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Objectives Determine whether the Heart Rate Variability Dysfunction score, a novel age-normalized measure of autonomic nervous system dysregulation, is associated with the development of new or progressive multiple organ dysfunction syndrome or death in critically ill children. Design, setting, and patients This was a retrospective, observational cohort study from 2012 to 2018. Patients admitted to the PICU with at least 12 hours of continuous heart rate data available from bedside monitors during the first 24 hours of admission were included in the analysis. Interventions None. Measurements and main results Heart rate variability was measured using the integer heart rate variability, which is the sd of the heart rate sampled every 1 second over 5 consecutive minutes. The Heart Rate Variability Dysfunction score was derived from age-normalized values of integer heart rate variability and transformed, so that higher scores were indicative of lower integer heart rate variability and a proxy for worsening autonomic nervous system dysregulation. Heart Rate Variability Dysfunction score performance as a predictor of new or progressive multiple organ dysfunction syndrome and 28-day mortality were determined using the area under the receiver operating characteristic curve. Of the 7,223 patients who met inclusion criteria, 346 patients (4.8%) developed new or progressive multiple organ dysfunction syndrome, and 103 (1.4%) died by day 28. For every one-point increase in the median Heart Rate Variability Dysfunction score in the first 24 hours of admission, there was a 25% increase in the odds of new or progressive multiple organ dysfunction syndrome and a 51% increase in the odds of mortality. The median Heart Rate Variability Dysfunction score in the first 24 hours had an area under the receiver operating characteristic curve to discriminate new or progressive multiple organ dysfunction syndrome of 0.67 and to discriminate mortality of 0.80. These results were reproducible in a temporal validation cohort. Conclusions The Heart Rate Variability Dysfunction score, an age-adjusted proxy for autonomic nervous system dysregulation derived from bedside monitor data is independently associated with new or progressive multiple organ dysfunction syndrome and mortality in PICU patients. The Heart Rate Variability Dysfunction score could potentially be used as a single continuous physiologic biomarker or as part of a multivariable prediction model to increase awareness of at-risk patients and augment clinical decision-making.

Objective Emergency department (ED)–initiated buprenorphine may prevent overdose. Microdosing is a novel approach that does not require withdrawal, which can be a barrier to standard inductions. We aimed to evaluate the feasibility of an ED‐initiated buprenorphine/naloxone program providing standard‐dosing and microdosing take‐home packages and of randomizing patients to either intervention. Methods We broadly screened patients ≥18 years old for opioid use disorder at a large, urban ED. In a first phase, we provided consecutive patients with 3‐day standard‐dosing packages, and then we provided a subsequent group with 6‐day microdosing packages. In a second phase, we randomized patients to standard dosing or microdosing. We attempted 7‐day telephone follow‐ups and 30‐day in‐person community follow‐ups. The primary feasibility outcome was number of patients enrolled and accepting randomization. Secondary outcomes were numbers screened, follow‐up rates, and 30‐day opioid agonist therapy retention. Results We screened 3954 ED patients and identified 94 with opioid use disorders. Of the patients, 26 (27.7%) declined participation: 10 identified a negative prior experience with buprenorphine/naloxone as the reason, 5 specifically cited precipitated withdrawal, and none cited randomization. We enrolled 68 patients. A total of 14 left the ED against medical advice, 8 were excluded post‐enrollment, 21 received standard dosing, and 25 received microdosing. The 7‐day and 30‐day follow‐up rates were 9/46 (19.6%) and 15/46 (32.6%), respectively. At least 5/21 (23.8%) provided standard dosing and 8/25 (32.0%) provided microdosing remained on opioid agonist therapy at 30 days. Conclusions ED‐initiated take‐home standard‐dosing and microdosing buprenorphine/naloxone programs are feasible, and a randomized controlled trial would be acceptable to our target population.

This paper compares two pioneering design educational approaches: the historic Bauhaus school founded in 1919 in Germany, and contemporary design thinking education, based on the example of the “HPI School of Design Thinking”. We compare both approaches according to six emerging categories: (1) curriculum, (2) multi-disciplinarity, (3) mind-set and culture, (4) study environment, (5) conditions for innovation, and (6) socio-economic context. We outline differences and similarities and discuss the possible impact for future design education.

Cigarette smoke (CS) exposure is one of the leading risk factors for human health. Nicotine-containing inhalable products, such as e-cigarettes, can effectively support tobacco harm reduction approaches. However, there are limited comparative data on the effects of the aerosols generated from electronic vapor products (e-vapor) and CS on bone. Here, we report the effects of e-vapor aerosols and CS on bone morphology, structure, and strength in a 6-month inhalation study. Eight-week-old ApoE-/- mice were exposed to aerosols from three different e-vapor formulations-CARRIER (propylene glycol and vegetable glycerol), BASE (CARRIER and nicotine), TEST (BASE and flavor)-to CS from 3R4F reference cigarettes at matched nicotine concentrations (35 µg/L) or to fresh air (Sham) (N = 10 per group). Tibiae were analyzed for bone morphology by µCT imaging, biomechanics by three-point bending, and by histological analysis. CS inhalation caused a significant decrease in cortical and total bone volume fraction and bone density relative to e-vapor aerosols. Additionally, CS exposure caused a decrease in ultimate load and stiffness. In contrast, bone structural and biomechanical parameters were not significantly affected by e-vapor aerosol or Sham exposure. At the dissection time point, there was no significant difference in body weight or tibia bone weight or length among the groups. Histological findings revealed microcracks in cortical bone areas among all exposed groups compared to Sham control. In conclusion, because of the bone-preserving effect of e-vapor aerosols relative to CS exposure, e-vapor products could potentially constitute less harmful alternatives to cigarettes in situations in which bone health is of importance.

Continuous cardiorespiratory physiological monitoring is a cornerstone of care in hospitalized children. The data generated by monitoring devices coupled with machine learning could transform the way we provide care. This scoping review summarizes existing evidence on novel approaches to continuous cardiorespiratory monitoring in hospitalized children. We aimed to identify opportunities for the development of monitoring technology and the use of machine learning to analyze continuous physiological data to improve the outcomes of hospitalized children. We included original research articles published on or after January 1, 2001, involving novel approaches to collect and use continuous cardiorespiratory physiological data in hospitalized children. OVID Medline, PubMed, and Embase databases were searched. We screened 2909 articles and performed full-text extraction of 105 articles. We identified 58 articles describing novel devices or approaches, which were generally small and single-center. In addition, we identified 47 articles that described the use of continuous physiological data in prediction models, but only 7 integrated multidimensional data (e.g., demographics, laboratory results). We identified three areas for development: (1) further validation of promising novel devices; (2) more studies of models integrating multidimensional data with continuous cardiorespiratory data; and (3) further dissemination, implementation, and validation of prediction models using continuous cardiorespiratory data. IMPACT: We performed a comprehensive scoping review of novel approaches to capture and use continuous cardiorespiratory physiological data for monitoring, diagnosis, providing care, and predicting events in hospitalized infants and children, from novel devices to machine learning-based prediction models. We identified three key areas for future development: (1) further validation of promising novel devices; (2) more studies of models integrating multidimensional data with continuous cardiorespiratory data; and (3) further dissemination, implementation, and validation of prediction models using cardiorespiratory data.

IntroductionSudden unexpected infant death (SUID) is the leading cause of death in children 28 days to 1 year of age. The study aim was to identify opportunities for healthcare professionals to provide families with education on sleep and prevention of SUID.MethodsWe performed a retrospective chart review of SUID infants over 10 years (12/2010–12/2020). The study included patients 0–12 months who presented to single institution with SUID (including asphyxia, suffocation, and SIDS). Baseline descriptive characteristics, sleep patterns (location, position, co-sleeping, presence of pillows/blankets), and prior healthcare encounters (type, duration, frequency, timing) were described.ResultsThirty-five infants met inclusion criteria. Twenty-three percent of families routinely practiced unsafe sleep, while 63% practiced unsafe sleep at the time of SUID. All unsafe sleep behaviors increased during the SUID event compared to routine, including inappropriate location (60%), co-sleeping (46%), and inappropriate position (37%) at the time of SUID. There were 54 total healthcare encounters (mean 1.5 per patient +/− 2.1) prior to SUID. Primary care physicians (57%) and NICU (29%) were the most frequent prior healthcare encounters, however visits spanned multiple specialties. Twenty-six percent had a healthcare encounter within 7 days of their death.DiscussionWe demonstrated the frequency and variability in healthcare encounters among SUID infants prior to their death. Majority of infants had prior healthcare encounters, with 26% seen by healthcare professionals within 7 days of their death. These results highlight the important role healthcare professionals across all specialties have the potential to play in educating families about safe sleep and SUID.

Background Exercise is crucial for individuals with paraplegia to reduce the risk of secondary diseases and improve independence and quality of life. However, numerous barriers such as inadequate accessibility restrict their participation in exercise programs. Digital exercise apps can help overcome these barriers. Personalization is considered a crucial feature of mobile exercise apps, as people with paraplegia have individual requirements regarding exercise programs depending on their level of impairment. Despite the increasing popularity of mobile exercise apps, there are none available that target the individual needs of this cohort. The ParaGym mobile exercise app prototype was designed to automatically tailor exercise sessions to the individual needs of users with paraplegia. Objective This study aims to evaluate the feasibility, usability, safety, and preliminary effectiveness of the ParaGym mobile exercise app prototype. Methods This pilot block-randomized controlled feasibility trial will include 45 adult participants with paraplegia. Eligible participants will be block randomized to either the intervention or waitlist control group. The intervention group will perform a 6-week exercise program using the ParaGym mobile exercise app, comprising three 35-minute exercise sessions per week. The waitlist control group will continue their usual care and receive access to the app after study completion. Participants will record all exercise sessions conducted with the app as well as additional exercise sessions conducted during the study period using exercise diaries. The primary outcomes include feasibility, usability, and safety. Feasibility will be assessed through semistructured interviews, study adherence, and retention rates. Usability will be measured using the System Usability Scale. Safety will be determined by the occurrence of adverse events. Secondary outcomes include the effects of the intervention on peak exercise capacity (VO2 peak); handgrip strength; independence, which will be measured using the Spinal Cord Independence Measure III (SCIM III); and health-related quality of life, which will be measured using the Short Form–36 Health Survey (SF-36). Results Recruitment commenced in November 2022. Overall, 12 participants were enrolled at the time of submission. Data collection commenced in January 2023, with completion expected in April 2023. Conclusions To the best of our knowledge, this is the first study to assess the feasibility, usability, and safety of an intelligent mobile exercise app for individuals with paraplegia. Thereafter, the app should be adapted according to the findings of this trial. Future trials with an updated version of the app should aim for a larger sample size, longer intervention duration, and more diverse target group. In the long term, a fully marketable version of the ParaGym app should be implemented. This would increase the access to personalized, independent, and evidence-based exercise training for this cohort and, in the future, other people who use wheelchairs. Trial Registration German Clinical Trials Register DRKS00030370; https://drks.de/search/de/trial/DRKS00030370 International Registered Report Identifier (IRRID) DERR1-10.2196/45652

Objective: to identify scientific evidence about validated educational technologies for health education for people with diabetes mellitus. Method: This is an integrative literature review, carried out in March 2021, in the databases Latin American Literature in Health Sciences, Bibliographic Data in the Nursing Area of ​​Brazil, Medical Literature Analysis and System Online and SciVerse Scopus, using the descriptors educational technology, diabetes mellitus, nursing, validation, followed by the Boolean operator AND, without time frame, resulting in 14 selected studies, which were analyzed descriptively. Results: The literature points to the use of educational technologies as devices to assist health professionals in screening for diabetes mellitus, supporting health education actions, changing health behavior, improving self-care, self-management and care the needs of clinical practice. Conclusion: validation studies for health education are little explored when related to diabetes mellitus. Objetivo: identificar evidencia científica sobre tecnologías educativas validadas para la educación en salud de personas con diabetes mellitus. Método: Se trata de una revisión integrativa de la literatura, realizada en marzo de 2021, en las bases de datos Literatura Latinoamericana en Ciencias de la Salud, Datos Bibliográficos en el Área de Enfermería de Brasil, Análisis de Literatura Médica y Sistema en Línea y SciVerse Scopus, utilizando los descriptores educativos tecnología, diabetes mellitus, enfermería, validación, seguida del operador booleano AND, sin marco temporal, resultando 14 estudios seleccionados, que fueron analizados descriptivamente. Resultados: La literatura apunta para el uso de tecnologías educativas como dispositivos para auxiliar a los profesionales de salud en el tamizaje de diabetes mellitus, apoyando acciones de educación en salud, modificando comportamientos en salud, mejorando el autocuidado, el automanejo y la atención a las necesidades de la práctica clínica. Conclusión: los estudios de validación de la educación en salud son poco explorados cuando se relacionan con la diabetes mellitus. Objetivo: identificar as evidências científicas acerca das tecnologias educacionais validadas para a educação em saúde de pessoas com diabetes mellitus. Método: Trata-se de uma revisão integrativa da literatura, realizada em março de 2021, nas bases de dados Literatura Latino-Americana em Ciências de Saúde, Dados Bibliográficos na Área de Enfermagem do Brasil, Medical Literature Analysis and System Online e SciVerse Scopus, utilizando os descritores tecnologia educacional, diabetes mellitus, enfermagem, validação, seguidas do operador booleano AND, sem recorte temporal, resultando em 14 estudos selecionados, os quais foram analisados de forma descritiva. Resultados: A literatura aponta a utilização de tecnologias educacionais como dispositivos para auxiliar o profissional de saúde no rastreio do diabetes mellitus, no suporte para ações de educação em saúde, na mudança de comportamento em saúde, no aprimoramento do autocuidado, da autogestão e no atendimento das necessidades da prática clínica. Conclusão: os estudos de validação para a educação em saúde são pouco explorados quando relacionadas ao diabetes mellitus.

This study's objective was to compare the best long-term treatment, mandibular advancement device (MAD) or continuous positive airway pressure (CPAP), for patients with mild obstructive sleep apnea (OSA) in improving excessive daytime sleepiness, fatigue, mood, sustained attention, and quality of life.This study was a single-blind, parallel, randomized clinical trial with controls. The sample was composed of individuals between 18 and 65 years of age with a body mass index of 35 kg/mOf 79 patients, 25 were in the MAD group, 31 in the CPAP group, and 23 in the control group. Polysomnographic parameters were best normalized with CPAP compared with MAD. Fatigue was improved in the MAD and CPAP groups, with no difference between these treatments. Quality of life was also improved with both treatments, but CPAP was superior to MAD. Daytime sleepiness, mood, and sustained attention showed no difference with the interventions. Greater adherence was obtained with MAD patients than with CPAP measured by hours of use.Treatment with CPAP was better at normalizing polysomnographic parameters and improving quality of life in patients with mild OSA. Both treatments improved fatigue with no difference between the two treatments. Neither treatment improved daytime sleepiness, mood or sustained attention.NTC01461486.

IntroductionMultiple organ dysfunction (MOD) is a common pathway to morbidity and death in critically ill children. Defining organ dysfunction is challenging, as we lack a complete understanding of the complex pathobiology. Current pediatric organ dysfunction criteria assign the same diagnostic value—the same “weight”— to each organ system. While each organ dysfunction in isolation contributes to the outcome, there are likely complex interactions between multiple failing organs that are not simply additive.ObjectiveDetermine whether certain combinations of organ system dysfunctions have a significant interaction associated with higher risk of morbidity or mortality in critically ill children.MethodsWe conducted a retrospective observational cohort study of critically ill children at two large academic medical centers from 2010 and 2018. Patients were included in the study if they had at least two organ dysfunctions by day 3 of PICU admission based on the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) criteria. Mortality was described as absolute number of deaths and mortality rate. Combinations of two pediatric organ dysfunctions were analyzed with interaction terms as independent variables and mortality or persistent MOD as the dependent variable in logistic regression models.ResultsOverall, 7,897 patients met inclusion criteria and 446 patients (5.6%) died. The organ dysfunction interactions that were significantly associated with the highest absolute number of deaths were cardiovascular + endocrinologic, cardiovascular + neurologic, and cardiovascular + respiratory. Additionally, the interactions associated with the highest mortality rates were liver + cardiovascular, respiratory + hematologic, and respiratory + renal. Among patients with persistent MOD, the most common organ dysfunctions with significant interaction terms were neurologic + respiratory, hematologic + immunologic, and endocrinologic + respiratory. Further analysis using classification and regression trees (CART) demonstrated that the absence of respiratory and liver dysfunction was associated with the lowest likelihood of mortality.Implications and Future DirectionsCertain combinations of organ dysfunctions are associated with a higher risk of persistent MOD or death. Notably, the three most common organ dysfunction interactions were associated with 75% of the mortality in our cohort. Critically ill children with MOD presenting with these combinations of organ dysfunctions warrant further study.

This paper is based on empirically revealed doubts on the universal preference of the golden ratio proportion. An empirical study has been conducted in order to examine differences about ‘preferences of proportions’ on the golden ratio between South Korean and Western preceding studies by Kimberly Elam’s “Geometry of Design: Studies in Proportion and Composition”. Proportions are determined by mathematical logic, however ‘preferred proportions’ arise from cultural influences and experience. The research was conducted with two hundred subjects between the ages of twenty to thirty in Korea, with questions that showed ten choices of different proportions of rectangles. The data of comparisons clearly revealed that Korean had a preference to root proportion (1:1.414). These results obviously contradict previous studies conducted in the Western culture showed preferences of the golden ratio (1:1.618) (Benjafield, 1979, 2010; Pittard, 2007). The aspect of the results will provide deeper insights of the influence of the design process in specifically on the design form. The paper continues to examine and introduce various Korean traditional and modern objects, architectural structures that exemplify the research results. The paper concludes that various examples of root proportions can be found in Korean design environment showing a Korean preference for root ratio reflecting the here presented results.

When facing a design problem, both novice and expert designers tend to rely on a variety of available sources to get inspired during idea generation. Therefore, searching for and collecting diverse stimuli during the early phases of the design process is considered a well-known practice amongst designers. Despite this general assumption, there is no clear empirical evidence on how novice or expert practitioners get inspired, their preferences on various material sources, or how they value such potential resources. A questionnaire for novice and expert designers was developed in order to better understand these issues. The findings indicate that novices and experts alike tend to look for existing design solutions that resemble the problem(s) at hand, potentially neglecting more abstract and distant information. The results suggest that the designers in this survey show a tendency to not fully explore a number of available resources, ultimately leading to hindrances in their creative processes. Further results of this study uncover interesting information strategies of designers which should be considered when developing creative approaches in design education.

This paper presents an empirical study, which was conducted in order to identify how designers deliver value in designing across different disciplines. Data collected during periods of observation provide insight into the characteristics and behavior of designers sharing the same working environment in three design disciplines, established in Graphic design, Architecture and Engineering. The present study reports findings on how designers’ deliver value in collaborative meetings. The study is based on the mapping and analysis of instances of value judgment during the meetings for the design of an exhibition, a train interface and a robot. Results show similarities but also differences on the iteration and interdependency of the instances of value judgment across the three cases. We integrated the results by developing an inductive procedure of interaction during instances of value judgment in decision-making in design meetings.

This paper presents an empirical study, which was conducted in order to identify how designers deliver value in designing across different disciplines. Data collected during periods of observation provide insight into the characteristics and behavior of designers sharing the same working environment in three design disciplines, established in Graphic design, Architecture and Engineering. The present study reports findings on how designers��� deliver value in collaborative meetings. The study is based on the mapping and analysis of instances of value judgment during the meetings for the design of an exhibition, a train interface and a robot. Results show similarities but also differences on the iteration and interdependency of the instances of value judgment across the three cases. We integrated the results by developing an inductive procedure of interaction during instances of value judgment in decision-making in design meetings.

Design is inherently uncertain. Therefore – aiming to support the designer - it is important to know how expert and novice designers deal with uncertainty. Historically, design methods have been proposed as a way for designers to solve complex and complicated problems systematically, thus reducing uncertainty. But do designers use methods like this? In this paper, we describe a study, which aimed to investigate how designers experience uncertainty in a design planning activity under time pressure. We assessed the design behavior of experts (more than 10 years of experience in practice) and advanced beginners (between 1 and 3 years of experience in practice). The results suggest that designers – novices and experts - articulate different purposes for the use of methods that go beyond the use of method as systematic instructions.

The theoretical understanding of design knowledge is a crucial concern for research in the design discipline. This article extends the rich existing research on design knowledge by providing a unifying model of design knowledge. The insights are derived from a rigorous review of existing literature. The resulting model presents an original framework of design knowledge that can help practitioners, scholars, and educators from the design discipline to better understand the characteristics of design knowledge and the possibilities for transferring it.

O presente estudo tem por objetivo de mapear as evidências científicas nacionais e internacionais sobre as propriedades da planta Anredera cordifolia no processo terapêutico das Doenças Crônicas Não Transmissíveis.

Objetivo: identificar as evidências científicas acerca das tecnologias educacionais validadas para a educação em saúde de pessoas com diabetes mellitus. Método: Trata-se de uma revisão integrativa da literatura, realizada em março de 2021, nas bases de dados Literatura Latino-Americana em Ciências de Saúde, Dados Bibliográficos na Área de Enfermagem do Brasil, Medical Literature Analysis and System Online e SciVerse Scopus, utilizando os descritores tecnologia educacional, diabetes mellitus, enfermagem, validação, seguidas do operador booleano AND, sem recorte temporal, resultando em 14 estudos selecionados, os quais foram analisados de forma descritiva. Resultados: A literatura aponta a utilização de tecnologias educacionais como dispositivos para auxiliar o profissional de saúde no rastreio do diabetes mellitus, no suporte para ações de educação em saúde, na mudança de comportamento em saúde, no aprimoramento do autocuidado, da autogestão e no atendimento das necessidades da prática clínica. Conclusão: os estudos de validação para a educação em saúde são pouco explorados quando relacionadas ao diabetes mellitus.

Objective: Re-hospitalization after sepsis can lead to impaired quality of life. Predictors of re-hospitalization could help identify sepsis survivors who may benefit from targeted interventions. Our goal was to determine whether low heart rate variability (HRV), a measure of autonomic nervous system dysfunction, is associated with re-hospitalization in pediatric septic shock survivors.Materials and Methods: This was a retrospective, observational cohort study of patients admitted between 6/2012 and 10/2020 at a single institution. Patients admitted to the pediatric intensive care unit with septic shock who had continuous heart rate data available from the bedside monitors and survived their hospitalization were included. HRV was measured using age-normalized z-scores of the integer HRV (HRVi), which is the standard deviation of the heart rate sampled every 1 s over 5 consecutive minutes. The 24-h median HRVi was assessed on two different days: the last 24 h of PICU admission (“last HRVi”) and the 24-h period with the lowest median HRVi (“lowest HRVi”). The change between the lowest and last HRVi was termed “delta HRVi.” The primary outcome was re-hospitalization within 1 year of discharge, including both emergency department encounters and hospital readmission, with sensitivity analyses at 30 and 90 days. Kruskal-Wallis, logistic regression, and Poisson regression evaluated the association between HRVi and re-hospitalizations and adjusted for potential confounders.Results: Of the 463 patients who met inclusion criteria, 306 (66%) were re-hospitalized, including 270 readmissions (58%). The last HRVi was significantly lower among re-hospitalized patients compared to those who were not (p = 0.02). There was no difference in the lowest HRVi, but patients who were re-hospitalized showed a smaller recovery in their delta HRVi compared to those who were not re-hospitalized (p = 0.02). This association remained significant after adjusting for potential confounders. In the sensitivity analysis, a smaller recovery in delta HRVi was consistently associated with a higher likelihood of re-hospitalization.Conclusion: In pediatric septic shock survivors, a smaller recovery in HRV during the index admission is significantly associated with re-hospitalization. This continuous physiologic measure could potentially be used as a predictor of patients at risk for re-hospitalization and lower health-related quality of life.