Search

Meaningful engagement is a key dimension of quality of life among persons living with dementia, yet little is known about how to best to promote it. Guided by grounded theory methods, we present analysis of data collected over a 1-year period in four diverse assisted living (AL) communities as part of the study, “Meaningful Engagement and Quality of Life among Assisted Living Residents with Dementia.” Our aims are to: (a) learn how meaningful engagement is negotiated among AL residents with dementia and their care partners; and (b) identify how to create these positive encounters. Researchers followed 33 residents and 100 care partners (formal and informal) and used participant observation, resident record review, and semi-structured interviews. Data analysis identified “engagement capacity” as central to the negotiation of meaningful engagement. We conclude that understanding and optimizing the engagement capacities of residents, care partners, care convoys, and settings, are essential to creating and enhancing meaningful engagement among persons living with dementia.

Nurses are an integral part of the multidisciplinary team caring for a patient eligible for endovascular thrombectomy. Their care includes obtaining health history, performing clinical assessments, using critical thinking to anticipate the care path, and communicating findings to other team members. The prehospital and emergency department nurses utilize stroke severity scales to identify a possible thrombectomy candidate and help expedite intervention. In the interventional laboratory, nursing collaborates with radiology technologists and interventionalists to ensure patient safety and monitor for intraprocedural complications. Post-procedure, the intensive care nurse delivers complex care to ensure optimal neurological outcome and assess for postprocedural complications. Nursing is essential in every phase of care along with collaboration with other disciplines.

Background: We sought to determine and validate a pre-reperfusion blood pressure threshold for MCA occlusions patients with better thrombectomy outcomes. Methods: We reviewed patients from 2013 to 2015 treated with thrombectomy for a MCA M1 occlusion at our center. Blood pressure measurements from available records at the time of EMS activation to the time of reperfusion were used to calculate an averaged pre-reperfusion mean arterial pressure (MAP). All patients in our analysis had successful reperfusion. Our endpoint was a mRS ≤2 at 90 days. The averaged MAP was grouped as follows: ≥85mmHg, ≥90mmHg, ≥95mmHg, ≥100mmHg, ≥110 mmHg and ≥115mmHg. We considered hourly epochs from symptom onset to reperfusion, pre-treatment ASPECTS, thrombolytics, and collateral status. Significant parameters from a univariate analysis were included into a multivariate logistic regression to determine independent predictors of outcome. The multivariate findings were then validated with a prospective set of similar patients evaluated with our mobile stroke treatment unit. Results: We reviewed 52 patients. Mean age was 70; NIHSS was 16±6; 40% (21) received t-PA; median ASPECTS score was 10; TICI 3 score was achieved in 63% (33), and 67% (35) had a good outcome. The number of patients having a mean arterial blood pressure threshold were as follows: ≥85mmHg (96%), ≥90mmHg (83%), ≥95mmHg (73%), ≥100mmHg (58%), ≥110mmHg (31%) and ≥115mmHg (15%). Reperfusion occurred as follows: ≤3hrs (4%), ≤4hrs (21%), ≤5hrs (39%), ≤6hrs (52%), ≤7hrs (67%), ≤8hrs (79%), ≤9hrs (87%), and ≤12hrs (90%). Our multivariate logistic regression model identified an average pre-reperfusion MAP ≥95mmHg as the sole factor statistically associated with a better outcome post successful thrombectomy [OR 15.1, CI 1.3-170.1,p=0.02]. Good clinical outcome in those patients with an averaged MAP ≥95mmHg was 76% and 43% in those below the threshold [OR 5.2, p=0.02]. Our validation cohort consisted of 32 patients, and a pre-reperfusion averaged MAP ≥ 95 mmHg had a sensitivity of of 93% for a good outcome. Conclusion: Our analysis suggests with validation that a pre-reperfusion averaged MAP ≥ 95mmHg results in better outcomes with successful thrombectomy and may be used as a therapeutic target in the pre-hospital setting.

Title: Effect of hypertension on clinical recovery after stroke thrombectomy Objective: Our goal was to identify what vascular risk factors for stroke affect outcomes after mechanical thrombectomy. Methods: We retrospectively reviewed stroke thrombectomy patients at our comprehensive stroke center from June 2013 to August 2016. Patients were determined to have atrial fibrillation, hypertension, diabetes, or hyperlipidemia based on historical information pre-treatment or based on hospital records during their index hospitalization. All patients in our series achieved recanalization after thrombectomy defined as a Thrombolysis in cerebral infarction (TICI) score of 2b or higher. Our endpoint was mild to moderate disability at 90 days defined by the modified Rankin Scale (mRS) score of 2 or less. We performed a univariate analysis on the above covariates affecting clinical outcome and studies all variables with a p-value of < 0.2 in a multivariate analysis to determine which independent variables affected outcome. Multi-variate analyses were performed separately for males and females. Results: We reviewed 288 stroke patients that underwent thrombectomy. The mean age was 69±15; NIHSS was 17±6; 36% (104 of 288) received t-PA and 42% (121 of 288) had a modified Rankin Score of < 2. 42.7% (123 of 288) were females. From the entire group, 47.5% (137 of 288) had atrial fibrillation, 29% (83 of 288) had diabetes mellitus 68% (197 of 288) had hypertension, 38.5% (111 of 288) had hyperlipidemia and 16% (47 of 288) had a history of tobacco smoking. After considering positive univariates from above, our multivariate logistic regression model identified that not having hypertension [ OR 2.32, CI 1.01-5.41, p=0.05 ] predicted better outcome post thrombectomy procedure for males after a successful recanalization. Conclusion: Our analysis suggests that, for males, the odds of a positive outcome after a successful thrombectomy procedure is positively influenced when the patient is not hypertensive. No traditional risk factor appeared to influence the outcome in females. Further prospective study is required to validate these findings.

Diagnosis of oesophageal adenocarcinoma, or Barrett’s oesophagus, a pre-malignant condition associated with an increased risk of the adenocarcinoma, currently requires expensive and invasive endoscopy-biopsy procedures, which are often only performed when obvious symptoms have manifested (usually at a late stage of the disease). A targeted mass spectrometry-based method was developed to analyse serum samples for oesophageal adenocarcinoma. Panels of lectin-pulled down serum protein biomarkers were identified that correlate with the presence of early stage oesophageal adenocarcinoma (high grade dysplasia). The method was automated and optimised the methodology to measure 33 target peptides in the lectin pulldown in a short 20 minute mass spectrometry run. Analysis of an initial cohort (n = 50) shows the method to be robust and reproducible with an average intraday CV of 9.3% across the 33 peptides and an average interday CV of 11.5%. A larger cohort (n = 266) showed consistent results and was used to build statistical models which distinguished between disease status, using protein biomarker measurements and simple clinical parameters. Several models achieved good discrimination with AUROC values ranging from 0.89–0.97. Model validation was undertaken in the smaller cohort, with the two best performing models achieving AUROC values of 0.82 and 0.87. The assay has the potential to produce a clinically viable diagnostic test to support screening and early detection in populations at high risk of oesophageal adenocarcinoma and Barrett’s oesophagus.

This paper presents the cyclic deformation behaviour and fatigue properties of a wire + arc additive manufactured Ti-6Al-4V alloy in the as built condition under strain-controlled test condition. Higher local energy input used to build the material has resulted in a coarser primary columnar β grain structure along with a coarser α microstructure compared to Ti-6Al-4V alloys produced by other additive manufacture processes. Test specimens were manufactured in horizontal and vertical orientations with respect to the deposited layers. Isotropic fatigue property was observed at lower applied strain values. When the strain amplitude was above 0.6%, the vertical samples, where the loading axis was parallel with the primary columnar β grains, showed marginally higher fatigue life owing to the material being more ductile in this direction. Moreover, higher cyclic softening rate by a factor of two was measured in the vertical samples. No porosity defects were found in the material. Cracks were initiated from either the α laths or α/β interface due to cyclic slip localisation.

Aims Length of hospital stay for colorectal patients can be prolonged by stoma training. This study explores the impact of 2 variables on time to stoma competency; day of the week that surgery is performed and whether stoma education was available at the weekends. Methods Retrospective review of a prospectively maintained stoma database identified all patients who had a GI tract stoma formed between 1st January and 31st December 2020. Demographics, operative details and time to stoma competence data was collated. Results 158 patients had a stoma formed. Mean age was 59 years (range 13 – 94). Conclusions Time to stoma competence was shorter when stoma education was available at the weekends, despite similar numbers of reviews being provided. This suggests that length of hospital stay could be reduced for this cohort by providing stoma education 7 days a week. The day that surgery was performed did not have a clear impact on time to stoma competence.

BACKGROUND A change in the pupillary light reflex (PLR) is a sensitive indicator for detecting expanding intracranial lesions. Changes in PLR may be a prognostic marker for patients with intracranial lesions. The purpose of this analysis was to explore how PLR readings, size, constriction velocity (CV), dilation velocity (DV), Neurologic Pupil Index (NPi), and latency predict clinical outcome in patients with subarachnoid hemorrhage. METHODS This is a secondary analysis of prospectively collected multicenter registry data. The within-subject standard deviation (WSD) of PLR values, NPi, size, CV, DV, and latency were explored as predictors of discharge modified Rankin Scale (mRS) in patients with subarachnoid hemorrhagic. RESULTS Among 4403 pupillary readings from 82 patients with a diagnosis of subarachnoid hemorrhage, with a mean age of 57.7 years, the admission Glasgow Coma Scale median score was 14 (eye, 4; verbal, 4; motor, 6), and the mRS median was 0 on admission and 4 at discharge. Correlation between standard deviation of PLR values and discharge mRS was moderate and negative (r = -0.3 to -0.47, P < .01). The standard deviations for NPi, size, CV, and DV were significant for predicting discharge mRS (r = 0.23-0.28, P < .05) after controlling for admission Glasgow Coma Scale. CONCLUSION Patients with higher WSD PLR values showed better outcomes (ie, lower mRS at discharge), suggesting that patients with narrower WSD PLR are at a higher risk for poor outcomes.

Kidney failure is frequently observed during and after COVID-19, but it remains elusive whether this is a direct effect of the virus. Here, we report that SARS-CoV-2 directly infects kidney cells and is associated with increased tubule-interstitial kidney fibrosis in patient autopsy samples. To study direct effects of the virus on the kidney independent of systemic effects of COVID-19, we infected human induced pluripotent stem cell-derived kidney organoids with SARS-CoV-2. Single cell RNA-sequencing indicated injury and dedifferentiation of infected cells with activation of pro-fibrotic signaling pathways. Importantly, SARS-CoV-2 infection also led to increased collagen 1 protein expression in organoids. A SARS-CoV-2 protease inhibitor was able to ameliorate the infection of kidney cells by SARS-CoV-2. Our results suggest that SARS-CoV-2 can directly infect kidney cells and induce cell injury with subsequent fibrosis. These data could explain both acute kidney injury in COVID-19 patients and the development of chronic kidney disease in Long-COVID., Graphical Abstract, Jansen, Reimer, Nagai et al report that SARS-CoV-2 infects kidney cells and is associated with kidney fibrosis in patients. Using single cell transcriptomics of infected kidney organoids, they show that SARS-CoV-2 causes kidney injury and stimulates pro-fibrotic signaling. Viral infection in organoids was inhibited by a recently developed protease blocker.

During the COVID-19 pandemic, restrictions on reimbursement for telehealth visits were lifted and this visit type was suddenly available to patients around the United States of America. Telehealth visits offer potential cost savings for patients and families, which may vary by region of the world studied. Also, aggressiveness of the care patients receive may differ, and patients or families may be more likely to choose one visit type over another based on seizure control. This is a prospective face-to-face clinic versus telehealth clinic visit comparison study involving patients with seizures, their legal guardians, and caretakers who attend clinic. We compared travel distance, work-related factors, childcare, satisfaction of care, changes in seizure medication or diagnostics tests ordered, and willingness to cancel appointments to better understand the behavioral patterns of patients, caretakers, and providers. Our results indicate that many patients and families still prefer in-person interactions with their medical providers. Patient and family satisfaction levels were equal with both visit types. No significant difference was seen in medical management between face-to-face and telehealth visits. Also, prior seizure control did not dictate the type of visit chosen. Telehealth participants were significantly more willing to cancel appointments if asked to switch to face-to-face then face-to-face participants asked to complete telehealth visits. Surprisingly, we found that patients and families choosing telehealth were not statistically more likely to be employed or take less time off work. Also, distance from home to office was not significantly shorter for participants choosing face-to-face visits. Offering a combination of telehealth and face-to-face visits appears to be the optimal strategy in caring for patients with controlled and uncontrolled seizure disorders to ensure adherence with clinic visits and satisfaction with care. Our study suggests that providers are equally willing to adjust medications or order additional diagnostic testing regardless of visit type. Patients and families may be less likely to cancel telehealth visits than face-to-face visits; this finding may translate to improved seizure control and long-term decreased cost of care.

To enhance nursing staff retention and ensure a consistently high standard of care, a study was conducted to determine an appropriate nurse staffing model for a neurocritical care unit. In addition to being critically ill, these patients often require extensive diagnostic testing to determine treatment. Nurses traveling with patients leave higher nurse-patient ratios remaining on the unit.Prospective observation was used to assess relationships between neurologic assessment, documentation, and the amount of time spent traveling with patients. Patient acuity and nursing experience were also measured.Over the 30-day study period, more than 226 hours were spent traveling, equivalent to approximately 38% of a single nurse's shift. There was no correlation between the experience of nurses and the time necessary to perform a neurologic assessment. When controlling for acuity, a relationship was found between nursing experience and the time needed to chart an assessment.Significant time was spent every day off the floor, in addition to the documentation and performance of frequent assessments. These results advocate for a staffing position without a dedicated patient assignment but to assist with traveling and high-acuity patients so that safe and attentive care can be consistently given.

This ethnographic case study explored how children build and use working theories in play (Hill, 2015), specifically theories about existential matters of life, death and dying, human nature, and the social, physical and natural world. The concepts of funds of knowledge and interests are integrated to theorise children's agency and competence in how they collectively build working theories. This conceptualisation reflects contemporary socio-cultural theories in which peer cultures, relationships and interactions are central to play and learning, with interaction conceived as multimodal, encompassing artefacts, embodiment and affect. Data is presented from research conducted with children age 4–6 (Hill, 2015), using videotaped episodes of their ‘Dead Forever’ play, and post-video discussions with children and parents. Findings indicate that children's interests and working theories are sources of knowledge in peer-led learning, as evidenced in the social, cognitive, cultural and affective content of their play. We propose a complex understanding of play and learning within child-led Zones for Proximal Development. The extent to which children's interests and working theories are understood by teachers to connect with curriculum goals is problematized in the context of contemporary ECE frameworks.

The field of neurointerventional radiology (NIR) therapy, including acute ischemic stroke intervention, endovascular intracranial aneurysm management, and treatment of intra- and extracranial large-vessel disease, has evolved over the past 18 years. To support this specialized advanced care requires nursing standards of care for staff to provide direct patient care in NIR suites and intensive management of this high-risk patient population. The intent of this paper is to provide a complementary document for the Stroke Interventional Laboratory Consensus (SILC) statement that will specifically address the nursing standards of care for patients in an NIR suite.

Targeted temperature management (TTM) is often used in neurocritical care to minimize secondary neurologic injury and improve outcomes. TTM encompasses therapeutic hypothermia, controlled normothermia, and treatment of fever. TTM is best supported by evidence from neonatal hypoxic-ischemic encephalopathy and out-of-hospital cardiac arrest, although it has also been explored in ischemic stroke, traumatic brain injury, and intracranial hemorrhage patients. Critical care clinicians using TTM must select appropriate cooling techniques, provide a reasonable rate of cooling, manage shivering, and ensure adequate patient monitoring among other challenges. The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacotherapy to form a writing Committee in 2015. The group generated a set of 16 clinical questions relevant to TTM using the PICO format. With the assistance of a research librarian, the Committee undertook a comprehensive literature search with no back date through November 2016 with additional references up to March 2017. The Committee utilized GRADE methodology to adjudicate the quality of evidence as high, moderate, low, or very low based on their confidence that the estimate of effect approximated the true effect. They generated recommendations regarding the implementation of TTM based on this systematic review only after considering the quality of evidence, relative risks and benefits, patient values and preferences, and resource allocation. This guideline is intended for neurocritical care clinicians who have chosen to use TTM in patient care; it is not meant to provide guidance regarding the clinical indications for TTM itself. While there are areas of TTM practice where clear evidence guides strong recommendations, many of the recommendations are conditional, and must be contextualized to individual patient and system needs.

The author examines how immigrant networks and labor segmentation by race and gender facilitate inequality in immigrant-owned restaurants. The author conducted three months of participant observation at an immigrant-owned restaurant and supplemental interviews with 18 workers and owners at similar restaurants in Austin, Texas. Labor segmentation by gender and race resulted in varied degrees of wage inequality, surveillance, and exposure to hazardous working conditions. Also, although ethnic networks among workers offer benefits, embedded in these networks are unwritten rules of obligation, gift giving, and repayment. Shared ethnicity or identity as immigrants did not prevent immigrant owners from exploiting workers of the same ethnicity and other immigrant workers. Ultimately, the author argues that ethnic networks are embedded in the larger economy and context of racial-ethnic hierarchies. This research sheds light on everyday interactions among Asian immigrant restaurant owners and workers. The author highlights how an uncritical focus on the benefits of ethnic networks obscures constraints in social networks.

This paper describes strain controlled fatigue testing of a titanium Ti-6Al-4V alloy, additive manufactured by “electron beam melting” (EBM). The EBM material is manufactured in two conditions; with no post-manufacture heat treatment (“As-Built”) and after a hot isostatic pressing (HIP) treatment. The EBM HIP treatment condition is manufactured in three build orientations; vertical, horizontal and at 45°. The fatigue test results for these EBM material conditions are compared with those for similar titanium Ti-6Al-4V alloy powder, manufactured by powder metallurgy hot-isostatic pressing (PM HIP), and for similar titanium Ti-6Al-4V alloy manufactured by traditional wrought mill into bar and sheet material.

The pupillary light reflex (PLR) describes the response when light hits the retina and sends a signal (cranial nerve II) to the Edinger-Westphal Nucleus which via cranial nerve III results in pupillary constriction. The Neurological Pupil indexTM (NPi) and pupil constriction velocity (CV) are two distinct variables that can be observed and measured using a pupillometer. We examine NPi and CV in 27,462 pupil readings (1,617 subjects). NPi values

The National Trust owns and opens to the public historic houses containing an enormous quantity and range of decorative arts. Conserving these features in ways that enhance visitors' enjoyment through their experience of the conservation work is now as important an objective of conservation in the National Trust as improving these features' state of conservation. This paper takes as an example the conservation of the early eighteenth-century Baroque wall paintings decorating the staircase of Hanbury Hall (Worcestershire, UK) which presented considerable challenges not only in conservation but also in enabling the visiting public to experience the work. Evaluation of visitors' response is presented and discussed in the context of evaluations of other ‘conservation in action’ projects across the National Trust.

External ventricular drain (EVD) placement is a common practice in neurocritical care units. The EVDs are the "gold" standard and the most cost-effective treatment for intracranial hypertension and hydrocephalus caused by a variety of neurological conditions. The EVD drains excess cerebrospinal fluid in an attempt to maintain balance within the cranial vault and provides intermittent monitoring of intracranial pressure. This invasive procedure, as with any other procedures, carries an increased risk of a device-related infection that can lead to devastating consequences such as meningitis, ventriculitis, and death. This article will discuss how Riverside Methodist Hospital, which is located in Central Ohio, identified an increase in the rate of EVD infections in 2007 and responded with changes in procedure and processes. The implementation of the improvement plan has resulted in 25 months without an EVD infection, a triumph for the patients, staff, and the hospital system.

PurposeThe purpose of this paper is to examine an audit that was performed of all patients referred to a liaison psychiatry inpatient consultation service which sought to establish a baseline for demographics, type of referral, and management of referrals, with a view to introducing improved evidence‐based treatments. It also aims to examine timeliness of response to referrals benchmarked against published standards.Design/methodology/approachAll inpatient referrals to a liaison psychiatry service were recorded over a six‐month period, including demographics, diagnosis, management and timeliness of response to referrals. The data were retrospectively analysed and compared against international standards.FindingsA total of 172 referrals were received in the six months. Commonest referral reasons included assessments regarding depressive disorders (23.8 per cent), delirium/other cognitive disorders (19.2 per cent), alcohol‐related disorders (18.6 per cent), anxiety disorders (14.5 per cent), and risk management (12.2 per cent). Evidence‐based practices were not utilised effectively for a number of different types of presentations. A total of 40.1 per cent of referrals were seen on the same day, 75.4 per cent by the end of the next day, and 93.4 per cent by the end of the following day.Practical implicationsUse of a hospital protocol for management of delirium may improve outcomes for these patients. Evidence‐based techniques, such as brief intervention therapies, may be beneficial for referrals involving alcohol dependence. Referrals were seen reasonably quickly, but there is room for improvement when compared with published standards.Originality/valueThis paper provides valuable information for those involved in management of liaison psychiatry consultation services, providing ideas for development and implementation of evidence based practices.

BACKGROUND Conducting research on the work outcomes of first episode psychosis (FEP) samples may extend our understanding of the factors associated with the work outcome of people with schizophrenia and other psychotic illnesses. OBJECTIVE To conduct a detailed study of the work outcome of an FEP sample. METHODS Members of a FEP cohort, who had completed a 12-year clinical outcome assessment, were invited to participate in an adjunctive work outcome study. Engagement in paid and non-paid work was first established and the relationship with potentially influential baseline characteristics investigated. Subsequently the influence of work outcome to participants' level of quality of life, mental health, recovery, and social inclusion were examined. RESULTS Among the 38 participants the mean percentage of time spent in work was 62% of which 50% was in paid work and 12% was in non-paid work. Being employed at inception was the only independent predictor of the duration of the follow-up period spent in work. Relationships between work outcome and all measures of wellbeing were found. CONCLUSION The paid and non-paid work attained by people affected by a psychotic illness played an important role in the extent of their wellbeing, recovery, and social inclusion.

Proton magnetic resonance spectroscopy (1H MRS) is a noninvasive technique, important for investigating metabolic changes occurring in the nervous system as a result of pathology. Recent technical advances have improved spinal cord 1H MRS feasibility for preclinical and clinical studies, despite its technical challenges. This chapter will focus on the use of 1H MRS in the spinal cord in preclinical and clinical studies. We will first discuss the importance of using spinal cord 1H MRS to obtain insights into the metabolic abnormalities of neurological illnesses. We will then review the methodological challenges of this technique, followed by a brief overview of disease “models” to illustrate 1H MRS applications in spinal cord for preclinical and clinical research, including the following: multiple sclerosis, spinal cord injury, tumor, and amyotrophic lateral sclerosis. Finally, we will highlight future opportunities.

Este documento propone herramientas para profesoras/es de la educación superior interesadas/os en realizar la transversalización de género desde una perspectiva interseccional. Planteamos que las y los educadores deben empezar su camino hacia una pedagogía no discriminatoria analizando sus propias prácticas y presuposiciones - en la clase y fuera de ella - para poder evaluar y transformar sus creencias y pedagogías, con el objetivo de encontrar una forma de aprender y de enseñar más crítica, política, personal y democrática; que avance en el objetivo de eliminar desigualdades basadas en género y otras diferencias. Este artículo incluye herramientas y estrategias para los ámbitos educativos, institucionales y personales, con la idea que deben ser trabajados de manera integral para generar cambios reales

Aim Correct identification of the protein that is causing amyloidosis is crucial for clinical management. Current standard laboratory methods have limited ability to detect the full range of amyloid forming proteins. We assessed the diagnostic value of LCM-MS/MS, which combines specific sampling of amyloid deposits by LCM with protein identification by MS/MS. Methods Biopsy specimens were referred to the Princess Alexandra Hospital Amyloidosis Centre. For all specimens, 10µm sections of formalin-fixed paraffin embedded tissue were stained with Congo Red using a standard technique. LCM was performed using an Arcturus XT instrument with an infrared capture laser. Proteins were extracted with FFPE Protein Extraction Solution (Agilent Technologies), digested with trypsin and peptides were analysed by nano-liquid chromatography-coupled MS/MS using an Agilent Chip CUBE-QTOF. Database searching was performed using Spectrum Mill (Agilent) with the NCBInr human protein database. Results Biopsies were received on 136 patients: there was insufficient tissue in the block in 7, repeat LCM was required in15 cases and no amyloid forming protein was identified in 8. In 121/136 (89%) an amyloid forming protein was identified. Proteins identified included immunoglobulin light chain (localised amyloid n=25, systemic AL n=45), immunoglobulin heavy chain (AH n=6), transthyretin (senile amyloid n=25, hereditary ATTR n=6), serum amyloid A (AA n=7), fibrinogen alpha chain (AFib n=2), LECT2 (ALect2 n=2), TGFb (corneal lattice amyloid n=1) and semenogelin (seminal vesicle amyloid n=2). It was not infrequent, particularly in cases of localised amyloidosis (>80% of cases), for smaller amounts of other amyloid forming proteins to be present especially immunoglobulins, transthyretin and ApoA1 (Table 1). This suggests that these inherently amyloidogenic proteins are capable of integrating within the amyloid deposit. An amyloid proteomic signature as previously defined by the Mayo Clinic (at least two of SAP, ApoE and ApoA4; Haematologica 2014;99(7):1239) was present in 76% of cases and was more likely to be found if larger amounts of amyloid could be dissected (p=0.0001). In terms of clinical impact, amyloid typing by immunohistochemical stains had been attempted in 87 cases and reported as diagnostic in 39. Five of these were subsequently revealed by proteomic analysis to be incorrect. Overall, the clinical diagnosis of amyloid subtype was altered by proteomic analysis in 24% of cases. Conclusion. LCMMS/MS identifies an amyloid forming protein in ~90% of clinical biopsy samples. Amyloid deposits often contain small amounts of other amyloid forming proteins which may reflect not just contamination but co-deposition of fibrils due to a shared beta pleated sheet conformation. Because of this, results need to be interpreted in the context of full clinical information to enable correct diagnosis of amyloid subtype. Table 1. LCM-MS/MS results Amyloidosis subtype AL-lambda AL-kappa AH Localised lambda Localised kappa ATTRwt ATTRmut AA Number of subtype cases 32 13 5 16 9 25 6 7 Amyloid forming proteins Lambda light chain 32 16 1 2 Kappa light chain 4 13 2 5 9 4 1 Ig heavy chain 8 5 6 6 4 1 3 Transthyretin 1 3 3 25 6 ApoA1 2 3 7 3 SAA 7 Fibrinogen alpha chain 2 1 2 1 Lysozyme 1 1 1 Cases with low levels of 2nd amyloid forming protein 34% 46% 40% 81% 89% 20% 17% 57% Amyloid associated proteins ApoE 21 12 2 16 7 19 6 5 SAP 16 8 13 6 24 6 4 ApoA4 23 10 1 16 8 22 6 2 Amyloid proteomic signature 63% 77% 0% 100% 78% 92% 100% 57% Disclosures Mollee: Onyx: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

Using industry leading methods and software products, this article explores the potential for health risk adjustment in the Department of Defense (DoD) Military Health System. From an epidemiologic perspective, the study assesses whether DoD populations enrolled to and served by different provider groups exhibit sufficient variation in risk to justify changes in resource allocation, such as staffing, services, and facility modification. In addition, the study investigates whether systematic differences in risk exist between TRICARE enrollees and commercially insured enrollees. Given the interest of the DoD in managed care, risk prediction tools are shown to project future risk for individuals with sufficient accuracy to justify development of disease management programs for patients with chronic conditions. Analyses demonstrate that Military Health System data support industry requirements to perform risk grouping among a random sample of 200,000 enrollees selected from 495,941 eligible enrollees.

Este documento propone herramientas para profesoras/es de la educación superior interesadas/os en realizar la transversalización de género desde una perspectiva interseccional. Planteamos que las y los educadores deben empezar su camino hacia una pedagogía no discriminatoria analizando sus propias prácticas y presuposiciones - en la clase y fuera de ella - para poder evaluar y transformar sus creencias y pedagogías, con el objetivo de encontrar una forma de aprender y de enseñar más crítica, política, personal y democrática; que avance en el objetivo de eliminar desigualdades basadas en género y otras diferencias. Este artículo incluye herramientas y estrategias para los ámbitos educativos, institucionales y personales, con la idea que deben ser trabajados de manera integral para generar cambios reales.

minimum, to NHSN benchmark rates. The team identified several factors believed to be contributing to the higher-thanaverageVAP rates, and subsequently implemented the following interventions to address these issues: 1) identification of VAP Reduction Team Champions on all shifts to reinforce VAP prevention strategies in real time to front line staff 2) reviewandreinforcementof bundleelementsduringdaily carerounds3)assignmentof chart audits tounit staff toassure documentation of head of bed elevation (HOB) and bundle compliance 4) staff re-education and audits on the use of oral care products and protocols 5) designation of separate oral and endotracheal suction set-ups to reduce environmental and hand contamination, and 6) implementation of transfer procedures for ventilated patients that included subglottic and endotracheal suctioning prior to transfer and maintaining HOB elevation.30 degrees unless contraindicated.