses drain ~47% of surface runoff, lake hydrofracture drains ~3% during the hydrofracturing events themselves, while the subsequent surface-to-bed connections drain ~21% and moulins outside of lake basins drain ~15%. Lake hydrofracture forms the primary drainage pathway at higher elevations (above ~850 m) while crevasses drain a significant proportion of meltwater at lower elevations. During the two higher intensity melt seasons, model results show an increase (~5 and ~6% of total surface runoff) in the proportion of runoff drained above ~1300 m relative to the melt season of average intensity. The potential for interannual changes in meltwater partitioning could have implications for how the dynamics of the ice sheet respond to ongoing changes in meltwater production.
Volumetric atrophy and microstructural alterations in diffusion tensor imaging (DTI) measures of the hippocampus have been reported in people with Alzheimer's disease (AD) and mild cognitive impairment (MCI). However, no study to date has jointly investigated concomitant microstructural and volumetric changes of the hippocampus in dementia with Lewy bodies (DLB).
Methods:
A total of 84 subjects (23 MCI, 17 DLB, 14 AD, and 30 healthy controls) were recruited for a multi-modal imaging (3T MRI and DTI) study that included neuropsychological evaluation. Freesurfer was used to segment the total hippocampus and delineate its subfields. The hippocampal segmentations were co-registered to the mean diffusivity (MD) and fractional anisotropy (FA) maps obtained from the DTI images.
Results:
Both AD and MCI groups showed significantly smaller hippocampal volumes compared to DLB and controls, predominantly in the CA1 and subiculum subfields. Compared to controls, hippocampal MD was elevated in AD, but not in MCI. DLB was characterized by both volumetric and microstructural preservation of the hippocampus. In MCI, higher hippocampal MD was associated with greater atrophy of the hippocampus and CA1 region. Hippocampal volume was a stronger predictor of memory scores compared to MD within the MCI group.
Conclusions:
Through a multi-modal integration, we report novel evidence that the hippocampus in DLB is characterized by both macrostructural and microstructural preservation. Contrary to recent suggestions, our findings do not support the view that DTI measurements of the hippocampus are superior to volumetric changes in characterizing group differences, particularly between MCI and controls.
We studied neuroinflammation in individuals with late-life, depression, as a
risk factor for dementia, using [11C]PK11195 positron emission
tomography (PET). Five older participants with major depression and 13
controls underwent PET and multimodal 3T magnetic resonance imaging (MRI),
with blood taken to measure C-reactive protein (CRP). We found significantly
higher CRP levels in those with late-life depression and raised
[11C]PK11195 binding compared with controls in brain regions
associated with depression, including subgenual anterior cingulate cortex,
and significant hippocampal subfield atrophy in cornu ammonis 1 and
subiculum. Our findings suggest neuroinflammation requires further
investigation in late-life depression, both as a possible aetiological
factor and a potential therapeutic target.
Many fossil assemblages are time-averaged, with multiple generations of organisms mixed into a single stratigraphic horizon. A time-averaged sample of a taxon should be more variable than a single-generation sample if enough morphologic change occurred during the interval of time-averaging. Time-averaging may also alter correlations between morphologic variables and obscure allometric relationships in an evolving population. To investigate these issues, we estimated the variability of six modern, single-generation samples of the bivalve Mercenaria campechiensis using Procrustes analysis and compared them with several time-averaged Pleistocene samples of M. campechiensis and M. permagna. Both the modern and the fossil samples ranged in variability, but these ranges were virtually identical. Morphology was quite stable over the hundreds to many thousands of years that passed as the assemblages accumulated, and the variabilities of the fossil samples could be used to estimate single-generation variability. At one fossil locality, the environment and paleocommunity changed partway through the collection interval; the morphology of Mercenaria appears stable above and below the transition but changes across it. This change is similar in magnitude to the differences between geographically separated modern populations, whereas temporal variation within single environmental settings is distinctly less than geographic variation. Analytical time-averaging (the mixing of fossils from different horizons) between paleocommunities increased variability slightly (but not significantly) above that found in living populations. While its constituent populations appear stable on millennial timescales, M. campechiensis has been evolutionarily static since at least the early to middle Pleistocene.
A 40-year-old female with a recurrent mixed astrocytoma/oligodendroglioma was treated with intraarterial BCNU at six week intervals. Phosphorus magnetic resonance spectroscopy was performed before, and on two occasions after her third treatment.
Before treatment, phosphodiesters were 25% less than normal and intracellular pH was 7.14 (normal 6.97 ± 0.02). Eight hours following treatment phosphocreatine and phosphodiesters were reduced by ∼40% and pHi increased to 7.24. Thirty-two hours after treatment, phosphocreatine and phosphodiesters had reversed their decline, but pHi had increased further to 7.35. MRI and x-ray CT scans did not show any change during this period.
This study demonstrates that chemical changes can be observed in a glioma by magnetic resonance spectroscopy shortly after chemotherapy in a clinical setting and before changes are observable by imaging modalities. This approach evidently offers a possible means of monitoring the acute metabolic response of tumours to chemotherapy or other forms of treatment by a non-invasive repeatable quantitative method.
The evolutionary origin of Morozovella angulata from its immediate ancestor, Praemurica uncinata, is preserved in Paleocene sediments from the Gulf of Mexico. This event represents the beginning of the morozovellid radiation and marks the first appearance of keeled planktonic foraminifera after the Cretaceous/Tertiary extinction. Parallel biometric and isotopic analyses were performed on size-segregated specimens from a succession of stratigraphic horizons. The biometric data reveal a temporal pattern of variation consistent with paedomorphosis. The appearance of angulose juvenile chambers in the otherwise rounded ancestral form (Praemurica uncinata) results in an allometry that becomes more pronounced upsection. At the origin of M. angulata, the juvenile morphology of the ancestor is retained throughout the entire ontogeny. Isotopic analysis of this sequence reveals the gradual acquisition of an increasingly heavy adult δ13C signal relative to that of the juvenile, while the δ18O data display no temporal or size-related trends. The temporal increase seen in the slope of the δ13C/size relationship may reflect the evolution of an increased dependency on photosymbionts.
The government's cocoa spraying gangs in Ghana treat about two million hectares of the crop against black pod disease and mirids, the key insect pests of cocoa in West Africa, each August through to December, based on recommendations issued in the 1950s. A few cocoa farmers use additional pesticides. We studied the temporal distribution of two important mirid species, Distantiella theobroma (Dist.) and Sahlbergella singularis Hagl., in 1991, 1999, 2003 and 2012 to determine the appropriate timing for the application of control measures in current farming systems. There was a significant correlation between mirid abundance and pod availability on trees, as well as the number of basal shoots and the cocoa variety grown. Mirid populations peaked between January and April and from September to October. Surveys (interviews and focus group discussions involving over 300 farmers in 33 cocoa-growing districts) on pesticide use, sources of recommendations, and perceived successes and failures of current cocoa pest treatments suggested that the 1950 recommendations on the timing of insecticide application need revising.
We present preliminary results of a 4-month campaign carried out in the framework of the Mons project, where time-resolved Hα observations are used to study the wind and circumstellar properties of a number of OB stars.
We present the results from the spectroscopic follow-up of WR140 (WC7 + O4-5) during its last periastron passage in january 2009. This object is known as the archetype of colliding wind binaries and has a relatively large period (≃8 years) and eccentricity (≃0.89). We provide updated values for the orbital parameters, new estimates for the WR and O star masses and new constraints on the mass-loss rates.
The network approach proposed by Cramer et al. suggests fascinating new directions of research on mental disorders. Research is needed to find evidence for the causal power of symptoms, to examine symptoms thoroughly, to investigate individual differences in edge strength, to discover etiological processes for each symptom, and to determine whether and why symptoms cohere into distinct mental disorders.