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This article documents experiences of Glasgow Improvisers Orchestra's virtual, synchronous improvisation sessions during COVID-19 pandemic via interviews with 29 participants. Sessions included an international, gender balanced, and cross generational group of over 70 musicians all of whom were living under conditions of social distancing. All sessions were recorded using Zoom software. After 3 months of twice weekly improvisation sessions, 29 interviews with participants were undertaken, recorded, transcribed, and analyzed. Key themes include how the sessions provided opportunities for artistic development, enhanced mood, reduced feelings of isolation, and sustained and developed community. Particular attention is placed upon how improvisation as a universal, real time, social, and collaborative process facilitates interaction, allowing the technological affordances of software (latencies, sound quality, and gallery/speaker view) and hardware (laptop, tablet, instruments, microphones, headphones, and objects in room) to become emergent properties of artistic collaborations. The extent to which this process affects new perceptual and conceptual breakthroughs for practitioners is discussed as is the crucial and innovative relationship between audio and visual elements. Analysis of edited films of the sessions highlight artistic and theoretical and conceptual issues discussed. Emphasis is given to how the domestic environment merges with technologies to create The Theatre of Home ., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 MacDonald, Burke, De Nora, Sappho Donohue and Birrell.)

Although approximately one in five Medicare beneficiaries are discharged from hospital acute care to postacute care at skilled nursing facilities (SNFs), little is known about access to timely medical care for these patients after they are admitted to a SNF. Our analysis of 2,392,753 such discharges from hospitals under fee-for-service Medicare in the period January 2012-October 2014 indicated that first visits by a physician or advanced practitioner (a nurse practitioner or physician assistant) for initial medical assessment occurred within four days of SNF admission in 71.5 percent of the stays. However, there was considerable variation in days to first visit at the regional, facility, and patient levels. We estimated that in 10.4 percent of stays there was no physician or advanced practitioner visit. Understanding the underlying reasons for, and consequences of, variability in timing and receipt of initial medical assessment after admission to a SNF for postacute care may prove important for improving patient outcomes and particularly relevant to current efforts to promote value-based purchasing in postacute care.

Background: Adapting promising health care interventions to local settings is a critical component in the dissemination and implementation process. The Veterans Health Administration (VHA) rural transitions nurse program (TNP) is a nurse-led, Veteran-centered intervention designed to improve transitional care for rural Veterans funded by VA national offices for dissemination to other VA sites serving a predominantly rural Veteran population. Here, we describe our novel approach to the implementation and evaluation = the TNP., Methods: This is a controlled before and after study that assesses both implementation and intervention outcomes. During pre-implementation, we assessed site context using a mixed method approach with data from diverse sources including facility-level quantitative data, key informant and Veteran interviews, observations of the discharge process, and a group brainstorming activity. We used the Practical Robust Implementation and Sustainability Model (PRISM) to inform our inquiries, to integrate data from all sources, and to identify factors that may affect implementation. In the implementation phase, we will use internal and external facilitation, paired with audit and feedback, to encourage appropriate contextual adaptations. We will use a modified Stirman framework to document adaptations. During the evaluation phase, we will measure intervention and implementation outcomes at each site using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). We will conduct a difference-in-differences analysis with propensity-matched Veterans and VA facilities as a control. Our primary intervention outcome is 30-day readmission and Emergency Department visit rates. We will use our findings to develop an implementation toolkit that will inform the larger scale-up of the TNP across the VA., Discussion: The use of PRISM to inform pre-implementation evaluation and synthesize data from multiple sources, coupled with internal and external facilitation, is a novel approach to engaging sites in adapting interventions while promoting fidelity to the intervention. Our application of PRISM to pre-implementation and midline evaluation, as well as documentation of adaptations, provides an opportunity to identify and address contextual factors that may impede or enhance implementation and sustainability of health interventions and inform dissemination.

Background: The process of transitioning Veterans to primary care following a non-Veterans Affairs (VA) hospitalization can be challenging. Poor transitions result in medical complications and increased hospital readmissions. The goal of this transition of care quality improvement (QI) project is to identify gaps in the current transition process and implement an intervention that bridges the gap and improves the current transition of care process within the Eastern Colorado Health Care System (ECHCS)., Methods: We will employ qualitative methods to understand the current transition of care process back to VA primary care for Veterans who received care in a non-VA hospital in ECHCS. We will conduct in-depth semi-structured interviews with Veterans hospitalized in 2015 in non-VA hospitals as well as both VA and non-VA providers, staff, and administrators involved in the current care transition process. Participants will be recruited using convenience and snowball sampling. Qualitative data analysis will be guided by conventional content analysis and Lean Six Sigma process improvement tools. We will use VA claim data to identify the top ten non-VA hospitals serving rural and urban Veterans by volume and Veterans that received inpatient services at non-VA hospitals. Informed by both qualitative and quantitative data, we will then develop a transitions care coordinator led intervention to improve the transitions process. We will test the transition of care coordinator intervention using repeated improvement cycles incorporating salient factors in value stream mapping that are important for an efficient and effective transition process. Furthermore, we will complete a value stream map of the transition process at two other VA Medical Centers and test whether an implementation strategy of audit and feedback (the value stream map of the current transition process with the Transition of Care Dashboard) versus audit and feedback with Transition Nurse facilitation of the process using the Resource Guide and Transition of Care Dashboard improves the transition process, continuity of care, patient satisfaction and clinical outcomes., Discussion: Our current transition of care process has shortcomings. An intervention utilizing a transition care coordinator has the potential to improve this process. Transitioning Veterans to primary care following a non-VA hospitalization is a crucial step for improving care coordination for Veterans.

This study examines the association between nursing home administrators (NHAs) professional membership, certification, and fellow status with quality indicators in nursing homes. Membership, certification, and fellow information (representing increasing levels of participation) originated from the American College of Health Care Administrators (ACHCA). ACHCA is a professional association which represents long-term care administrators. The Quality Measures reported on the Nursing Home Compare web-site, and facility information from the On-line Survey Certification of Automated Records (OSCAR) were used. The period of interest was 2010 and a total of 19 quality indicators were examined. Data were analyzed through multivariate analyses using negative binomial regression. The results indicate NHAs who are members of ACHCA are associated with better quality in 6 of the 19 quality indicators examined; ACHCA certified member fellows are associated with better quality in 7 of the 19 quality indicators examined; ACHCA fellows are associated with better quality in 10 of the 19 quality indicators examined; and, ACHCA members (excluding certified, certified fellows, and fellows) are associated with better quality in 13 of the 19 quality indicators examined. These findings support the value of professional membership, as well as voluntary certification or fellow credentialing of NHAs with respect to quality improvement.

The pediatric primary care provider in the medical home has a central and unique role in the care of children with spina bifida. The primary care provider addresses not only the typical issues of preventive and acute health care but also the needs specific to these children. Optimal care requires communication and comanagement with pediatric medical and developmental subspecialists, surgical specialists, therapists, and community providers. The medical home provider is essential in supporting the family and advocating for the child from the time of entry into the practice through adolescence, which includes transition and transfer to adult health care. This report reviews aspects of care specific to the infant with spina bifida (particularly myelomeningocele) that will facilitate optimal medical, functional, and developmental outcomes.

Objective: To examine the impact of adherence to a ventilator-associated pneumonia (VAP) bundle on the incidence of VAP in our surgical intensive care units (SICUs)., Design: Prospectively collected data were retrospectively examined from our Infection Control Committee surveillance database of SICU patients over a 38-month period. Cost of VAP was estimated at $30,000 per patient stay., Setting: Two SICUs at a tertiary care academic level I trauma center., Patients: Ventilated patients admitted to a SICU., Intervention: The Institute for Healthcare Improvement VAP bundle was instituted at the beginning of the study and included head-of-bed elevation, extubation assessment, sedation break, peptic ulcer prophylaxis, and deep vein thrombosis prophylaxis. A daily checklist was considered compliant if all 5 items were performed for each patient., Main Outcome Measures: Patients were assessed for VAP. Staff were assessed for compliance with the VAP bundle., Results: Prior to initiation of the bundle, VAP was seen at a rate of 10.2 cases/1000 ventilator days. Compliance with the VAP bundle increased over the study period from 53% and 63% to 91% and 81% in each respective SICU. The rate of VAP decreased to 3.4 cases/1000 ventilator days. A cost savings of $1.08 million was estimated., Conclusions: Initiation of the VAP bundle is associated with a significantly reduced incidence of VAP in patients in the SICU and with cost savings. Initiation of a VAP bundle protocol is an effective method for VAP reduction when compliance is maintained.

Background: Active vitamin D metabolite, 1, 25-dihydroxyvitamin D, has pleomorphic effects on both innate and acquired immunity. Sarcoid granuloma derived 1, 25-dihydroxyvitamin D leads to hypercalcemia, but the association of 1, 25-dihydroxyvitamin D with the clinical phenotype of the disease is currently unknown., Objective: To determine the relationship between serum 1, 25-dihydroxyvitamin D levels and the degree of sarcoidosis disease chronicity., Design: Serum 1, 25-dihydroxyvitamin D levels were measured and associated with sarcoidosis activity and phenotypes as assessed by Sarcoidosis Severity Score and Sarcoidosis Clinical Activity Classification respectively., Results: Fifty nine patients were recruited with 44% having a sub-acute onset, and the chronic disease phenotype. There was no significant difference in serum 1, 25-dihydroxyvitamin D levels by chest radiograph stage (p = 0.092) nor did the levels correlate with the Sarcoidosis Severity Score (r = -0.16; p = 0.216). Serum 1, 25-dihydroxyvitamin D levels were associated with patients requiring repeated regimens of systemic immunosuppressive therapy or >1 year of therapy (SCAC Class 6). Increasing quartiles of serum 1, 25-dihydroxyvitamin D level was associated increased odds of the chronic phenotype (OR 1.82, 95% CI, 1.11, 2.99, p = 0.019). The majority (71%) of the patients with levels >51 pg/mL required chronic immunosuppressive therapy as defined by SCAC class 6., Conclusions: In patients with sarcoidosis, elevated 1, 25-dihydroxyvitamin D levels are associated with chronic treatment needs., (Copyright 2009 Elsevier Ltd. All rights reserved.)

Keyboards in intensive care units have been shown to serve as reservoirs for multidrug-resistant microorganisms. The thoroughness of disinfection cleaning of keyboards on computers on wheels (COWs) in an intensive care units of an academic medical center were evaluated using an invisible florescent marker, and the movements of the COWs were tracked using their serial numbers. Following a series of educational and programmatic interventions, we were able to improve the thoroughness of cleaning to 100%.

Devices capable of automatically aligning cells onto geometrical arrays are of great interest to biomedical researchers. Such devices can facilitate the study of numerous cells while the cells remain physically separated from one another. In this way, cell arrays reduce cell-to-cell interactions while the cells are all subjected to common stimuli, which allows individual cell behaviour to be revealed. The use of arrays allows for the parallel analysis of single cells, facilitates data logging, and opens the door to the use of automated machine-based single cell analysis techniques. A novel permalloy based magnetic single cell micro array (MSCMA) is presented in this paper. The MSCMA creates an array of magnetic traps by generating magnetic flux density peaks at predefined locations. When using cells labelled with immunomagnetic labels, the cells will interact with the magnetic fields, and can be captured at the magnetic trap sites. Prototypes of the MSCMA have been successfully fabricated and tested using both fixed and live Jurkat cells (10 microm average diameter) that were labelled. The prototypes performed as predicted during experimental trials. The experimental results show that the MSCMA can randomly array up to 136 single cells per square mm. The results also show that the number of single cells captured is a function of the trap site density of the MSCMA design and the cell density in the fluid sample.

Health care spending comprises about 16% of the total United States gross domestic product and continues to rise. This article examines patterns of health care spending and the factors underlying their proportional growth. We examine the "usual suspects" most frequently cited as drivers of health care costs and explain why these may not be as important as they seem. We suggest that the drive for technological advancement, coupled with the entrepreneurial nature of the health care industry, has produced inherently inequitable and unsustainable health care expenditure and growth patterns. Successful health reform will need to address these factors and their consequences.

Summary: The ProteoWizard software project provides a modular and extensible set of open-source, cross-platform tools and libraries. The tools perform proteomics data analyses; the libraries enable rapid tool creation by providing a robust, pluggable development framework that simplifies and unifies data file access, and performs standard proteomics and LCMS dataset computations. The library contains readers and writers of the mzML data format, which has been written using modern C++ techniques and design principles and supports a variety of platforms with native compilers. The software has been specifically released under the Apache v2 license to ensure it can be used in both academic and commercial projects. In addition to the library, we also introduce a rapidly growing set of companion tools whose implementation helps to illustrate the simplicity of developing applications on top of the ProteoWizard library., Availability: Cross-platform software that compiles using native compilers (i.e. GCC on Linux, MSVC on Windows and XCode on OSX) is available for download free of charge, at http://proteowizard.sourceforge.net. This website also provides code examples, and documentation. It is our hope the ProteoWizard project will become a standard platform for proteomics development; consequently, code use, contribution and further development are strongly encouraged.

This article summarizes the current progress in imaging the sequence of blood flow inside the cardiac chambers. Observations from experimental models and computational fluid dynamics have been compared with in vivo findings from phase contrast MRI, high-resolution Doppler imaging, and echo particle imaging velocimetry. The discussion includes chamber and valve geometry and its role in asymmetric flow propagation with an emphasis on the cardiac mechanical sequence that helps stabilize the redirected blood streams. Mapping intracardiac flow patterns in health and disease provides a rich and challenging field of research that warrants careful application in future investigations.

The transition and transfer from pediatrics to adult health care of youth with and without special health care needs has become a focus of professional organizations, health care insurers, national policy makers, and providers. To understand transition and transfer at a primary care practice level, all primary care pediatricians in Rhode Island were surveyed. Responses were received from 103 of 169 (60.9%) practicing pediatricians. Few responders had practice policies on transfer. Most reported that transition should begin later than recommended. Few practices communicated with adult providers at transfer. Most reported that health insurers were of little help in transfer. Many pediatric practices had young adults after age 22 and many with special needs. Responders reported adolescents left their practices by 1 of 6 methods. The survey indicates the need for further study of transition and transfer and the need for additional training and education if transfers are to be successful.

The No Child Left Behind Act of 2001 was signed into law by President George W. Bush in January 2002 and is regarded as the most significant federal education policy initiative in a generation. The primary focus of the No Child Left Behind Act is on promoting educational success for all children; however, the legislation also contains opportunities to advance school-based mental health. Unfortunately, the complexities of the provisions of the No Child Left Behind Act have made it difficult for educators, stakeholders, and mental health professionals to understand the legal and practical interface between No Child Left Behind and the school mental health movement. Therefore, the goals of this article are to (1) raise awareness about the challenges educators and school mental health professionals face as a result of the implementation of No Child Left Behind and (2) provide ideas and recommendations to advance the interface between No Child Left Behind and school mental health, which will support key provisions of the act and the growth of the field.

Mesenchymal-epithelial interactions are an important source of information for pattern formation during organogenesis. In the developing excretory system, one of the secreted mesenchymal factors thought to play a critical role in patterning the growth and branching of the epithelial ureteric bud is GDNF. We have tested the requirement for GDNF as a paracrine chemoattractive factor by altering its site of expression during excretory system development. Normally, GDNF is secreted by the metanephric mesenchyme and acts via receptors on the Wolffian duct and ureteric bud epithelium. Misexpression of GDNF in the Wolffian duct and ureteric buds resulted in formation of multiple, ectopic buds, which branched independently of the metanephric mesenchyme. This confirmed the ability of GDNF to induce ureter outgrowth and epithelial branching in vivo. However, in mutant mice lacking endogenous GDNF, kidney development was rescued to a substantial degree by GDNF supplied only by the Wolffian duct and ureteric bud. These results indicate that mesenchymal GDNF is not required as a chemoattractive factor to pattern the growth of the ureteric bud within the developing kidney, and that any positional information provided by the mesenchymal expression of GDNF may provide for renal branching morphogenesis is redundant with other signals.

Parkinson's disease (PD) is most commonly a sporadic illness, and is characterized by degeneration of substantia nigra dopamine (DA) neurons and abnormal cytoplasmic aggregates of alpha-synuclein. Rarely, PD may be caused by missense mutations in alpha-synuclein. MPTP, a neurotoxin that inhibits mitochondrial complex I, is a prototype for an environmental cause of PD because it produces a pattern of DA neurodegeneration that closely resembles the neuropathology of PD. Here we show that alpha-synuclein null mice display striking resistance to MPTP-induced degeneration of DA neurons and DA release, and this resistance appears to result from an inability of the toxin to inhibit complex I. Contrary to predictions from in vitro data, this resistance is not due to abnormalities of the DA transporter, which appears to function normally in alpha-synuclein null mice. Our results suggest that some genetic and environmental factors that increase susceptibility to PD may interact with a common molecular pathway, and represent the first demonstration that normal alpha-synuclein function may be important to DA neuron viability.