Plan to Have No Unplanned: A Collaborative, Hospital-Based Quality-Improvement Project to Reduce the Rate of Unplanned Extubations in the Pediatric ICU

BACKGROUND

Although under-reported and understudied, unplanned extubations carry a significant risk of patient harm and even death. They are an important yardstick of quality control of care of intubated patients in the ICU. A unit-based risk assessment and multidisciplinary approach is required to decrease the incidence of unplanned extubations.

METHODS

As part of a quality-improvement initiative of Children's Hospital at Montefiore, all planned and unplanned extubations in a multidisciplinary 20-bed pediatric ICU were evaluated over a 12-month period (January to December 2010). At the end of 6 months, an interim analysis was performed, and high-risk patient groups and patient care factors were identified. These factors were targeted in the second phase of the project.

RESULTS

Over this period, there were a total of 267 extubations, of which 231 (87%) were planned extubations and 36 (13%) were unplanned. A patient care policy targeting the risk factors was instituted, along with extensive nursing and other personnel education in the second phase. As a result of this intervention, the unplanned extubation rate in the pediatric ICU decreased from 3.55 to 2.59/100 intubation days. All subjects who had an unplanned extubation during nursing procedures or transport required re-intubation, whereas none of the unplanned extubations during ventilator weaning required re-intubation.

CONCLUSIONS

A targeted approach based on unit-specific risk factors is most effective in quality-improvement projects. A specific policy for sedation and weaning can be very helpful in managing intubated patients and preventing unintended harm.

Effect of intermaxillary tooth-size discrepancy on accuracy of prediction equations for mixed dentition space analysis

AIM

Correlation-statistical methods are widely used for prediction of size of unerupted permanent canines and premolars in mixed dentition space analysis. The present study was planned to evaluate the effect of selecting dental study casts with no intermaxillary tooth-size discrepancy on the accuracy of predicting mesiodistal widths (MDWS) of permanent canines and premolars.

STUDY DESIGN

Bolton ratios were calculated for all the screened study dental casts fulfilling the inclusion criteria. Subjects were divided into two groups. Group A: all subjects with no intermaxillary tooth-size discrepancy within ±2 SD (Standard deviation) of the mean values. Group B: increased percentage of subjects with intermaxillary tooth-size discrepancy beyond ±2 SD (Standard deviation) of the mean values.

STATISTICS

Linear regression equations were established for both maxilla and mandible in both the groups, with different tooth combinations as independent variables. Validation of best possible regression equations was done on an independent set of 40 subjects. The actual and predicted values of MDWS of permanent canines and premolars were compared by paired samples t test in both groups, for both arches.

RESULTS

The accuracy of equations derived from group A was higher than those derived from group B. The difference between actual and predicted values was statistically insignificant in group A and statistically significant in group B.

CONCLUSION

The results confirm the accuracy of simple linear regression equations derived from a sample of children with no intermaxillary tooth-size discrepancy.

Assessment of water quality index of bore well water samples from some selected locations of South Gujarat, India

The present study calculates the water quality index (WQI) of some selected sites from South Gujarat (India) and assesses the impact of industries, agriculture and human activities. Chemical parameters were monitored for the calculation of WQI of some selected bore well samples. The results revealed that the WQI of the some bore well samples exceeded acceptable levels due to the dumping of wastes from municipal, industrial and domestic sources and agricultural runoff as well. Inverse Distance Weighting (IDW) was implemented for interpolation of each water quality parameter (pH, EC, alkalinity, total hardness, chloride, nitrate and sulphate) for the entire sampled area. The bore water is unsuitable for drinking and if the present state of affairs continues for long, it may soon become an ecologically dead bore.

Structural and photoluminescence study of Mn2+-activated CaYAl3 O7 blue phosphors

The structural and photoluminescence properties of CaYAl3 O7 phosphor material doped with varying concentration of Mn(2+) have been studied. The phosphor material was synthesized by the combustion method at 500 °C and was characterized using X-ray diffraction, Fourier transform infrared spectroscopy and photoluminescence spectroscopy (PL). X-ray diffraction showed that the crystallites have average sizes in the range of ~58-70 nm. Corresponding Fourier transform infrared spectroscopy investigations confirm the phase formation and the presence of aluminate group (Al-O bands) in CaYAl3 O7 :Mn(2+) phosphor. Under the excitation at 356 nm wavelength, the PL spectra show the occurrence of two emission peaks obtained in the blue region at 389 nm and 412 nm, which is attributed to the 4 T1(G) → 6A1 transition of Mn(2+) ion. Upon increasing Mn(2+) concentration, the relative PL intensity shows an initial decrement followed by an increase displaying the effect of concentration quenching. Overall the results suggest the possibility of using this material in white lighting devices and plasma display panels.

Differential functional connectivity within an emotion regulation neural network among individuals resilient and susceptible to the depressogenic effects of early life stress

BACKGROUND

Early life stress (ELS) is a significant risk factor for depression. The effects of ELS exposure on neural network organization have not been differentiated from the effect of depression. Furthermore, many individuals exposed to ELS do not develop depression, yet the network organization patterns differentiating resiliency versus susceptibility to the depressogenic effects of ELS are not clear.

METHOD

Women aged 18-44 years with either a history of ELS and no history of depression (n = 7), a history of ELS and current or past depression (n = 19), or a history of neither ELS nor depression (n = 12) underwent a resting-state 3-T functional magnetic resonance imaging (fMRI) scan. An emotion regulation brain network consisting of 21 nodes was described using graph analyses and compared between groups.

RESULTS

Group differences in network topology involved decreased global connectivity and hub-like properties for the right ventrolateral prefrontal cortex (vlPFC) and decreased local network connectivity for the dorsal anterior cingulate cortex (dACC) among resilient individuals. Decreased local connectivity and increased hub-like properties of the left amygdala, decreased hub-like properties of the dACC and decreased local connectivity of the left vlPFC were observed among susceptible individuals. Regression analyses suggested that the severity of ELS (measured by self-report) correlated negatively with global connectivity and hub-like qualities for the left dorsolateral PFC (dlPFC).

CONCLUSIONS

These preliminary results suggest functional neural connectivity patterns specific to ELS exposure and resiliency versus susceptibility to the depressogenic effects of ELS exposure.

Autopsy findings in fatal dengue haemorrhagic fever - 06 Cases

BACKGROUND

During recent outbreak of dengue fever in Delhi, there has been a significant increase in dengue-associated admission in hospitals. To better understand the pathology of dengue haemorrhagic fever, we conducted autopsies of dengue infections deaths within our hospital.

METHOD

This was an autopsy study of dengue-associated deaths at a large tertiary care hospital.

RESULTS

From Sep 2009 to Dec 2010, a total of 1032 patients with serological evidence of dengue infection were admitted to our hospital. There were twelve deaths and autopsies were conducted in six. Adult respiratory distress syndrome, bleeding diathesis, hypotension, hepatic failure and acute renal failure were the common causes of death despite early hospitalization, intravenous fluid, and blood-product support.

CONCLUSION

Dengue is associated with severe disease, and deaths do occur despite current supportive management. Early predictors of disease severity and better clinical interventions are needed.

Tolerance to MHC class II disparate allografts through genetic modification of bone marrow

Induction of molecular chimerism through genetic modification of bone marrow is a powerful tool for the induction of tolerance. Here we demonstrate for the first time that expression of an allogeneic MHC class II gene in autologous bone marrow cells, resulting in a state of molecular chimerism, induces tolerance to MHC class II mismatched skin grafts, a stringent test of transplant tolerance. Reconstitution of recipients with syngeneic bone marrow transduced with retrovirus encoding H-2I-A^b (I-A^b) resulted the long-term expression of the retroviral gene product on the surface of MHC class II-expressing bone marrow derived cell types. Mechanistically, tolerance was maintained by the presence of regulatory T cells, which prevented proliferation and cytokine production by alloreactive host T cells. Thus, the introduction of MHC class II genes into bone marrow derived cells through genetic engineering results in tolerance. These results have the potential to extend the clinical applicability of molecular chimerism for tolerance induction.

Regulation of GPCR-mediated smooth muscle contraction: implications for asthma and pulmonary hypertension

Contractile G-protein-coupled receptors (GPCRs) have emerged as key regulators of smooth muscle contraction, both under healthy and diseased conditions. This brief review will discuss some key topics and novel insights regarding GPCR-mediated airway and vascular smooth muscle contraction as discussed at the 7th International Young Investigators' Symposium on Smooth Muscle (2011, Winnipeg, Manitoba, Canada) and will in particular focus on processes driving Ca(2+)-mobilization and -sensitization.

First Report of Pepper mottle virus Infecting Tomato in Hawaii

In August 2011, tomato (Solanum lycopersicum L.) fruit from a University of Hawaii field trial displayed mottling symptoms similar to that caused by Tomato spotted wilt virus (TSWV) or other tospoviruses. The foliage from affected plants, however, appeared symptomless. Fruit and leaf tissue from affected plants were negative for TSWV analyzed by double antibody sandwich (DAS)-ELISA and/or TSWV ImmunoStrips (Agdia, Elkhart, IN) when performed following the manufacturer's instructions. Total RNA from a symptomatic and an asymptomatic plant was isolated using an RNeasy Plant Mini Kit (Qiagen, Valencia, CA) and reverse transcribed using Invitrogen SuperScript III reverse transcriptase (Life Technologies, Grand Island, NY) and primer 900 (5'- CACTCCCTATTATCCAGG(T)₁₆-3') following the enzyme manufacturer's instructions. The cDNA was then used as template in a universal potyvirus PCR assay using primers 900 and Sprimer, which amplify sequences encoding the partial inclusion body protein (NIb), coat protein, and 3' untranslated region of potyviruses (1). A ~1,700-bp product was amplified from the cDNA of the symptomatic plant but not the asymptomatic plant. This product was cloned using pGEM-T Easy (Promega, Madison, WI) and three clones were sequenced at the University of Hawaii's Advanced Studies in Genomics, Proteomics, and Bioinformatics laboratory. The 1,747-bp consensus sequence of the three clones was deposited in GenBank (Accession No. JQ429788) and, following primer sequence trimming, found to be 97% identical to positions 7,934 through 9,640 of Pepper mottle virus (PepMoV; family Potyviridae, genus Potyvirus) accessions from Korea (isolate '217' from tomato; EU586126) and California (isolate 'C' from pepper; M96425). To determine the incidence of PepMoV in the field trial, all 292 plants representing 14 tomato cultivars were assayed for the virus 17 weeks after planting using a PepMoV-specific DAS-ELISA (Agdia) following the manufacturer's directions. Plants were considered positive if their mean absorbance at 405 nm was greater than the mean absorbance + 3 standard deviations + 10% of the negative control samples. The virus incidence ranged from 4.8 to 47.6% for the different varieties, with an overall incidence of 19.9%. Although plant growth was not noticeably impaired by PepMoV infection, the majority of fruit from infected plants was unsaleable, making PepMoV a considerable threat to tomato production in Hawaii. PepMoV has been reported to naturally infect tomato in Guatemala (3) and South Korea (2). To our knowledge, this is the first report of this virus in Hawaii and the first report of this virus naturally infecting tomato in the United States. References: (1) J. Chen et al. Arch. Virol. 146:757, 2001. (2) M.-K. Kim et al. Plant Pathol. J. 24:152, 2008. (3) J. Th. J. Verhoeven et al. Plant Dis. 86:186, 2002.

The kinetic dose limit in room-temperature time-resolved macromolecular crystallography

Protein X-ray structures are determined with ionizing radiation that damages the protein at high X-ray doses. As a result, diffraction patterns deteriorate with the increased absorbed dose. Several strategies such as sample freezing or scavenging of X-ray-generated free radicals are currently employed to minimize this damage. However, little is known about how the absorbed X-ray dose affects time-resolved Laue data collected at physiological temperatures where the protein is fully functional in the crystal, and how the kinetic analysis of such data depends on the absorbed dose. Here, direct evidence for the impact of radiation damage on the function of a protein is presented using time-resolved macromolecular crystallography. The effect of radiation damage on the kinetic analysis of time-resolved X-ray data is also explored.

Iodine deficiency disorder control programme impact in pregnant women and status of universal salt iodization

BACKGROUND

Several studies pertaining to current status of Iodine Deficiency Disorder Control Programme in India have revealed goiter prevalence in the range of 1.5-44.5%, mean urinary iodine excretion level ranging from 92.5-160 mcg/L and iodized salt coverage ranging from 37-62.3%. Most of these studies were based on school children. However, very few studies have focused on pregnant women. This population is very sensitive to marginalized iodine deficiency throughout their gestational period.

METHODS

This 40 cluster cross sectional study was done in Raipur district. Iodine content of salt was estimated by using "Rapid Salt Testing Kits" along with observing salt storage practices, at household and in shops. Pregnant women were interviewed by using semi structured comprehensive questionnaire, which was based on knowledge attitude, and practices about salt use pattern and awareness about IDDCP, UIE level were also estimated.

RESULTS

Prevalence of goiter was 0.17%. Many (41.12%) pregnant women had <15ppm iodine content in the salt sample and 51.58% of women had subnormal iodine uptake. Wrong salt storage practice was observed in 36.3% of households.

CONCLUSIONS

There were lacunae in Iodine deficiency control program in Chhattisgarh. Implementation and monitoring of program was weak. Thus for monitoring purpose IDD Cell & IDD Laboratory should be established at district level. This will lead to periodic assessment of Iodine Deficiency Disorders, by monitoring of Iodine intake and all other preventive, promotive as well as curative measures in the state.

Progress in antimicrobial activities of chitin, chitosan and its oligosaccharides: a systematic study needs for food applications

In recent years, active biomolecules such as chitosan and its derivatives are undergoing a significant and very fast development in food application area. Due to recent outbreaks of contaminations associated with food products, there have been growing concerns regarding the negative environmental impact of packaging materials of antimicrobial biofilms, which have been studied. Chitosan has a great potential for a wide range of applications due to its biodegradability, biocompatibility, antimicrobial activity, nontoxicity and versatile chemical and physical properties. It can be formed into fibers, films, gels, sponges, beads or nanoparticles. Chitosan films have been used as a packaging material for the quality preservation of a variety of foods. Chitosan has high antimicrobial activities against a wide variety of pathogenic and spoilage microorganisms, including fungi, and Gram-positive and Gram-negative bacteria. A tremendous effort has been made over the past decade to develop and test films with antimicrobial properties to improve food safety and shelf-life. This review highlights the preparation, mechanism, antimicrobial activity, optimization of biocide properties of chitosan films and applications including biocatalysts for the improvement of quality and shelf-life of foods.