bluuebunny/crossref_metadata_2025 huggingface dataset:
Functional acetabular component position with supine total hip replacement
Authors: Eilander W. , Harris S. J. , Henkus H. E. , Cobb J. P. , Hogervorst T.
Published: September 2013

Orientation of the acetabular component influences wear, range of movement and the incidence of dislocation after total hip replacement (THR). During surgery, such orientation is often referenced to the anterior pelvic plane (APP), but APP inclination relative to the coronal plane (pelvic tilt) varies substantially between individuals. In contrast, the change in pelvic tilt from supine to standing (dPT) is small for nearly all individuals. Therefore, in THR performed with the patient supine and the patient’s coronal plane parallel to the operating table, we propose that freehand placement of the acetabular component placement is reliable and reflects standing (functional) cup position. We examined this hypothesis in 56 hips in 56 patients (19 men) with a mean age of 61 years (29 to 80) using three-dimensional CT pelvic reconstructions and standing lateral pelvic radiographs. We found a low variability of acetabular component placement, with 46 implants (82%) placed within a combined range of 30° to 50° inclination and 5° to 25° anteversion. Changing from the supine to the standing position (analysed in 47 patients) was associated with an anteversion change < 10° in 45 patients (96%). dPT was < 10° in 41 patients (87%). In conclusion, supine THR appears to provide reliable freehand acetabular component placement. In most patients a small reclination of the pelvis going from supine to standing causes a small increase in anteversion of the acetabular component.

Cite this article: Bone Joint J 2013;95-B:1326–31.
Three-dimensional assessment of the dimensions of the osteoarthritic glenoid
Authors: Walch G. , Mesiha M. , Boileau P. , Edwards T. B. , Lévigne C. , Moineau G. , Young A.
Published: September 2013

Osteoarthritis results in changes in the dimensions of the glenoid. This study aimed to assess the size and radius of curvature of arthritic glenoids. A total of 145 CT scans were analysed, performed as part of routine pre-operative assessment before total shoulder replacement in 91 women and 54 men. Only patients with primary osteoarthritis and a concentric glenoid were included in the study. The CT scans underwent three-dimensional (3D) reconstruction and were analysed using dedicated computer software. The measurements consisted of maximum superoinferior height, anteroposterior width and a best-fit sphere radius of curvature of the glenoid.

The mean height was 40.2 mm (sd 4.9), the mean width was 29 mm (sd 4.3) and the mean radius of curvature was 35.4 mm (sd 7.8). The measurements were statistically different in men and women and had a Gaussian distribution with marked variation. All measurements were greater than the known values in normal subjects.

With current shoulder replacement systems using a unique backside radius of curvature for the glenoid component, there is a risk of undertaking excessive reaming to adapt the bone to the component resulting in sacrifice of subchondral bone or under-reaming and instability of the component due to a ’rocking horse‘ phenomenon.

Cite this article: Bone Joint J 2013;95-B:1377–82.
Metal ion levels from well-functioning Birmingham Hip Resurfacings decline significantly at ten years
Authors: Van Der Straeten C. , Van Quickenborne D. , De Roest B. , Calistri A. , Victor J. , De Smet K.
Published: September 2013

A retrospective study was conducted to investigate the changes in metal ion levels in a consecutive series of Birmingham Hip Resurfacings (BHRs) at a minimum ten-year follow-up. We reviewed 250 BHRs implanted in 232 patients between 1998 and 2001. Implant survival, clinical outcome (Harris hip score), radiographs and serum chromium (Cr) and cobalt (Co) ion levels were assessed.

Of 232 patients, 18 were dead (five bilateral BHRs), 15 lost to follow-up and ten had been revised. The remaining 202 BHRs in 190 patients (136 men and 54 women; mean age at surgery 50.5 years (17 to 76)) were evaluated at a minimum follow-up of ten years (mean 10.8 years (10 to 13.6)). The overall implant survival at 13.2 years was 92.4% (95% confidence interval 90.8 to 94.0). The mean Harris hip score was 97.7 (median 100; 65 to 100). Median and mean ion levels were low for unilateral resurfacings (Cr: median 1.3 µg/l, mean 1.95 µg/l (< 0.5 to 16.2); Co: median 1.0 µg/l, mean 1.62 µg/l (< 0.5 to 17.3)) and bilateral resurfacings (Cr: median 3.2 µg/l, mean 3.46 µg/l (< 0.5 to 10.0); Co: median 2.3 µg/l, mean 2.66 µg/l (< 0.5 to 9.5)). In 80 unilateral BHRs with sequential ion measurements, Cr and Co levels were found to decrease significantly (p < 0.001) from the initial assessment at a median of six years (4 to 8) to the last assessment at a median of 11 years (9 to 13), with a mean reduction of 1.24 µg/l for Cr and 0.88 µg/l for Co. Three female patients had a > 2.5 µg/l increase of Co ions, associated with head sizes ≤ 50 mm, clinical symptoms and osteolysis. Overall, there was no significant difference in change of ion levels between genders (Cr, p = 0.845; Co, p = 0.310) or component sizes (Cr, p = 0.505; Co, p = 0.370). Higher acetabular component inclination angles correlated with greater change in ion levels (Cr, p = 0.013; Co, p = 0.002). Patients with increased ion levels had lower Harris hip scores (p = 0.038).

In conclusion, in well-functioning BHRs the metal ion levels decreased significantly at ten years. An increase > 2.5 µg/l was associated with poor function.

Cite this article: Bone Joint J 2013;95-B:1332–8.
Stjórnskipunin og meðferð á fé lífeyrissjóða
Authors: Helgadóttir Ragnhildur
Published: September 2013

Í greininni er fjallað um það hvaða takmarkanir stjórnarskrá og meginreglur stjórnskipunarréttarins setja því hversu mikil og hvernig afskipti ríkið geti haft af því hvernig lífeyrissjóðir nota féð sem í þeim er. Fjallað er um hvernig mismunandi tegundir afskipta (þ.e.a.s. heimildir og skyldur til að leggja fé í ýmist arðbær eða óarðbær verkefni) af því hvernig lífeyrissjóðir nota féð horfa við gagnvart ákvæðum 76. gr. stjórnarskrár um lágmarksframfærslu og 72. gr. hennar um eignarrétt auk skilyrða um að boð og bönn sé að finna í lögum, hafi samfélagslegan tilgang, séu almenn og gæti jafnræðis og meðalhófs. Í ljós kemur að 76. gr. hefur lítil áhrif vægi í þessu sambandi en vernd eignarréttarins leiðir til þess að tæpast er hægt að heimila lífeyrissjóðum né skylda þá til að taka þátt í verkefnum sem ekki eru arðbær. Þá leiða aðrar kröfur sem gera verður til lagasetningar einnig til þess að ákveðin afskipti væru tæpast heimil. Niðurstaðan er sú að lögbundin skylduaðild að lífeyrissjóðum leiðir af sér verulegar takmarkanir á því hve mikil inngrip er hægt að gera í það hvernig lífeyrissjóðirnir fara með fé.
Útgjöld ríkisins í Norðausturkjördæmi og tekjur ímyndaðs "Norðausturríkis"
Authors: Bjarnason Þóroddur , Heiðarsson Jón Þorvaldur
Published: September 2013

Hlutdeild einstakra landshluta í tekjuöflun þjóðarinnar og skipting ríkisútgjalda milli höfuðborgar og landsbyggða eru meðal umdeildustu mála í íslenskri byggðaumræðu. Slík umræða endurspeglar ólík viðhorf til félagslegs réttlætis og ólíka hagsmuni íbúa mismunandi landssvæða. Þrátt fyrir harðvítugar deilur um mikla hagsmuni eru rannsóknir á dreifingu ríkisútgjalda eftir landsvæðum af skornum skammti. Í þessari rannsókn er sjónum beint að útgjöldum ríkisins í Norðausturkjördæmi á grundvelli fjárlaga ársins 2011 og viðbótarupplýsinga sem safnað var hjá einstökum stofnunum og ráðuneytum. Niðurstöður sýna að starfsemi ríkisins á Norðurlandi eystra er um 11% minni en mannfjöldi segir til um eða sem nemur rúmlega 74 þúsund krónum á hvern íbúa á ári. Starfsemi ríkisins á Austurlandi er um 23% minni en mannfjöldi segir til um eða sem nemur rúmlega 159 þúsund krónum á hvern íbúa á ári. Á hinn bóginn leggur ríkið til svipaða upphæð til að stuðla að því að þjónusta sveitarfélaga sé sambærileg því sem gerist annars staðar og til að styðja við landbúnað á þessum svæðum. Ef áætlaðar tekjur ríkisins eru bornar saman við útgjöld ríkisins í kjördæminu kemur í ljós að útgjöldin eru hærri sem nemur 625 Mkr eða 1,2% af skatttekjum miðað við fjárlög ársins 2011. Til samanburðar var halli af rekstri íslenska ríkisins skv. fjárlögum 2011 um 7,9% eftir vaxtagreiðslur. Þetta er vísbending um að ímyndað, sjálfstætt "Norðausturríki" gæti staðið á eigin fótum en til að svara því þyrfti þó mun viðameiri rannsóknir.
Analysis of Robust Parameter-Free Multilevel Methods for Neumann Boundary Control Problems
Authors: Gonçalves Etereldes , Sarkis Marcus
Published: September 2013

We consider a linear-quadratic elliptic control problem (LQECP)
where the control
variable corresponds to the Neumann data on the boundary of a convex
polygonal domain. The optimal control unknown is the
one for which the harmonic extension approximates best a
specified target in the interior of the domain. We propose multilevel
preconditioners for the reduced system (the discrete Hessian system)
resulting from the application
of the Schur complement method to the discrete LQECP. In order to
derive robust preconditioners with respect to stabilization parameters,
we first show that the continuous reduced Hessian operator and the
corresponding discrete Hessian matrix are associated to a
linear combination of fractional negative Sobolev norms. Then we propose a
preconditioner based on multilevel methods, including cases
where the stabilization parameters are set equal to zero.
We also present numerical experiments
which agree with the theoretical results.
Fast Domain Decomposition Type Solver for Stiffness Matrices of Reference p-Elements
Authors: Korneev Vadim
Published: September 2013

A key component of domain decomposition solvers for hp discretizations of elliptic equations
is the solver for internal stiffness matrices of p-elements.
We consider an
algorithm which belongs to the family of secondary domain
decomposition solvers, based on the finite-difference like preconditioning of p-elements,
and was outlined by the author earlier. We remove the
uncertainty in the choice of the coarse (decomposition) grid
solver and suggest the new interface Schur complement
preconditioner. The latter essentially uses the boundary norm for discrete harmonic functions
induced by orthotropic discretizations on slim rectangles,
which was derived recently.
We prove that the algorithm has linear arithmetical complexity.
Comparison of Split Step Solvers for Multidimensional Schrödinger Problems
Authors: Čiegis Raimondas , Mirinavičius Aleksas , Radziunas Mindaugas
Published: September 2013

This paper presents the analysis of the split step solvers
for multidimensional Schrödinger problems.
The second-order symmetrical splitting
techniques are applied. The standard operator splitting is used
to split the linear diffraction and reaction/potential processes.
The dimension splitting exploits
the commuting property of one-dimensional discrete diffraction operators.
Alternating Direction Implicit (ADI) and Locally One-Dimensional (LOD)
algorithms are constructed and stability is investigated for
two- and three-dimensional problems. Compact
high-order approximations are applied to discretize diffraction operators.
Results of numerical experiments are presented and convergence
of finite difference schemes is investigated.
A Family of Finite-Difference Schemes with Discrete Transparent Boundary Conditions for a Parabolic Equation on the Half-Axis
Authors: Zlotnik Alexander , Koltsova Natalya
Published: September 2013

An initial-boundary value problem for the 1D self-adjoint parabolic equation on the half-axis is solved.
We study a broad family of two-level finite-difference schemes with two parameters
related to averages both in time and space.
Stability in two norms is proved by the energy method.
Also discrete transparent boundary conditions are rigorously derived for schemes by applying the method of reproducing functions.
Results of numerical experiments are included as well.
A Posteriori Error Estimation for Highly Indefinite Helmholtz Problems
Authors: Dörfler Willy , Sauter Stefan
Published: September 2013

We develop a new analysis for residual-type a posteriori error estimation for
a class of highly indefinite elliptic boundary value problems by considering
the Helmholtz equation at high wavenumber as our model problem. We
employ a classical conforming Galerkin discretization by using hp-finite elements.
In [Convergence analysis for finite element discretizations of the Helmholtz equation with
Dirichlet-to-Neumann boundary conditions, Math. Comp., 79 (2010), pp. 1871–1914], Melenk and Sauter introduced an hp-finite element discretization which leads to a stable
and pollution-free discretization of the Helmholtz equation under a mild
resolution condition which requires only
degrees of freedom, where denotes the spatial dimension.
In the present paper, we will introduce an a posteriori error estimator for this
problem and prove its reliability and efficiency. The constants in these
estimates become independent of the, possibly, high wavenumber
provided the aforementioned resolution condition for stability is satisfied.
We emphasize that, by using the classical theory, the constants in the a posteriori estimates would be amplified by a factor k.
On Finite Difference Schemes for Elliptic Equations with Discontinuous Coefficients
Authors: Dobrowolski Manfred
Published: September 2013

We study the convergence of finite difference schemes for approximating
elliptic equations of second order with discontinuous coefficients.
Two of these finite difference schemes arise from the discretization
by the finite element method using bilinear shape functions.
We prove
an convergence for the gradient, if the solution is locally in H3. Thus, in contrast to the first order convergence
for the gradient obtained by the finite element theory we show that the gradient is superclose.
From the Bramble–Hilbert Lemma we derive a higher order compact (HOC) difference scheme
that gives an approximation error of order four for the gradient.
A numerical example is given.
The covert language in Kenyan hip hop lyrics
Authors: Ochoki, Beatrice , Schroeder, Helga
Published: September 2013

This article discusses the covert language of Kenyan hip hop lyrics. It will show that it has two interacting factors for its covertness, one is the uniqueness of Sheng and the other is the lexical adjustment processes that involve the construction of ad hoc concepts based on the interrelation between the encoded concepts, contextual information and the pragmatic processes of narrowing and broadening. This article will also show that Kenyan hip hop lyrics are prone to misinterpretation as a result of the lexical manipulation processes and the figurative language used. It will also prove that the misunderstanding of Kenyan hip hop lyrics is triggered intentionally by the speakers� abilities and preferences to exploit covert language, which is intended to lock out outsiders and create a new identity for the Kenyan urban youth. Hidden in the figurative language is a demeaning understanding of women as sex objects.
Effect of Focused Debriefing on Team Communication Skills
Authors: Nwokorie Ndidi , Svoboda Deborah , Rovito Debra K. , Krugman Scott D.
Published: September 2013

Background and Objective:

Community hospitals often lack tertiary care support such as pediatric intensivists and anesthesiologists. Resuscitation of critically ill and injured children in community hospitals requires a well-coordinated team effort, because good team performance improves quality of care. The lack of subspecialty support makes team coordination and communication more imperative yet much more challenging. This study sought to determine if the addition of a defined focused post-mock code debriefing session improved communication skills among team members in a community pediatric emergency department.

Methods:

Twenty-two volunteer members of the pediatric emergency and respiratory therapy departments at Medstar Franklin Square Medical Center took part in monthly simulated resuscitations for 3 consecutive months. After each simulation, participants answered an 18-item survey on observed communication among their team members. Members then participated in a 30-minute debriefing session in which they reflected on their own communication skills. A video taping of the resuscitation was later scored by one of the investigators by using a rubric designed by the investigators. Descriptive statistics were calculated for both the participant survey and the team communication indicator scores. Paired-sample Wilcoxon signed rank test examined the difference in the scores between each of 3 sessions.

Results:

The mean scores by investigator-scored video recordings of the teams’ mock resuscitation by session showed overall team communication improved between sessions 1 and 3 for all communication areas (P = .03), with significant improvement in 4 of 9 communication areas by the third session. All team members improved communication skills as well, with the greatest improvement by the clinical multifunctional technicians.

Conclusions:

Communication skills improve with the addition of focused debriefing sessions after mock codes as perceived by participants during debriefing sessions and evidenced by investigator-scored video recordings of resuscitations.
Traditional Measures of Hospital Utilization May Not Accurately Reflect Dynamic Patient Demand: Findings From a Children’s Hospital
Authors: Fieldston Evan , Ragavan Meera , Jayaraman Bhuvaneswari , Metlay Joshua , Pati Susmita
Published: September 2013

Objectives:

Hospital crowding adversely affects access to emergent and elective care, quality and safety, patient and staff satisfaction, and trainee education. Reliable and valid measurements are crucial to operational planning and improvement, but traditional measures of hospital utilization may not accurately describe dynamic demand at hospitals. The goal of this study was to determine how effectively traditional measures express demand for hospital services and to describe the dynamic nature of patient flow in children’s hospitals compared with alternative measures.

Methods:

This was a retrospective administrative data review conducted at an urban, tertiary care children’s hospital. A total of 28 045 inpatients (22 310 from fiscal year 2008 and 5735 from 2 months in the fall of 2009 during the H1N1 influenza surge [October 16, 2009–November 18, 2009]) were reviewed. Admission-discharge-transfer data were abstracted from a total of 14 months (1 fiscal year and a separate 2 months including an influenza surge). Hourly hospital census and occupancy were determined. Measures of mean and median length of stay (LOS) were compared. Turnover was calculated by summing admissions, discharges, and interunit transfers. Coefficient of variation (SD/mean) was used to describe variation.

Results:

Midnight occupancy was generally closer to minimum occupancy than peak. Peak was usually between 10 AM and 12 PM and was a mean of 4% points higher than midnight (but as large as 13% points). Median LOS was 58% shorter than average LOS. There was a high level of turnover, and patient-days did not express the wide variation in how demand was generated by day of week.

Conclusions:

Traditional metrics for hospital utilization do not accurately express the true extent and dynamic nature of patient flow and inpatient demand at a children’s hospital. Hospitals and government regulatory agencies should consider additional means of measuring utilization to accurately determine demand, including its variation, and thus assist in budgeting, staffing, and capacity planning.
Neonatal Bilirubin Triage With Transcutaneous Meters: When is a Blood Draw Necessary?
Authors: Hoppenot Claire , Emmett Gary A.
Published: September 2013

Objective:

To find the optimal transcutaneous bilirubin (TcB) screening level in term neonates that minimizes the discomfort of phlebotomy, while protecting the child from harm and controlling costs.

Methods:

All available TcB and total serum bilirubin (TSB) measurements taken between 27 and 51 hours of life from a cohort of term newborns were analyzed in a retrospective chart review. TcB cutoffs between 6 and 12 mg/dL were evaluated for their negative predictive values (NPVs) for high risk (HR) and for the combination of high-intermediate risk and HR on the Bhutani TSB risk nomogram.

Results:

One thousand seventy-one full-term newborns were entered into the study. Of 601 newborns with TcB <7 mg/dL, none were HR by TSB. Of newborns with a TcB of <8 mg/dL, 1 in 759 was HR. The NPVs for screening levels of 7 and 8 mg/dL were of 100% and 99.9%, respectively, for HR and 99% and 97.6%, respectively, for high-intermediate/HR. A cutoff at 12 mg/dL had NPVs of 99.3% for HR, with 7 neonates, and 92.7% for high-intermediate/HR, with 76 infants of 1041.

Conclusions:

In our center, term infants with a TcB of <8 mg/dL may be safely discharged without a follow-up TSB, with the understanding that ~1/1000 infants may be at HR for developing severe hyperbilirubinemia. Practices with universal follow-up may safely choose cutoffs up to 12 mg/dL. An institution’s degree of comfort and confidence in follow-up of the newborn cohort will guide the choice of an appropriate TcB cutoff requiring a TSB.
A Qualitative Description of the Development and Evaluation of Our Voice, a Health Promotion Magazine Created by Pediatric Patients for Hospitalized Pediatric Patients
Authors: Luca Paola D. , Chan Melissa , Basak Sanjukta , Segal Audrey O. , Porepa Michelle , Pinard Marie , Au Hosanna , Birken Catherine S.
Published: September 2013

Objectives:

To facilitate a peer-developed health promotion magazine that provides health education and engages hospitalized pediatric patients during a hospital admission. To evaluate patient satisfaction with the content and layout of the magazine and its impact on patients’ attitudes toward healthy living.

Methods:

A pediatric resident–led multidisciplinary team collaborated with the Children’s Council at The Hospital for Sick Children to create a health promotion magazine for inpatients. Articles included a scavenger hunt, healthy recipes, physical activities, hospital staff interviews, and patient stories. Patients 7 to 18 years of age admitted to Pediatric Medicine or Respirology were invited to read the magazine and complete a questionnaire 24 hours later on their satisfaction with the magazine and their attitudes regarding healthy living.

Results:

Thirty-seven patients received a copy of the magazine, and 24 patients completed the questionnaire (mean 13.4 years, 54% female, 25% overweight/obese). Eleven of 24 (46%) read the entire magazine, and 19 of 23 (83%) reported learning. The exercises, recipes, and patient stories were most liked. Ten of 24 (42%) participants performed the exercises; the most common reason for not trying an exercise was pain. After reading the magazine, 15 of 24 (65%) patients reported that they will try to be more active, and 11 of 23 (48%) reported that they will try to eat more fruits and vegetables. Eighty-three percent were interested in a future edition.

Conclusions:

A health promotion magazine created by patients for patients changed patient-reported attitudes about healthy living. Peer-led interventions in the inpatient setting may be an important opportunity to promote healthy lifestyles and require further study.
Successful Implementation of a Referral-based Academic Pediatric Hospitalist Service
Authors: Hrach Christine M. , Smith Carolyn A. , Shah Purvi P. , Guth Rebecca M. , Lashly Dana , Carlson Douglas W.
Published: September 2013

Objective:

St Louis Children’s Hospital (SLCH) developed Service for Hospital Admissions by Referring Physicians (SHARP) in January 2008 as an inpatient referral service for pediatricians who previously admitted their own patients. We hypothesized that use of SHARP would make hospitalization more efficient and cost-effective compared with the general pediatric medicine (GM) service.

Methods:

Admission volumes, diagnoses, length of stay (LOS), costs, and physician billing data were abstracted from SLCH information systems and the Pediatric Health Information System database. We compared admissions for SHARP and GM from January 2008 through June 2010.

Results:

SHARP had lower LOS and costs versus GM, with no change in 7-day readmission rate. Median LOS was 2 days for SHARP and 3 days for GM (P < .001). Median hospital cost per patient was $2719 for SHARP and $3062 for GM (P < .001). Over the study period, the admission rate increased 37% and daily patient encounters increased 39%. Physician billing revenue increased 25% in the first 6 months, then continued to increase steadily. Total physicians and geographic referral area using SHARP increased, and referring physician satisfaction was high.

Conclusions:

SHARP approaches financial independence and provides a cost savings to SLCH. LOS decreased by a statistically significant amount compared with GM with no change in readmission rate. Referring physician satisfaction was high, likely allowing for growth in referrals to SLCH. SHARP hospitalists’ collaboration with referring physicians, ensuring excellent follow-up, provides decreased duration of hospitalization and resource utilization. Our availability throughout the day to reassess patients increases efficiency. We project that we must average 12.6 daily encounters to be financially independent.
The Prevalence of Bacteremia in Pediatric Patients With Community-Acquired Pneumonia: Guidelines to Reduce the Frequency of Obtaining Blood Cultures
Authors: Heine Daniel , Cochran Christina , Moore Melissa , Titus M. Olivia , Andrews Annie Lintzenich
Published: September 2013

Objective:

The goal of this study was to determine the prevalence of bacteremia in pediatric patients with community-acquired pneumonia (CAP) at our institution and to test the effectiveness of newly developed guidelines for obtaining blood cultures.

Methods:

Using recent literature and local expert opinion, institutional guidelines for obtaining blood cultures in pediatric patients with CAP were developed. A retrospective chart review of children treated in the emergency department or admitted for CAP from January 2010 through June 2011 was conducted. Demographic and clinical data were collected, including results of blood cultures. χ2 tests assessed for variables associated with bacteremia, whether a blood culture was obtained, and if the decision to obtain a culture was appropriate based on our guidelines.

Results:

The study included 330 patients; 155 (47%) blood cultures were obtained in our patient population. Five cultures were true-positive findings, making the prevalence of bacteremia 3.2% in patients with blood cultures and 1.5% in all patients. All 5 true positive results met criteria for blood culture based on our guidelines. Applying our guidelines retrospectively, the decision to obtain a blood culture met criteria in 55% of the cases. Bivariate analysis showed that patients discharged from the emergency department had higher rates of guideline-appropriate decisions than patients admitted. Radiographic findings were associated with making a guideline-appropriate decision regarding blood culture.

Conclusions:

Instituting local guidelines that limit the frequency of obtaining blood cultures in pediatric patients with CAP is likely to capture any patient with bacteremia. This study suggests that blood cultures may not need to be routinely obtained in all patients admitted to the hospital with CAP.
Development of Performance Tracking for a Pediatric Hospitalist Division
Authors: Paciorkowski Natalia , Pruitt Cassandra , Lashly Dana , Hrach Chrissy , Harrison Elizabeth , Srinivasan Mythili , Turmelle Michael , Carlson Douglas
Published: September 2013

OBJECTIVES:

Our goal was to develop a comprehensive performance tracking process for a large pediatric hospitalist division. We aimed to use established dimensions and theory of health care quality to identify measures relevant to common inpatient diagnoses, reflective of current standards of clinical care, and applicable to individual physician performance. We also sought to implement a reproducible data collection strategy that minimizes manual data collection and measurement bias.

METHODS:

Washington University Division of Pediatric Hospital Medicine provides clinical care in 17 units within 3 different hospitals. Hospitalist services were grouped into 5 areas, and a task group was created of divisional leaders representing clinical services. The group was educated on the health care quality theory and tasked to search clinical practice standards and quality resources. The groups proposed a broad spectrum of performance questions that were screened for electronic data availability and modified into measurable formulas.

RESULTS:

Eighty-seven performance questions were identified and analyzed for their alignment with known clinical guidelines and value in measuring performance. Questions were distributed across quality domains, with most addressing safety. They reflected structure, outcome, and, most commonly, process. Forty-seven questions were disease specific, and 79 questions reflected individual physician performance; 52 questions had electronically available data.

CONCLUSIONS:

We describe a systematic approach to the development of performance indicators for a pediatric hospitalist division that can be used to measure performance on a division and physician level. We outline steps to develop a broad-spectrum quality tracking process to standardize clinical care and build invaluable resources for quality improvement research.
Are there risks associated with empiric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease?
Authors: Chung Erica Y. , Yardley Jeremy
Published: September 2013

Background:

It has become common practice to empirically treat infants and children who have suspected gastroesophageal reflux disease by using acid-suppressive medications. However, evidence to support the effectiveness of these medications in the pediatric population is limited. With multiple studies in adult patients indicating increased risk of infection, we reviewed the literature to determine the association between acid-suppressive medications and serious adverse effects in infants and children.

Methods:

We conducted a PubMed search on the adverse effects of H2 antagonists and proton pump inhibitors in pediatric patients. The studies selected were original research and systematic reviews with control groups and study objectives evaluating the relationship between acid-suppressive medications and serious adverse effects (namely, infections).

Results:

Fourteen studies met our inclusion criteria. The majority of studies found a significant association between acid-suppressive medications and the risk of necrotizing enterocolitis, sepsis/bacteremia, pneumonia, and gastrointestinal infections in infants and children.

Conclusions:

Given the questionable efficacy of H2 antagonists and proton pump inhibitors and the growing evidence of increased risk of serious infections, acid-suppressive medications should be used cautiously in infants and children suspected of having gastroesophageal reflux disease.
Association Between Practice Setting and Pediatric Hospitalist Career Satisfaction
Authors: Pane Laurie A. , Davis Aisha B. , Ottolini Mary C.
Published: September 2013

Background:

Pediatric hospital medicine has become a viable long-term career choice. To retain qualified physicians, both academic and community hospital leaders seek to improve their job satisfaction.

Objective:

The goal of this study was to determine whether practice in a community versus academic setting is associated with pediatric hospitalists’ career satisfaction.

Methods:

The study was based on data from an anonymous electronic cross-sectional survey sent to the American Academy of Pediatrics Section on Hospital Medicine Listserv between November 2009 and January 2010. Questions were rated on a standard 5-point Likert scale. A total career satisfaction score was calculated for each respondent by summing across all 23 questions. Multivariate logistic regression was conducted to assess job satisfaction according to practice setting.

Results:

A total of 222 pediatric hospitalists responded. Sixty-six percent of respondents practiced in an academic setting and 34% in a community hospital. Fifty-eight percent of academic and 42% of community hospitalists were satisfied with their careers, defined as a mean per-question Likert score ≥4. Adjusting for gender, average daily census, percentage of complex patients, years as a hospitalist, and years since residency graduation, academic hospitalists were more likely than community hospitalists to be satisfied with their careers (adjusted odds ratio: 2.43 [95% confidence interval: 1.25–4.72]; P = .009).

Conclusions:

Pediatric hospitalists practicing in academic settings seem more likely to be satisfied with their careers than those in a community hospital. Overall, however, there is room for improvement in career satisfaction for both groups. Further study is warranted to confirm and clarify these findings on a larger scale, perhaps with oversampling of community hospitalists.
A Randomized Trial of Facilitated Family-Centered Rounds
Authors: Alverson Brian K. , Wilson Karen M. , Shah Samir S.
Published: September 2013

BACKGROUND:

Family-centered rounds (FCR) are becoming the status quo for inpatient pediatric medical care; however, barriers still exist. The use of facilitators in FCR is gaining popularity. Although facilitators can increase comfort with FCR, the choice of preferred facilitator has not been studied by using rigorous methodology. In this study, we performed a randomized trial of facilitated FCR with bunnies and clowns, 2 commonly mentioned facilitators, and compared their results with the usual care condition.

METHODS:

The 3 floor teams were randomized to have rounds facilitated with bunnies and clowns or the usual care model facilitated by distracted residents and overbearing attending physicians. Infection control procedures were instituted. Outcome measures were parent satisfaction scores, use of anxiolytic agents during examinations as part of FCR, resident satisfaction, and the number of times presenters were interrupted by their attending. Differences between the experimental and control groups were analyzed by using t tests, χ2 statistics, and multiple regression analysis. Qualitative analyses were also performed by using participant-observers.

RESULTS:

Bunnies had the best overall improvement in parent satisfaction, anxiety, and resident satisfaction. Both intervention groups were successful at reducing attending interruptions. The clown arm was suspended by the Data Safety Monitoring Board before study completion due to adverse events.

DISCUSSION:

Facilitated FCR has the potential to improve satisfaction among parents, patients, and residents, and to decrease attending interruptions. Care needs to be taken, however, to avoid unanticipated adverse effects from potentially emotionally damaging interventions. Tularemia was not identified in any of our treatment conditions.
Resource Utilization and Cost of Inserting Peripheral Intravenous Catheters in Hospitalized Children
Authors: Goff David A. , Larsen Pamela , Brinkley Jason , Eldridge David , Newton Dale , Hartzog Timothy , Reigart J. Routt
Published: September 2013

Objective:

The goal of this study was to measure the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children; measures of resource utilization. We measured the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children. This common procedure has implications for the utilization of hospital resources.

Methods:

This was a prospective, large-scale observational study in 2 southeastern US pediatric teaching hospitals evaluating 592 children needing peripheral IV catheters in the inpatient setting. The median age was 2.25 years with an age range of 2 days to 18 years. Costs were estimated by using directly measured staff time and national salary data. Analyses included costs according to patient characteristics (age, weight, dehydration, and difficulty of stick attempts), and nurse characteristics (experience in years and anticipated difficulty).

Results:

The median cost of the pediatric IV insertions was $41, and 60% of the placements were obtained with the first nurse. Seventy-two percent of the children had a successful IV insertion in 1 to 2 attempts and accounted for 53% of total costs. However, the 28% of children who required ≥3 IV attempts had a cost range of $69 to more than $125, and they consumed 43% of the total IV costs. This subset was often <2 years old or dehydrated (P = .0002).

Conclusions:

The insertion of peripheral IV catheters in an inpatient setting can be time intensive and requires significant skill. Our study suggests that resource utilization may improve when nurses and personnel proficient in starting peripheral IV catheters are used when the initial nurse has failed to obtain IV access. This systems improvement should result in shortened time to administration of parenteral therapies, positively improving outcomes and lessening length of stay, as well as improving patient/family satisfaction due to reduced perceptions of pain.
Association Between Language, Serious Adverse Events, and Length of Stay Among Hospitalized Children
Authors: Lion K. Casey , Rafton Sarah A. , Shafii Jaleh , Brownstein Dena , Michel Eriberto , Tolman Michelle , Ebel Beth E.
Published: September 2013

Objective:

To evaluate the risk for serious/sentinel adverse events among hospitalized children according to race, ethnicity, and language and to evaluate factors affecting length of stay associated with serious/sentinel adverse events.

Methods:

We conducted a retrospective cohort study of all pediatric inpatients at a large children’s hospital from October 2007 to October 2009. We evaluated the relationship between self-reported race, ethnicity, and primary language; with having a serious or sentinel adverse event, defined as an unexpected occurrence involving risk of death or serious injury; or a potentially harmful event resulting from nonstandard practice. We also examined length of stay. Clinical complexity was adjusted for by using Clinical Risk Groups.

Results:

Of 33 885 patients, 8% spoke Spanish and 4% spoke other languages. Serious and sentinel events were rare; however, among patients with such events, 14% spoke Spanish. Adjusting for potential confounders, Spanish speakers trended toward an elevated odds of adverse event (odds ratio: 1.83 [95% confidence interval: 0.98–3.39]). Controlling for age, language, and clinical complexity, having an adverse event was associated with a nearly fivefold increase in length of stay (95% confidence interval: 3.87–6.12). Spanish-speaking patients with an adverse event were hospitalized significantly longer than comparable English speakers (26 vs 12.7 days; P = .03 for interaction between language and adverse event).

Conclusions:

Hospitalized children from Spanish-speaking families had significantly longer hospital stays in association with an adverse event and may have increased odds of a serious or sentinel event. These findings suggest that an important component of patient safety may be to address communication barriers.
DNA Repair Gene Patterns as Prognostic and Predictive Factors in Molecular Breast Cancer Subtypes
Authors: Santarpia Libero , Iwamoto Takayuki , Di Leo Angelo , Hayashi Naoki , Bottai Giulia , Stampfer Martha , André Fabrice , Turner Nicholas C. , Symmans W. Fraser , Hortobágyi Gabriel N. , Pusztai Lajos , Bianchini Giampaolo
Published: September 2013

DNA repair pathways can enable tumor cells to survive DNA damage induced by chemotherapy and thus provide prognostic and/or predictive value. We evaluated Affymetrix gene expression profiles for 145 DNA repair genes in untreated breast cancer (BC) patients (n = 684) and BC patients treated with regimens containing neoadjuvant taxane/anthracycline (n = 294) or anthracycline (n = 210). We independently assessed estrogen receptor (ER)-positive/HER2-negative, HER2-positive, and ER-negative/HER2-negative subgroups for differential expression, bimodal distribution, and the prognostic and predictive value of DNA repair gene expression. Twenty-two genes were consistently overexpressed in ER-negative tumors, and five genes were overexpressed in ER-positive tumors, but no differences in expression were associated with HER2 status. In ER-positive/HER2-negative tumors, the expression of nine genes (BUB1, FANCI, MNAT1, PARP2, PCNA, POLQ, RPA3, TOP2A, and UBE2V2) was associated with poor prognosis, and the expression of one gene (ATM) was associated with good prognosis. Furthermore, the prognostic value of specific genes did not correlate with proliferation. A few genes were associated with chemotherapy response in BC subtypes and treatment-specific manner. In ER-negative/HER2-negative tumors, the MSH2, MSH6, and FAN1 (previously MTMR15) genes were associated with pathological complete response and residual invasive cancer in taxane/anthracycline-treated patients. Conversely, PMS2 expression was associated with residual invasive cancer in treatments using anthracycline as a single agent. In HER2-positive tumors, TOP2A was associated with patient response to anthracyclines but not to taxane/anthracycline regimens. In genes expressed in a bimodal fashion, RECQL4 was significantly associated with clinical outcome. In vitro studies showed that defects in RECQL4 impair homologous recombination, sensitizing BC cells to DNA-damaging agents.
Trends in shell fragmentation as evidence of mid-Paleozoic changes in marine predation
Authors: Salamon Mariusz A. , Gorzelak Przemysław , Niedźwiedzki Robert , Trzęsiok Dawid , Baumiller Tomasz K.
Published: September 2013

Recent observations indicate that shell fragmentation can be a useful tool in assessing crushing predation in marine communities. However, criteria for recognizing shell breakage caused by durophagous predators versus physical factors are still not well established. Here, we provide data from tumbling and aquarium experiments to argue that physical and biotic processes lead to different patterns of shell damage, specifically that angular shell fragments are good indicators of durophagous predation. Using such angular shell fragments as a predation proxy, we analyze data from 57 European Paleozoic localities spanning the Ordovician through the Mississippian. Our results reveal a significant increase in angular shell fragments (either occurring as isolated valves or present in regurgitalites) in the Mississippian. The timing of this increase is coincident with the increased diversity of crushing predators as well as marked anti-predatory changes in the architecture and mode of life of invertebrate prey observed after the end-Devonian Hangenberg extinction (359 Ma). More specifically, the observed trend in shell fragmentation constitutes strong and independent confirmation of a recently suggested end-Devonian changeover in the primary method of fish predation from shearing to crushing. These results also highlight the important effect of extinction events, not only on taxonomic diversity, but also on the nature of predator-prey interactions.
Structural health monitoring for wind turbine foundations
Authors: Currie Magnus , Saafi Mohamed , Tachtatzis Christos , Quail Francis
Published: September 2013

The construction of onshore wind turbines has been increasing rapidly as the UK attempts to meet its renewable energy targets. As the UK’s future energy depends increasingly on wind farms, safety and security are critical to the success of this renewable energy source. Structural integrity of the tower and its components is a critical element of this security of supply. With the stochastic nature of the load regime, a bespoke structural health monitoring system is required to monitor the integrity of the concrete foundations supporting the tower. This paper presents an assessment of ‘embedded can’-style foundation failure modes in large onshore wind turbines and proposes a novel condition-based monitoring solution to aid in early warning of failure.
Social entrepreneurs and temporary public space supply: Beirut, Lebanon
Authors: Mady Christine
Published: September 2013

Public spaces constitute one of the first urban elements to be threatened in times of instability. Their efficient supply and management becomes a concern for both public authorities and individual users. This paper examines the role and objectives of social entrepreneurs in supplying temporary public spaces within an unstable setting and focuses on small group collective action. The mechanisms used to identify potential land, negotiate use-rights and promote these spaces are discussed for the case of Beirut, Lebanon, a society segregated by the effects of war and political upheaval. The case of an organic food market is used to illustrate temporary public spaces in the critical period of 2005–2007, when political instability reigned in the country and rendered conventional public spaces undesirable. The paper concludes by drawing lessons for land readjustment in crisis situations from the movement of temporary public spaces within a city while still attracting people that formerly had difficulties meeting elsewhere.
Breeding Cycles Expedited by FT‐mediated Reduction in Generation Time
Authors: Eickholt David P. , Lewis Ramsey S.
Published: September 2013

Methods for rapid inbreeding are desirable for reducing the time required to complete a breeding cycle and to increase genetic gain per year. Constitutive expression of FLOWERING LOCUS T (FT) derived from Arabidopsis has previously been shown to reduce generation time in tobacco (Nicotiana tabacum L.) and other crop plants. Here, we used tobacco as a model system to investigate the utility of a modified single‐seed descent (SSD) breeding method where transgenic expression of 35S:FT was used to reduce generation time during inbreeding. The transgene was maintained in hemizygous condition during inbreeding, and null segregants were isolated in the F4:5 generation to create nontransgenic F5:6 lines that were produced in nearly half the time that would have been required using conventional SSD. Opportunities for selection among 35S:FT plants during inbreeding were demonstrated by selecting for quantitative levels of resistance to the soil‐borne pathogen Phytophthora nicotianae. Populations of selected lines exhibited significantly higher levels of resistance relative to random lines, greater frequencies of highly resistant genotypes, and lower frequencies of highly susceptible genotypes. The system outlined here could lead to more rapid commercialization of improved cultivars in crop species amenable to manipulation of flowering time via transgenic expression of FT‐like genes. Strategies to enhance the frequency of favorable alleles in resulting populations can be incorporated into the method.