bluuebunny/crossref_metadata_2025 huggingface dataset:
The New Destination Disadvantage: Disparities in Hispanic Health Insurance Coverage Rates in Metropolitan and Nonmetropolitan New and Established Destinations
Authors: Monnat Shannon M.
Published: August 2016

Hispanics have the lowest health insurance rates of any racial or ethnic group, but rates vary significantly across the United States. The unprecedented growth of the Hispanic population since 1990 in rural areas with previously small or nonexistent Hispanic populations raises questions about disparities in access to health insurance coverage. Identifying spatial disparities in Hispanic health insurance rates can illuminate the specific contexts within which Hispanics are least likely to have health care access and inform policy approaches for increasing coverage in different spatial contexts. Using county‐level data from the 2009–13 American Community Survey, I find that early new destinations (i.e., those that experienced rapid Hispanic population growth during the 1990s) have the lowest Hispanic adult health insurance coverage rates, with little variation by metropolitan status. Conversely, among the most recent new destinations that experienced significant Hispanic population growth during the first decade of the 2000s, metropolitan counties have Hispanic health insurance rates that are similar to established destinations, but rural counties have Hispanic health insurance rates that are significantly lower than those in established destinations. Findings demonstrate that the new destination disadvantage is driven entirely by higher concentrations of immigrant noncitizen Hispanics in these counties, but labor market conditions were salient drivers of the spatially uneven distribution of foreign‐born noncitizen Hispanics to new destinations, particularly in rural areas.
Evolution of cave suspension feeding in Protodrilidae (Annelida)
Authors: Martínez Alejandro , Kvindebjerg Kirsten , Iliffe Thomas M. , Worsaae Katrine
Published: August 2016

Protodrilidae belongs in a lineage that until now entirely consisted of deposit‐feeding, highly adapted interstitial annelids. Except for a pair of anterior palps, all protodrilids lack appendages, parapodia and chaetae; and have slender bodies adapted to glide between the sand grains by ciliary motion. The first exception to these characteristics isMegadrilus pelagicus n. sp. inhabiting the water column of the anchialine La Corona cave system in Lanzarote. Its morphology and evolutionary history are here investigated by combining observations fromin vivovideo recordings and advanced microscopy with phylogenetic analyses. Our studies revealed a unique pelagic, suspension feeding behaviour attained by its long ciliated palps in combination with an autopomorphic dorsal ciliated keel and several longitudinal and transverse ciliary bands. Phylogenetic analyses recoveredMegadrilus pelagicusn. sp. nested within Protodrilidae indicating that its unique traits are derived within the family. These traits are traced in the tree topologies in correlation to cave colonization. The evolution of these traits can be functionally explained by the different demands of a pelagic suspension feeding strategy compared to the ancestral deposit‐feeding guild of the family. The origin of this suspension feeding strategy was presumably favoured by the partial isolation of the anchialine ecosystem, connected to the sea only through the highly porous volcanic subterranean bedrock. This crevicular connection limits the amount of predators and turbulence in the cave, but allows continuous water flow into the system carrying organic particles, which is the main source of food when photosynthetic primary production does not occur and sedimentation is limited. These conditions may select for pelagic suspension feeding as the most feasible life‐strategy in anchialine caves, which the dominance of pelagic, suspension feeding crustaceans and annelids in anchialine cave assemblages may also reflect. For species of ancestrally deposit‐feeding lineages entering the cave system, such as the annelid families Protodrilidae and Nerillidae, an adaptive‐shift from interstitial to crevicular habitats seemingly correlates with dramatic morphological changes and speciation. The dramatic changes observed in these primarily interstitial lineages compared to their relatives, point to alternative adaptive evolutionary pathways related to ecological fitness contrary to the previously proposed theories focusing on geological or stochastic processes.
Spherical Elastic–Plastic Contact Model for Power-Law Hardening Materials Under Combined Normal and Tangential Loads
Authors: Zhao Bin , Zhang Song , Keer Leon M.
Published: August 2016

The contact between a power-law hardening elastic–plastic sphere and a rigid flat under combined normal and tangential loads in full stick is studied in this work. The displacement-driven loading is used since the frictional contact problems under the displacement-driven loading are widespread in the fields of metal forming and orthogonal cutting. The loading process is as follows: First, a normal displacement-driven loading is imposed on the rigid flat and kept constant; then, an additional tangential displacement-driven loading is applied to the rigid flat. The elastic–plastic contact behavior in presliding is investigated with a proposed finite element (FE) model, including the tangential force, the von Mises stress, the normal force, the contact pressure, and the contact area. The effect of the strain-hardening exponent on contact behavior is considered. It is seen that the tangential force increases nonlinearly with the increase of the tangential displacement, exhibiting gradual stiffness reduction which implies that the junction becomes more plastic. The von Mises stresses moves along the direction of the tangential load, while the maximum stress moves to the contact surface from the below. The normal force diminishes as the tangential load increases, and more obviously for the lower hardening exponent cases. The contact pressure also decreases more significantly for the lower hardening exponent cases. In addition, smaller exponents result in a greater increase of the contact area. The empirical expressions of the tangential force and the contact area in the tangential loading process are also proposed by fitting to the FE results.
Generalized Free-Edge Stress Analysis Using Mechanics of Structure Genome
Authors: Peng Bo , Goodsell Johnathan , Byron Pipes R. , Yu Wenbin
Published: August 2016

This work reveals the potential of mechanics of structure genome (MSG) for the free-edge stress analysis of composite laminates. First, the cross-sectional analysis specialized from MSG is formulated for solving a generalized free-edge problem of composite laminates. Then, MSG and the companion code SwiftComp™ are applied to the free-edge stress analysis of several composite laminates with arbitrary layups and general loads including extension, torsion, in-plane and out-of-plane bending, and their combinations. The results of MSG are compared with various existing solutions for symmetric angle-ply laminates. New results are presented for the free-edge stress fields in general laminates for combined mechanical loads and compared with three-dimensional (3D) finite element analysis (FEA) results, which agree very well.
Fabrication of Foamed Polyethersulfone–Zeolite Mixed Matrix Membranes for Polymer Electrolyte Membrane Fuel Cell Humidification
Authors: Borduin Russell , Li Wei
Published: August 2016

Polymer electrolyte membrane (PEM) fuel cell efficiency must be improved in order to become cost competitive with fossil fuel-based technologies. Approaches to increasing cost efficiency include raising fuel cell operating temperature, reducing component cost, and properly controlling fuel cell humidification. We sought to fulfill all three requirements by developing a new low-cost, high-temperature humidification membrane material. Currently, Nafion dominates the membrane humidifier market due to its excellent water transport characteristics, but its high price (∼$1000/m2) and low maximum operating temperature (<90 °C) drive up fuel cell cost. We developed a competing polyethersulfone (PES)–zeolite mixed matrix membrane (MMM) with a porous microstructure. Solvent casting was used to form the initial PES–zeolite films, followed by solid-state foaming to alter the film morphology and create a porous structure. The effects of both zeolite weight loading and foaming duration on membrane permeability were investigated. Membrane measurement results show that both foaming and increased zeolite weight loading enhance membrane water permeability close to levels seen in Nafion. Meanwhile, the membranes satisfy the Department of Energy (DOE) crossover gas requirement for humidification membrane materials.
Leak Estimation Method for Complex Pipelines With Branch Junctions
Authors: González O. , Verde C. , Torres L.
Published: August 2016

This work proposes a methodology to estimate positions of leaks in pipelines with multiple elevation profiles and branch junctions in which only data of pressure and flow at the extremes of the pipeline and the branch junctions are assumed known. The key of the proposition is the error of the position at the branch junction in the presence of leaks. Specifically, the sign of the error determines if the leak is located downstream or upstream from the branch junction. This information then allows us to obtain static equations which characterize the leak position. To simplify the leak position expression, the piezometric variable instead of the pressure head is used for its derivation. Simulation results and real industrial data tests acquired from a liquefied petroleum gas (LPG) pipeline of 60 km with five elevation profiles and one branch junction with known extraction flow and position show the potentiality of the suggested method.
Measurement of Multiscale Thermal Transport Phenomena in Li-Ion Cells: A Review
Authors: Shah Krishna , Vishwakarma Vivek , Jain Ankur
Published: August 2016

The performance, safety, and reliability of electrochemical energy storage and conversion systems based on Li-ion cells depend critically on the nature of heat transfer in Li-ion cells, which occurs over multiple length scales, ranging from thin material layers all the way to large battery packs. Thermal phenomena in Li-ion cells are also closely coupled with other transport phenomena such as ionic and charge transport, making this a challenging, multidisciplinary problem. This review paper presents a critical analysis of recent research literature related to experimental measurement of multiscale thermal transport in Li-ion cells. Recent research on several topics related to thermal transport is summarized, including temperature and thermal property measurements, heat generation measurements, thermal management, and thermal runaway measurements on Li-ion materials, cells, and battery packs. Key measurement techniques and challenges in each of these fields are discussed. Critical directions for future research in these fields are identified.
Finite-Element and Residual Stress Analysis of Self-Pierce Riveting in Dissimilar Metal Sheets
Authors: Huang Li , Moraes J. F. C. , Sediako Dimitry G. , Jordon J. B. , Guo Haiding , Su Xuming
Published: August 2016

The residual stress profile in dissimilar metal sheets joined by a self-piercing rivet is simulated and compared to experimental measurements. Simulation of joining aluminum alloy 6111-T4 and steel HSLA340 sheets by self-piercing riveting (SPR) is performed using a two-dimensional axisymmetric model with an internal state variable (ISV) plasticity material model. Strain rate and temperature dependent deformation of the base materials is described by the ISV material model and calibrated with experimental data. Using the LS-DYNA simulation package, an element erosion technique is adopted in an explicit analysis of the separation of the upper sheet with maximum shear strain failure criterion. An explicit analysis with dynamic relaxation technique was then used for springback and cooling down analysis following the riveting simulation. The residual stress profile of SPR experimental joint with same configuration is characterized using neutron diffraction, and good agreement was found between the simulation and residual stress measurements.
A Novel Portable Device to Measure Transmittance and Reflectance of Parabolic Trough Receiver Tubes in the Field
Authors: Espinosa-Rueda Guillermo , Martinez-Sanz Noelia , Izquierdo-Nuñez David , Osta-Lombardo Marta
Published: August 2016

The performance of parabolic trough (PT) receiver tubes (RTs) has a direct impact on concentrated solar power (CSP) plant production. As a result, one major need of operation and maintenance (O&M) in operating plants is to monitor the state of the receiver tube as a key element in the solar field. In order to fulfill this necessity, Abengoa Solar has developed the first existing portable device for measuring the transmittance and reflectance of parabolic trough receiver tubes directly in the field. This paper offers a description of the technical features of the instrument and reviews the issues related to its usability as a workable portable device in operating solar fields. To evaluate its performance, laboratory studies have been carried out using two patterns to determine the accuracy and standard deviation of the measurements, obtaining excellent results. This information is complemented with data collected by O&M using this instrument in solar power plants. Studies have been carried out to determine the effect of both rainfall and artificial cleaning on the increase of transmittance. These values are then compared to those obtained from hand-cleaning, and show important differences. The results are discussed in this paper.
Large-Eddy Simulation of a Reacting Jet in Cross Flow With NOx Prediction
Authors: Weinzierl Johannes , Kolb Michael , Ahrens Denise , Hirsch Christoph , Sattelmayer Thomas
Published: August 2016

The reduction of full and part load emissions and the increase of the turndown ratio are important goals for gas turbine combustor development. Combustion techniques, which generate lower NOx emissions than unstaged premixed combustion in the full load range, and which have the potential of reducing minimum load while complying with emission legislation, are of high technical interest. Therefore, axial-staged combustion systems have been designed, either with or without expansion in a turbine stage between both stages. In its simpler form without intermediate expansion stage, a flow of hot combustion products is generated in the first stage of the premixed combustor, which interacts with the jets of premixed gas injected into the second stage. The level of NOx formation during combustion of the premixed jets in the hot cross flow determines the advantage of axially staged combustion regarding full load NOx emission reduction. Employing large-eddy simulation in openfoam, a tool has been developed, which allows to investigate staged combustion systems including not only temperature distribution but also NOx emissions under engine conditions. To be able to compute NOx formation correctly, the combustion process has to be captured with sufficient level of accuracy. This is achieved by the partially stirred reactor model. It is combined with a newly developed NOx model, which is a combination of a tabulation technique for the NOx source term based on mixture fraction and progress variable and a partial equilibrium approach. The NOx model is successfully validated with generic burner stabilized flame data and with measurements from a large-scale reacting jet in cross flow experiment. The new NOx model is finally used to compute a reacting jet in cross flow under engine conditions to investigate the NOx formation of staged combustion in detail. The comparison between the atmospheric and the pressurized configuration gives valuable insight in the NOx formation process. It can be shown that the NOx formation within a reacting jet in cross flow configuration is reduced and not only diluted.
Development of a Fast-Response Aerodynamic Pressure Probe Based on a Waveguide Approach
Authors: Fioravanti Andrea , Lenzi Giulio , Ferrara Giovanni , Ferrari Lorenzo
Published: August 2016

Currently, fast-response aerodynamic probes are widely used for advanced experimental investigations in turbomachinery applications. The most common configuration is a virtual three-hole probe. This solution is a good compromise between probe dimension and accuracy. Several authors have attempted to extend the capabilities of these probes in terms of bandwidth and operating conditions. Even though differences exist between the solutions in the literature, all of the designs involve the positioning of a dynamic pressure sensor close to the measurement point. In general terms, the higher the frequency response, the more the sensor is exposed to the flow. This physical constraint puts a limit on the probe applicability since the measurement conditions have to comply with the maximum allowed operating conditions of the sensor. In other applications, when the conditions are particularly harsh and a direct measurement is not possible, a waveguide probe is commonly used to estimate the local pressure. In this device, the sensor is connected to the measurement point through a transmitting duct which guarantees that the sensor is operating in a less critical condition. Generally, the measurement is performed through a pressure tap and particular attention must be paid to the probe design in order to have an acceptable frequency response function. In this study, the authors conceived, developed, and tested a probe which combines the concept of a fast-response aerodynamic pressure probe with that of a waveguide probe. Such a device exploits the benefits of having the sensor far from the harsh conditions while maintaining the capability to perform an accurate flow measurement.
Sci‐Thur PM – Colourful Interactions: Highlights 01: Design to delivery of spatially fractionated mini‐beam canine radiotherapy
Authors: Alexander Andrew , Crewson Cody , Davis William , Mayer Monique , Cranmer‐Sargison Gavin , Kundapur Vijayananda
Published: August 2016

Spatial fractionation of radiation using arrays of narrow parallel micro‐planar beams (less than 1 mm), is a relatively new concept with many unknowns specifically within the underlying biology of cell death. A tungsten collimator has been designed to produce mini‐beams with a Varian linear accelerator for translational animal research into the effectiveness of spatial fractionation mini‐beam radiotherapy (MBRT). This work presents the treatment planning process and workflow for the application of MBRT treatments within a clinical study. For patient dose calculations, the MBRT collimator was incorporated into a Monte Carlo based treatment planning system called MMCTP. Treatment planning was split between Eclipse and MMCTP, as the field apertures were determined within Eclipse prior to being sent to MMCTP for dose calculations. The calculated plan was transferred back into Aria with updated MUs per field for patient treatment. Patients were positioned within a vac‐lock bag lying prone with a bite block and a thermoplastic mask to immobilize the head. Prior to treatment, a delivery verification plan was created within MMCTP. DQA output measurements of the treatment fields agreed with the calculated dose to within 1.5%. We have presented a workflow for MBRT treatments that include the planning technique, dose calculation method, DQA process and data integration into a record and verify system. The clinical study following this workflow represent the first series of linac based MBRT patients and depending on the clinical outcome of the study, our technique could be applied to human MBRT treatments.
Poster ‐ 40: Treatment Verification of a 3D‐printed Eye Phantom for Proton Therapy
Authors: Dunning Chelsea , Lindsay Clay , Unick Nick , Sossi Vesna , Martinez Mark , Hoehr Cornelia
Published: August 2016

Purpose:

Ocular melanoma is a form of eye cancer which is often treated using proton therapy. The benefit of the steep proton dose gradient can only be leveraged for accurate patient eye alignment. A treatment‐planning program was written to plan on a 3D‐printed anatomical eye‐phantom, which was then irradiated to demonstrate the feasibility of verifying in vivo dosimetry for proton therapy using PET imaging.

Methods:

A 3D CAD eye model with critical organs was designed and voxelized into the Monte‐Carlo transport code FLUKA. Proton dose and PET isotope production were simulated for a treatment plan of a test tumour, generated by a 2D treatment‐planning program developed using NumPy and proton range tables. Next, a plastic eye‐phantom was 3D‐printed from the CAD model, irradiated at the TRIUMF Proton Therapy facility, and imaged using a PET scanner.

Results:

The treatment‐planning program prediction of the range setting and modulator wheel was verified in FLUKA to treat the tumour with at least 90% dose coverage for both tissue and plastic. An axial isotope distribution of the PET isotopes was simulated in FLUKA and converted to PET scan counts. Meanwhile, the 3D‐printed eye‐phantom successfully yielded a PET signal.

Conclusions:

The 2D treatment‐planning program can predict required parameters to sufficiently treat an eye tumour, which was experimentally verified using commercial 3D‐printing hardware to manufacture eye‐phantoms. Comparison between the simulated and measured PET isotope distribution could provide a more realistic test of eye alignment, and a variation of the method using radiographic film is being developed.
Color Fringes Bordering Black Stripes at the Bottom of a Swimming Pool
Authors: Fuster Gonzalo , Rojas Roberto , Slüsarenko Viktor
Published: August 2016

We have observed a nice example of chromatic dispersion due to refraction in water, in the form of color fringes bordering the black stripes that exist at the bottom of a swimming pool. Here we give a qualitative description of the phenomenon, explaining the role of the black stripes and the dispersive index of refraction of water.
Linear transformation method to control flexural waves in thin plates
Authors: Liu Yongquan , Ma Zhaoyang , Su Xianyue
Published: August 2016

In this paper, the linear transformation method (LTM) to control flexural waves propagating in thin plates is presented. Unlike earlier studies, only a small number of homogeneous materials with no requirement of in-plane forces or pre-stress are needed, which tremendously simplifies the implementation of devices for flexural waves. An invisibility cloak with homogeneous materials is studied to confirm the validity of the present approach, and to show its imperfection due to impedance mismatch at interfaces. Required materials can be further simplified as layered isotropic materials using the effective medium theory. Finally, the LTM can be extended to the case of flexural waves propagating in anisotropic thin plates. The present method opens a promising avenue toward the realization of advanced structured shields and other devices.
Formation of the Isthmus of Panama
Authors: O’Dea Aaron , Lessios Harilaos A. , Coates Anthony G. , Eytan Ron I. , Restrepo-Moreno Sergio A. , Cione Alberto L. , Collins Laurel S. , de Queiroz Alan , Farris David W. , Norris Richard D. , Stallard Robert F. , Woodburne Michael O. , Aguilera Orangel , Aubry Marie-Pierre , Berggren William A. , Budd Ann F. , Cozzuol Mario A. , Coppard Simon E. , Duque-Caro Herman , Finnegan Seth , Gasparini Germán M. , Grossman Ethan L. , Johnson Kenneth G. , Keigwin Lloyd D. , Knowlton Nancy , Leigh Egbert G. , Leonard-Pingel Jill S. , Marko Peter B. , Pyenson Nicholas D. , Rachello-Dolmen Paola G. , Soibelzon Esteban , Soibelzon Leopoldo , Todd Jonathan A. , Vermeij Geerat J. , Jackson Jeremy B. C.
Published: August 2016

Independent evidence from rocks, fossils, and genes converge on a cohesive narrative of isthmus formation in the Pliocene.
Tough love for technology
The Ethics of Invention Technology and the Human Future
Sheila Jasanoff
Norton, 2016, 318 pp.
Authors: Selin Cynthia
Published: August 2016

A legal scholar probes how new technologies are raising risks, accentuating inequality, and affecting human nature
Respiratory Syncytial Virus Infection Triggers Epithelial HMGB1 Release as a Damage-Associated Molecular Pattern Promoting a Monocytic Inflammatory Response
Authors: Hosakote Yashoda M. , Brasier Allan R. , Casola Antonella , Garofalo Roberto P. , Kurosky Alexander
Published: August 2016

Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infections in infant and elderly populations worldwide. Currently, there is no efficacious vaccine or therapy available for RSV infection. The molecular mechanisms underlying RSV-induced acute airway disease and associated long-term consequences remain largely unknown; however, experimental evidence suggests that the lung inflammatory response plays a fundamental role in the outcome of RSV infection. High-mobility group box 1 (HMGB1) is a nuclear protein that triggers inflammation when released from activated immune or necrotic cells and drives the pathogenesis of various infectious agents. Although HMGB1 has been implicated in many inflammatory diseases, its role in RSV-induced airway inflammation has not been investigated. This study investigates the molecular mechanism of action of extracellularly released HMGB1 in airway epithelial cells (A549 and small airway epithelial cells) to establish its role in RSV infection. Immunofluorescence microscopy and Western blotting results showed that RSV infection of human airway epithelial cells induced a significant release of HMGB1 as a result of translocation of HMGB1 from the cell nuclei to the cytoplasm and subsequent release into the extracellular space. Treating RSV-infected A549 cells with antioxidants significantly inhibited RSV-induced HMGB1 extracellular release. Studies using recombinant HMGB1 triggered immune responses by activating primary human monocytes. Finally, HMGB1 released by airway epithelial cells due to RSV infection appears to function as a paracrine factor priming epithelial cells and monocytes to inflammatory stimuli in the airways.

IMPORTANCE
RSV is a major cause of serious lower respiratory tract infections in young children and causes severe respiratory morbidity and mortality in the elderly. In addition, to date there is no effective treatment or vaccine available for RSV infection. The mechanisms responsible for RSV-induced acute airway disease and associated long-term consequences remain largely unknown. The oxidative stress response in the airways plays a major role in the pathogenesis of RSV. HMGB1 is a ubiquitous redox-sensitive multifunctional protein that serves as both a DNA regulatory protein and an extracellular cytokine signaling molecule that promotes airway inflammation as a damage-associated molecular pattern. This study investigated the mechanism of action of HMGB1 in RSV infection with the aim of identifying new inflammatory pathways at the molecular level that may be amenable to therapeutic interventions.
A systematic review and meta-analysis of Synacthen tests for assessing hypothalamic-pituitary-adrenal insufficiency in children
Authors: Ng Sze May , Agwu Juliana Chizo , Dwan Kerry
Published: August 2016

Background

The diagnostic value of tests used in assessing hypothalamic-pituitary-adrenal axis (HPA) in children remains controversial.

Design

A systematic review and meta-analysis with receiver-operated-characteristic curve was undertaken to assess the diagnostic values of conventional standard dose 250 μg tetracosactrin (ACTH), short Synacthen test (SSST) and/or low-dose Synacthen test (LDSST) in the assessment of HPA insufficiency in children. Studies eligible for inclusion were any study that compared the use of the LDSST and/or SSST in the assessment of central adrenal insufficiency in children compared with reference standard test.

Results

There were no randomised trials found. SSST resulted in higher specificity and positive likelihood ratio than LDSST. The LDSST had a higher sensitivity (86% vs 61%) but a lower specificity (88% vs 99%) than the SSST, but there was high heterogeneity from the LDSST studies with various doses of Synacthen used.

Conclusions

Lack of standardisation of assays and protocols with regard to timing, frequency and dose has resulted in diagnostic inaccuracies. There is no clear evidence to indicate that LDSST is superior to SSST in the assessment of HPA axis in children. The choice of either SSST or LDSST should be individualised based on clinical judgement for each patient. This systematic review has identified the need for a well-designed, adequately powered, randomised controlled trial on the use of diagnostic tests used in assessing HPA axis in children.
Managing the child with a diagnosis of Moebius syndrome: more than meets the eye
Authors: McKay Victoria H , Touil Leila L , Jenkins Dagan , Fattah Adel Y
Published: August 2016

Moebius syndrome (MBS) is a congenital, non-progressive facial and abducens nerve palsy in the presence of full vertical gaze and may be associated with limb abnormalities and craniofacial dysmorphisms. MBS is now defined as a disorder of rhombencephalic maldevelopment and recent gene discoveries have shown this to be a dominant disorder in a subset of patients. Accurate diagnosis and management by a multidisciplinary team with expertise in congenital facial palsy is paramount.
THE POTENTIAL FOR PHARMACISTS TO MANAGE CHILDREN ATTENDING EMERGENCY DEPARTMENTS
Authors: Terry David , Petridis Konstantinos , Aiello Matt , Sinclair Anthony , Huynh Chi , Mazard Louis , Ubhi Hirminder , Terry Alex , Hughes Elizabeth
Published: August 2016

Aim

There have been concerns about maintaining appropriate clinical staff levels in Emergency Departments in England.1 The aim of this study was to determine if Emergency Department attendees aged from 0–16 years could be managed by community pharmacists or hospital independent prescriber pharmacists with or without further advanced clinical practice training.

Method

A prospective, 48 site, cross-sectional, observational study of patients attending Emergency Departments (ED) in England, UK was conducted. Pharmacists at each site collected up to 400 admissions and paediatric patients were included in the data collection. The pharmacist independent prescribers (one for each site) were asked to identify patient attendance at their Emergency Department, record anonymised details of the cases—age, weight, presenting complaint, clinical grouping (e.g. medicine, orthopaedics), and categorise each presentation into one of four possible categories: CP, Community Pharmacist, cases which could be managed by a community pharmacist outside an ED setting; IP—cases that could be managed at ED by a hospital pharmacist with independent prescriber status; IPT, Independent Prescriber Pharmacist with additional training—cases which could be managed at ED by a hospital pharmacist independent prescriber with additional clinical training; and MT, Medical Team only—cases that were unsuitable for the pharmacist to manage. An Impact Index was calculated for the two most frequent clinical groupings using the formula: Impact index=percentage of the total workload of the clinical grouping multiplied by the percentage ability of pharmacists to manage that clinical group.

Results

1623 out of 18,229 (9%) attendees, from 45 of the 48 sites, were children aged from 0 to 16 years of age (median 8 yrs, range 0–16), 749 were female and 874 were male. Of the 1623 admissions, 9% of the cases were judged to be suitable for clinical management by a community pharmacist (CP), 4% suitable for a hospital pharmacist independent prescriber (IP), 32% suitable for a hospital independent pharmacist prescriber with additional training (IPT); and the remaining 55% were only suitable for the Medical Team (MT). The most frequent clinical groups and impact index for the attendees were General Medicine=10.78 and orthopaedics=10.60.

Conclusion

Paediatric patients attending Emergency Departments were judged by pharmacists to be suitable for management outside a hospital setting in approximately 1 in 11 cases, and by hospital independent prescriber pharmacists in 4 in 10 cases. With further training, it was found that the total proportion of cases that could be managed by a pharmacist was 45%. The greatest impact for pharmacist management occurs in general medicine and orthopaedics.
COMPARING ORAL PARACETAMOL DOSES IN PAEDIATRICS WITH THE NEW BNF-C DOSING
Authors: Ajjan Nour , Shenton Sian
Published: August 2016

The BNF-C 2014–20151 highlighted some key changes to the dosing of paracetamol in paediatrics, including a change in maximum daily dosage of oral paracetamol from 90 mg/kg/day to 75 mg/kg/day for post-operative pain, and inclusion of age-banded dosing for pain and pyrexia.

The local Trust Paediatric Acute Pain Management Manual2 has acknowledged this change, but advised a maximum daily dose of 80 mg/kg/day. This audit was undertaken to determine whether national proposed changes were implemented in practice, in comparison with local guidelines.

Aims

The aims and objectives of the audit were to compare oral paracetamol dosing in both medical and surgical settings with the new BNF-C dosing.

Method

Data were collected over a two week period in September 2014, from two medical and two surgical paediatric wards. The criteria for data collection included paediatric patients above the age of one month and up to 18 years, prescribed oral paracetamol for pain or pyrexia.

The following data were collected:

▸ Initials of patients and age (for identification purposes and to prevent duplications)

▸ Weight (to assess appropriate and safe prescribing)

▸ Reason for admission (to distinguish between medical and surgical settings).

Results

Data were collected from 24 medical and 48 surgical patients (age range 1 month–16 years).

The key findings were:

19/24 medical patients were dosed according to the BNF-C age banded guidelines; 5/24 were dosed according to weight: 3 followed the Trust Manual; 1/24 followed the BNF-C, and 1 miscellaneous. No patients had a dose exceeding 80 mg/kg/day.

87% of surgical patients were dosed according to the weight based calculation, 69% of whom were within the maximum daily dose of 75 mg/kg. Of the 31% whose daily dose exceeded 75 mg/kg, all were less than 80 mg/kg/day.

The Trust Pain Manual does not include the dose banding as per the BNF-C but recommends 20 mg/kg 6 hourly (max 80 mg/kg/day) for acute pain in this age group.

Conclusion

Children on the medical wards were prescribed paracetamol following age banded dosing as per BNF-C, whereas surgical wards were more likely to dose by weight following the Trust Pain Manual.

The Trust Pain Manual differs from the BNF-C and recommends a maximum daily dose of 80 mg/kg/day for acute severe pain, to ensure adequate pain control and minimise calculation errors. Despite the new guidance in the BNF-C, it was found that many patients were prescribed a maximal daily dose greater than 75 mg/kg/day; however no patient's daily dose exceeded 80 mg/kg/day as indicated in the Manual.

The main finding from the audit was that prescribers were not aware of the change in maximal daily dose of oral paracetamol. To highlight this important point, a poster was designed and distributed amongst the medical and surgical staff on the wards, highlighting that the dose should not exceed 75 mg/kg in a 24 hour period.
CHANGING INFUSION PRACTICE GENERATES SIGNIFICANT EFFICIENCIES IN NURSING TIME AND RESOURCE USAGE IN PAEDIATRIC INTENSIVE CARE
Authors: Sutherland Adam , Jemmett Liz , Barber Rachael
Published: August 2016

Introduction

Infusion preparation in British PICUs uses the Rule of Six (ROS) which was developed for administration without infusion devices. This method is inaccurate.1 Regulators recommend standardised approaches to IV infusions to improve patient safety and quality of care.2 Administration set changes also have an association with resource use and central line infections.3 We report the impact of fixed concentration infusions and reduced administration set changes on nursing time and infusion equipment cost.

Methods

Morphine and midazolam infusions were standardised in September 2014. Direct observation of infusion preparation was carried out beforeand after the introduction of fixed-concentration (FC) infusions to quantify the nursing time required to prepare infusions. Administration was prospectively documented using purposive sampling until a population-representative sample for age and weight was obtained (1 month). This data was then scaled up to predict activity over one year. Syringe use and administration set use was calculated. Reducing frequency of administration set changes to 72 hrs in accordance with infection control policy was then calculated retrospectively.

Results

It takes 40 minutes (2 nurses×20 minutes) to prepare ROS syringes and 30 minutes (2 nurses×15 minutes) for FC syringes.

In total ROS infusions required 2433 hrs of nursing time to prepare. FC infusions reduced this time by 25% (608 hrs) releasing 0.5 WTE nursing time back to patient care.

Mean duration of IV sedation in these patients was 100 hrs. The cost associated with replacing administration sets with each syringe was £16,060. By changing every 72 hrs, this cost is reduced to £4,400 – a cost saving of £11,660.

Conclusions

FC syringes are more efficient than ROS. FC preparations have released 0.5 WTE nurses back to patient care. Changing administration sets 72 hrly realises significant cost efficiencies.
PN FOR CHILDREN – INFORMATION LEAFLET
Authors: Riddell Rebecca , Lewis Anthony , Tuthill David
Published: August 2016

Aim

To produce a leaflet for parents and carers of children receiving parenteral nutrition (PN) explaining:

▸ What PN is

▸ Why it is given

▸ How it will be given

▸ Risks & Complications

▸ Other useful information

▸ Nutrition team contact information

Current practice is for the nutrition team pharmacist to give a verbal account of the above information to parents/carers. It was felt that providing this information in a written format would introduce consisitency and allow parents/carers more time to take information on board.

Method

An internet search and discussions with other organisations with paediatric gastroenterology specialists was conduted to see if something similar was in existence. A similar information leaflet to what we hoped to produce was not found. Members of the paediatric nutrition team, which included consultants, nurse specialists, pharmacist and dietician, provided input to the type of information that should be included in the information leaflet. A first draft of the leaflet was produced and shown to the parents of current paediatric PN inpatients. Feedback was received and the leaflet updated following consultation with the nutrition team.

Conclusion

Production of a very useful information leaflet for parents/carers, containing all the relevant information and detail. The leaflet uses colour and pictures to aid the transfer of information and makes it more attractive to read. The pharmacist is the main point of contact for the paediatric nutrition team and will be the individual responsible for distributing them.
THE DEVELOPMENT OF A QUALITY IMPROVEMENT SYSTEM TO MONITOR, ASSESS AND FEEDBACK PRESCRIBING ERRORS IN PAEDIATRIC INTENSIVE CARE
Authors: Morris Stephen , Rivett Claire
Published: August 2016

Background

Prescribing errors are a major contributing factor to many medication errors and therefore are at the forefront of strategies to reduce errors and improve patient safety.1 Many paediatric intensive care units have attempted to implement “Zero Tolerance Prescribing” to improve standards of prescribing. However the enforcement of these standards can be difficult and time consuming with varied success.2

Aims

The aim of this project was to reduce prescribing errors by adapting a previous study3 that had developed a novel way of analysing, interpreting and publishing prescribing audit data. This would allow us to promote an educational approach to our prescribing audits and allow us to provide constructive feedback and learning points for all prescribers on the unit. The main element would be to use a spreadsheet to automate this process to reduce the time required to produce the reports.

Methods

Prescriptions were assessed over a 2 week period according to local “Zero Tolerance” standards. An Excel spreadsheet was designed to provide individual feedback forms for prescribers. This contained data such as error rates and types, examples of specific errors and anonymous results from other prescribers for comparison. Additional reports were also generated to create posters that could be displayed around the unit and discussed at clinical governance meetings. This cycle was repeated after approximately 1 month.

Results

In total 376 and 275 prescription were assessed in each cycle. The overall unit mean error rate remained consistent between the two cycles at 12.5% and 13.0% respectively. In prescribers who prescribed at least 5 items in both cycles (n=7), there was a decrease in error rate over 5.9% from cycle 1 (M=15.3, SD=14.6) compared with cycle 2 (M=9.4 SD=7.3); t(6)=1.1710 p=0.29 although this was not statistically significant using a paired t-test.

Conclusion

The audits that we completed did not show any reduction in mean error rate. However, when we looked more closely at the data we had gathered, it was noticeable that there was a reduction when comparing individuals between each cycle. This demonstrated that our system of feedback for prescribers did lead to changes in practice and improvements.

The main limitation of our method was the lack data for each prescriber and that prescribers had varied total prescribing volume that resulted in easily skewed data.
HOW WELL DO OUTPATIENT PRESCRIPTIONS ADHERE TO GOOD ANTIMICROBIAL STEWARDSHIP?
Authors: Ubhi Hirminder , Patel Mitul , Ludwig Lisa
Published: August 2016

Aim

Aims of the study included evaluation of outpatient antibiotic prescribing practices relating to good Antimicrobial Stewardship1 focusing on documentation of indication and duration.

Method

Prescriptions dispensed at the Outpatient Pharmacy over a 6 week were evaluated. Data collected include patient's hospital identification in full, the antibiotic prescribed, duration of treatment, indication (in a specifically allocated area on the prescription) and route of administration, prescriber speciality and grade. Data were entered onto Microsoft Excel and reviewed by a committee that included a medical microbiologist and antimicrobial pharmacist.

Results

Five hundred and six antimicrobial prescriptions were reviewed. Therapeutic antibiotics accounted for 484/506 (95.6%) and the remaining 22/506 (4.4%) were prophylactic therapy. Indications were documented in 186/506 (36.8%) cases and 465/506 (91.9%) documented duration of therapy. By speciality, adherence with indication and duration, respectively, for oral medication, were as follows: Haematology 2/55 (3.6%) and 12/55 (21.8%), General paediatrics 26/42 (61.9%) and 41/42 (97.6%), Oncology 4/37 (10.8%) and 34/37 (91.9%), Dermatology 12/35 (34.3%) and 35/35 (100%), Nephrology 24/30 (80%) and 30/30 (100%), Ear Nose and Throat (ENT) 9/31 (29%) and 31/31 (100%). Oral route of administration was the most frequently prescribed 391/506 (77.3%), with topical and eye/ear drops prescribed in 63/506 (12.4%) and 50/506 (9.9%) respectively. Nebulised therapy accounted for only 2/506 (0.4%) prescriptions. Most commonly prescribed antibiotics were Co-amoxiclav 83/391 (21.2%), Flucloxacillin 50/391 (12.8%), Penicillin 35/391 (9.0%), Azithromycin 27/391 (6.9%) and Trimethoprim 26/391 (6.6%). Adherence to antibiotic guidelines was seen to be appropriate with 496/506 (98%).From the ten prescriptions that did not adhere, Azithromycin accounted for 8/10 (80%) with 50% of these used for prophylaxis, with lack of clear documentation.

Conclusion

A designated area on the Outpatient Pharmacy prescription for indication and duration can aid better Antimicrobial Stewardship. Duration of therapy was better documented than indication, however it is postulated that this was to ensure adequate supply on outpatient dispensing and not always through following good antimicrobial prescribing practice. On the whole, the most commonly prescribed antibiotics were predominantly prescribed by the specialities within the antibiotic guidelines. Azithromycin, which is restricted to respiratory team, was prescribed outside of the policy by other specialties. This study helped prioritise which specialities require further input to improve adherence with Antimicrobial Stewardship in the outpatient setting. As dermatology and ENT had 100% compliance with specifying duration, we are now reviewing their prescribing education which can be used to enhance the practice of the other specialities.
APPROPRIATE DOSE ROUNDING OF CYTOKINE MODULATORS FOR PAEDIATRIC RHEUMATOLOGY INPATIENTS
Authors: Paget Chris
Published: August 2016

Background

Cytokine modulators (adalimumab, infliximab, etanercept, anakinra, canakinumab, rituximab, tocilizumab and abatacept) are high-cost biologics used primarily in paediatrics to treat patients with juvenile idiopathic arthritis.1 Funding mechanisms are unreliable and inconsistent hence appropriate dose rounding is a key cost-saving measure.2 However, there is a lack of evidence-based guidance for dose rounding in paediatrics.3

Aims and objectives

Determine if 100% of inpatient cytokine modulator prescriptions in rheumatology are dose rounded up or down to the nearest whole vial, pen or syringe if within 5 or 10% of the dose for patients less or more than 10 kg respectively.

Establish financial impact of drug wastage due to failures in dose rounding.

Method

Retrospective data collection of electronic prescriptions for all cytokine modulators prescribed for rheumatology inpatients from January 2011 to December 2014. Prescriptions analysed using a five step process to determine if doses could have been rounded to nearest whole dose unit. Cost of waste resulting from failure to dose round also calculated.

Results

Only 35% (380/1100) of prescriptions rounded to the nearest whole dose unit therefore audit standard not met. 97% (698/720) of all prescriptions not dose rounded were for tocilizumab and infliximab with approximate annual wastage of £11,000. Unexpected and significant unavoidable wastage identified due to lack of paediatric-friendly dose unit sizes, particularly for canakinumab (approximately £740,000/year).

Discussion

Appropriate dose rounding does not appear to be common practice. Raising awareness and educating rheumatology and pharmacy teams as well as establishing local dose banding or rounding guidelines may improve future results. Tocilizumab is available in 80 mg, 200 mg and 400 mg vials therefore there is scope for flexibility in dose rounding if combinations are used appropriately. Unavoidable waste may be reduced through use of pharmacy central intravenous additive service (CIVAS) for preparation or use of biosimilars.