Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative.

BACKGROUND: Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. The authors embarked on a professional practice initiative to attain documented train-of-four ratios greater than or equal to 0.90 in all patients for improved patient outcomes through reducing residual paralysis. METHODS: The authors utilized equipment trials, educational videos, quantitative monitors in all anesthetizing locations, and electronic clinical decision support with real-time alerts, and initiated an ongoing professional practice metric. This was a retrospective assessment (2016 to 2020) of train-of-four ratios greater than or equal to 0.9 that were documented before extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients who received a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes. RESULTS: From pre- to postimplementation, more patients were assigned American Society of Anesthesiologists Physical Status III to V, fewer were inpatients, the rocuronium average dose was higher, and more patients had a prereversal train-of-four count less than 4. Manually reviewed anesthesia records (n = 2,807) had 2 of 172 (1%) cases with documentation of train-of-four ratios greater than or equal to 0.90 in November 2016, which was fewer than the cases in December 2020 (250 of 269 [93%]). Postimplementation (February 1, 2020, to December 31, 2020), sugammadex (650 of 935 [70%]), neostigmine (195 of 935 [21%]), and no reversal (90 of 935 [10%]) were used to attain train-of-four ratios greater than or equal to 0.90 in 856 of 935 (92%) of patients. In the electronically searched medical charts (n = 20,181), postimplementation inpatients had shorter postanesthesia care unit lengths of stay (7% difference; median [in min] [25th, 75th interquartile range], 73 [55, 102] to 68 [49, 95]; P < 0.001), pulmonary complications were less (43% difference; 94 of 4,138 [2.3%] to 23 of 1,817 [1.3%]; P = 0.010; -1.0% difference [95% CI, -1.7 to -0.3%]), and hospital length of stay was shorter (median [in days] [25th, 75th], 3 [2, 5] to 2 [1, 4]; P < 0.001). CONCLUSIONS: In this professional practice initiative, documentation of train-of-four ratios greater than or equal to 0.90 occurred for 93% of patients in a busy clinical practice. Return-of-strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes.

Cutaneous involvement in anti-HMGCR positive necrotizing myopathy.

OBJECTIVE: Anti-3-Hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) positive immune-mediated necrotizing myopathy (IMNM) is a rare disease. It is induced by exogenous substances, most often by statins. Little is known about cutaneous manifestations of HMGCR positive IMNM and about HMGCR antibody positivity in other diseases. METHODS: The characteristics of patients with anti-HMGCR autoantibodies measured at our laboratory between January 2012 and September 2020 were studied. Characteristics of patients with IMNM were compared to those patients with positive antibodies but without muscle involvement. Associations of IMNM with other organ involvements were searched for. RESULTS: Of the 32 patients studied, 23 showed characteristics of IMNM, 9 did not fulfill current classification criteria but most showed signs of connective tissue diseases. Patients with IMNM were older (66 and 35 years, respectively; 0.92 (0.73-0.98); p < 0.001), had more frequent statin exposure (87% and 33%, respectively; 0.84 (0.61-0.94); p = 0.005) and higher mean peak CK (8717U/l and 329U/l, respectively; 1.0 (0.85-1.0); p < 0.001). 13/23 (56%) of IMNM patients showed cutaneous lesions; none of the patients suffered from cancer; only three IMNM patients showed drug-free complete remission. Incidence of IMNM in the catchment area of our center is at least 2.7/Mio/year. CONCLUSION: Cutaneous lesions were found to be more frequent in anti-HMRCR positive IMNM than previously reported. Titer of anti-HMGCR antibodies and CK levels were significantly higher in IMNM than in other autoimmune connective tissue diseases. The data support the hypothesis of an antigen-driven response in IMNM, and suggests an activation of autoreactive B-lymphocytes in non-IMNM patients.

Interplay between grain digestion and fibre in relation to gastro-small-intestinal passage rate and feed intake in pigs.

PURPOSE: The combined effects of grain digestibility and dietary fibre on digesta passage rate and satiety in humans are poorly understood. Satiety can be increased through gastric distention, reduced gastric emptying rate and when partially digested nutrients reach the terminal ileum to stimulate peptide release through the ileal/colonic brakes to slow the rate of digesta passage. This study determined the effects of grain digestibility and insoluble fibre on mean retention time (MRT) of digesta from mouth-to-ileum, feed intake (FI), starch digestion to the terminal ileum and faecal short chain fatty acids (SCFA) in a pig model. METHOD: Twelve grain-based [milled sorghum (MS), steam-flaked-sorghum, milled wheat, and steam-flaked-wheat (SFW)] diets with different intrinsic rates of starch digestion, assessed by apparent amylase diffusion coefficient (ADC), and fibre from oat hulls (OH) at 0, 5 and 20% of the diet were fed to ileal-cannulated pigs. RESULT: MRT was affected by grain-type/processing (P < 0.05) and fibre amount (P < 0.05). An approximate tenfold increase in ADC showed a limited decline in MRT (P = 0.18). OH at 20% increased MRT (P < 0.05) and reduced FI (P < 0.05). Ileal digestibility of starch increased and faecal SCFA concentration decreased with ADC; values for MS being lower (P < 0.001) and higher (P < 0.05), respectively, than for SFW. CONCLUSIONS: Lower ileal digestibility of starch, higher faecal SCFA concentration and longer MRT of MS than SFW, suggest the ileal/colonic brakes may be operating. FI appeared to decrease with increasing MRT. MRT increased and intake decreased with grain-based foods/feeds that have low starch digestibility and substantial amounts of insoluble fibre.

Implementation of an integrated framework for a breast cancer screening and navigation program for women from underresourced communities.

BACKGROUND: Trends in breast cancer mortality in the United States are decreasing, but racial disparities persist. Using an implementation science framework to inform evidence-based breast cancer screening and navigation within federally qualified health centers (FQHCs) with community stakeholders can mitigate barriers to screening. METHODS: Using an integrated theoretical framework of the Practical, Robust Implementation and Sustainability Model and the Social Ecological Model, the University of Illinois Cancer Center and Mile Square Health Centers (MSHC) FQHC developed a breast cancer screening and navigation program, known as the Mile Square Accessible Mammogram Outreach and Engagement (Mi-MAMO) program, to tackle breast cancer disparities in Chicago among underresourced communities. To increase access to screening, patient navigators conducted community outreach activities. Partnerships were forged with community-based organizations, health care systems, and insurers. Outcomes were monitored with standardized performance measures. RESULTS: Between January and December 2017, 103 women received a screening mammogram at MSHC. To increase screening rates, Mi-MAMO was started in August 2017. Between January and December 2018, the number of women who received a screening mammogram increased to 567. From August 2017 to December 2018, 779 women received navigation to screening and/or diagnostic services through the Mi-MAMO program. The majority of women were uninsured (63.9%), and 95.5% were racial/ethnic minorities. Twenty-four percent (n = 185) completed diagnostic services, and 10 women received positive breast cancer diagnoses (mean age, 49.7 years); all successfully navigated to treatment. The Mi-MAMO program is ongoing. CONCLUSIONS: Deploying an integrated framework for patient navigation programs can increase breast cancer screening utilization and awareness among underresourced populations at higher risk for breast cancer.

Association of Use of Contract Nurses With Hospitalized Patient Pressure Injuries and Falls.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) and falls are outcomes sensitive to quality of nursing care. Use of contract (traveler) nurses varies among organizations, but there is little research on the effect of contract nurses on nurse-sensitive outcomes. OBJECTIVES: To explore the relationship between use of contract nurses and two key nurse-sensitive outcomes, HAPIs and falls. RESEARCH DESIGN: This was a cross-sectional study of unit-level nursing, patient, and hospital factors versus HAPIs and falls from a national nursing data consortium from 2015 to 2016. We used cluster analysis to identify similar units, and compared outcomes between clusters. SUBJECTS: 605 nursing units in 166 hospitals, 3.2 patients per nurse, and 5.3% contract nurses. MEASURES: Prevalence and incidence of HAPIs and number of falls, adjusted by patient days. RESULTS: For both prevalence and incidence of HAPIs, there was a statistically significant difference between the five independent cluster groups (p = .012 and p = .001, respectively). The cluster with the highest percentage of nurse travelers (>7%) had the highest HAPI prevalence (0.84%) and incidence (0.055 per 1,000 patient days) despite higher nurse staffing, compared to HAPI prevalence of 0.32% and incidence of 0.017 per 1,000 patient days in the cluster with the lowest percentage of nurse travelers (<2%). We did not identify a consistent relationship between use of contract nurses and falls. CONCLUSIONS: Use of contract nurses was associated with higher HAPI prevalence and incidence, independent of staffing levels. CLINICAL RELEVANCE: Our results suggest that institutions should either minimize the use of contract nurses, or engage in extensive training to confirm that contract nurses have understanding of the institutional practices around HAPIs.

Effectiveness of an Interdisciplinary, Nurse Driven In-Hospital Code Stroke Protocol on In-Patient Ischemic Stroke Recognition and Management.

BACKGROUND: In-hospital strokes account for up to nearly 1 in 5 strokes. Clinical outcomes, such as length of stay, disability, and mortality are worse for in-hospital strokes than for those that occur in the community. For a variety of reasons, stroke can be more difficult to recognize and treat in hospitalized patients. Earlier recognition of stroke results in better clinical outcomes, presumably due to faster diagnosis and subsequently, prompt treatment. METHODS: This investigation was a retrospective, interrupted time series, observational study of all in-hospital stroke patients between 2008 and 2017. This investigation was a quality improvement project, and a waiver was granted from the institutional review board. We used Lean methodologies to standardize our stroke protocol and optimize skill-task alignment to improve the time from onset of symptoms to brain imaging (primary outcome). RESULTS: Overall, we observed significant improvement in the time from onset of symptoms to brain imaging from a median of 69 minutes to 37 minutes (P = .002). CONCLUSIONS: If successfully implemented, this approach may be useful in other care settings with potential to improve stroke outcomes, and decrease associated complications of stroke.

Tattoos in Nursing: Do We Practice What We Preach?

Tattoos have become increasingly popular in the United States among the general population. Furthermore, the popularity of body art, primarily tattoos, among nursing students generates issues about professionalism in academics and in clinical settings. Nursing faculty are faced with conflicting views on cultural awareness, professionalism, and self-expression. With nursing viewed as one of the most trusted professions, the policy of covering tattoos should be discussed, and more research is necessary.

Preparation of Three-dimensional (3-D) Human Liver (HepaRG) Cultures for Histochemical and Immunohistochemical Staining and Light Microscopic Evaluation.

The use of three-dimensional (3-D) in vitro culture systems (spheroids, organoids) in biomolecular and drug discovery research has become increasingly popular. The popularity is due, in part, to a diminished reliance on animal bioassays and a desire to develop physiologically relevant cell culture systems that simulate the in vivo tissue microenvironment. Most evaluations of 3-D cultures are by confocal microscopy and high-content imaging; however, these technologies do not allow for detailed cellular morphologic assessments or permit basic hematoxylin and eosin histologic evaluations. There are few studies that have reported detailed processes for preparing 3-D cultures for paraffin embedding and subsequent use for histochemical or immunohistochemical staining. In an attempt to do so, we have developed a protocol to paraffin-embed human liver spheroids that can be sectioned with a microtome and mounted onto glass slides for routine histochemical and immunohistochemical staining and light microscopic evaluations.

Effectiveness of a Multifaceted Delirium Screening, Prevention, and Treatment Initiative on the Rate of Delirium Falls in the Acute Care Setting.

Delirium is a potentially modifiable fall risk factor, but few studies address the effects of delirium programs on falls. Beginning in 2011, we implemented a nursing-driven hospitalwide delirium program targeting improvements in risk identification, prevention, detection, and treatment. Over the course of the program, delirium falls decreased from 0.91 to 0.50 per patient day (P = .0002). A decrease in overall falls was also noted (P = .0007).

Models of utricular bouton afferents: role of afferent-hair cell connectivity in determining spike train regularity.

Vestibular bouton afferent terminals in turtle utricle can be categorized into four types depending on their location and terminal arbor structure: lateral extrastriolar (LES), striolar, juxtastriolar, and medial extrastriolar (MES). The terminal arbors of these afferents differ in surface area, total length, collecting area, number of boutons, number of bouton contacts per hair cell, and axon diameter (Huwe JA, Logan CJ, Williams B, Rowe MH, Peterson EH. J Neurophysiol 113: 2420-2433, 2015). To understand how differences in terminal morphology and the resulting hair cell inputs might affect afferent response properties, we modeled representative afferents from each region, using reconstructed bouton afferents. Collecting area and hair cell density were used to estimate hair cell-to-afferent convergence. Nonmorphological features were held constant to isolate effects of afferent structure and connectivity. The models suggest that all four bouton afferent types are electrotonically compact and that excitatory postsynaptic potentials are two to four times larger in MES afferents than in other afferents, making MES afferents more responsive to low input levels. The models also predict that MES and LES terminal structures permit higher spontaneous firing rates than those in striola and juxtastriola. We found that differences in spike train regularity are not a consequence of differences in peripheral terminal structure, per se, but that a higher proportion of multiple contacts between afferents and individual hair cells increases afferent firing irregularity. The prediction that afferents having primarily one bouton contact per hair cell will fire more regularly than afferents making multiple bouton contacts per hair cell has implications for spike train regularity in dimorphic and calyx afferents.NEW & NOTEWORTHY Bouton afferents in different regions of turtle utricle have very different morphologies and afferent-hair cell connectivities. Highly detailed computational modeling provides insights into how morphology impacts excitability and also reveals a new explanation for spike train irregularity based on relative numbers of multiple bouton contacts per hair cell. This mechanism is independent of other proposed mechanisms for spike train irregularity based on ionic conductances and can explain irregularity in dimorphic units and calyx endings.

Addition of arabinoxylan and mixed linkage glucans in porcine diets affects the large intestinal bacterial populations.

PURPOSE: To investigate the effects of two cereal soluble dietary fibres (SDF), wheat arabinoxylan (AX) and oat-mixed linkage glucans (MLG), on fermentative end-products and bacterial community profiles of the porcine caecum (Cae) and distal colon (DC). We hypothesised that feeding pigs these SDF would stimulate Cae and DC carbohydrate fermentation, resulting in a modification of the resident bacterial communities. METHODS: Five groups of six pigs were each fed one diet based on wheat starch (WS) only, or treatment diets in which some WS was replaced by 10 % AX, or 10 % MLG, a combination of 5 % AX:5 % MLG (AXMLG), or completely replaced with ground whole wheat. Post-euthanasia, Cae and DC digesta were collected for analysis of fermentative end-products, and bacterial community profiles were determined by 16S rRNA gene amplicon 454 pyrosequencing. RESULTS: Across all the SDF-containing diets, predominantly in the proximal region of the large intestine, Prevotella, Lactobacillus, Mitsuokella and Streptococcus were most significantly influenced (P < 0.05), while notable changes were observed for the Ruminococcaceae and Lachnospiraceae families in the Cae and DC. The addition of MLG or AXMLG had the greatest effect of influencing bacterial profiles, reducing sequence proportions assigned to the genus Clostridium, considered detrimental to gut health, with associated increases in short-chain fatty acid and reduced ammonia concentrations. CONCLUSIONS: This study demonstrated how the cereal SDF AX and MLG altered the large intestinal bacterial community composition, particularly proximally, further giving insights into how diets rich in specific complex carbohydrates shift the bacterial population, by increasing abundance and promoting greater diversity of those bacteria considered beneficial to gut health.

A stress response pathway regulates DNA damage through ß2-adrenoreceptors and ß-arrestin-1.

The human mind and body respond to stress, a state of perceived threat to homeostasis, by activating the sympathetic nervous system and secreting the catecholamines adrenaline and noradrenaline in the 'fight-or-flight' response. The stress response is generally transient because its accompanying effects (for example, immunosuppression, growth inhibition and enhanced catabolism) can be harmful in the long term. When chronic, the stress response can be associated with disease symptoms such as peptic ulcers or cardiovascular disorders, and epidemiological studies strongly indicate that chronic stress leads to DNA damage. This stress-induced DNA damage may promote ageing, tumorigenesis, neuropsychiatric conditions and miscarriages. However, the mechanisms by which these DNA-damage events occur in response to stress are unknown. The stress hormone adrenaline stimulates ß(2)-adrenoreceptors that are expressed throughout the body, including in germline cells and zygotic embryos. Activated ß(2)-adrenoreceptors promote Gs-protein-dependent activation of protein kinase A (PKA), followed by the recruitment of ß-arrestins, which desensitize G-protein signalling and function as signal transducers in their own right. Here we elucidate a molecular mechanism by which ß-adrenergic catecholamines, acting through both Gs-PKA and ß-arrestin-mediated signalling pathways, trigger DNA damage and suppress p53 levels respectively, thus synergistically leading to the accumulation of DNA damage. In mice and in human cell lines, ß-arrestin-1 (ARRB1), activated via ß(2)-adrenoreceptors, facilitates AKT-mediated activation of MDM2 and also promotes MDM2 binding to, and degradation of, p53, by acting as a molecular scaffold. Catecholamine-induced DNA damage is abrogated in Arrb1-knockout (Arrb1(-/-)) mice, which show preserved p53 levels in both the thymus, an organ that responds prominently to acute or chronic stress, and in the testes, in which paternal stress may affect the offspring's genome. Our results highlight the emerging role of ARRB1 as an E3-ligase adaptor in the nucleus, and reveal how DNA damage may accumulate in response to chronic stress.

Changes in Provider Prescribing Patterns After Implementation of an Emergency Department Prescription Opioid Policy.

BACKGROUND: Prescription opioid-associated abuse and overdose is a significant cause of morbidity and mortality in the United States. Opioid prescriptions generated from emergency departments (EDs) nationwide have increased dramatically over the past 20 years, and opioid-related overdose deaths have become an epidemic, according to the Centers for Disease Control and Prevention. OBJECTIVE: Our aim was to determine the effectiveness of implementing a prescription policy for opioids on overall opioid prescribing patterns in a hospital ED. METHODS: The ED provider group of an academic, non-university-affiliated urban hospital with 23,000 annual patient visits agreed to opioid prescribing guidelines for chronic pain with the goal of limiting prescriptions that may be used for abuse or diversion. These guidelines were instituted in the ED through collaborative staff meetings and educational and training sessions. We used the electronic medical record to analyze the number and type of opioid discharge prescriptions during the study period from 2006-2014, before and after the prescribing guidelines were instituted in the ED. RESULTS: The number of patients discharged with a prescription for opioids decreased 39.6% (25.7% to 15.6%; absolute decrease 10.2%; 95% confidence interval [CI] 9.6-10.7; p < 0.001) after the intervention. The improvements were sustained 2.5 years after the intervention. Decreases were seen in all major opioids (hydrocodone, oxycodone, hydromorphone, and codeine). The number of pills per prescription also decreased 14.8%, from 19.5% to 16.6% (absolute decrease 2.9; 95% CI 2.6-3.1; p < 0.001). CONCLUSIONS: Implementation of an ED prescription opioid policy was associated with a significant reduction in total opioid prescriptions and in the number of pills per prescription.

Gut Fermentation of Dietary Fibres: Physico-Chemistry of Plant Cell Walls and Implications for Health.

The majority of dietary fibre (DF) originates from plant cell walls. Chemically, DF mostly comprise carbohydrate polymers, which resist hydrolysis by digestive enzymes in the mammalian small intestine, but can be fermented by large intestinal bacteria. One of the main benefits of DF relate to its fermentability, which affects microbial diversity and function within the gastro-intestinal tract (GIT), as well as the by-products of the fermentation process. Much work examining DF tends to focus on various purified ingredients, which have been extracted from plants. Increasingly, the validity of this is being questioned in terms of human nutrition, as there is evidence to suggest that it is the actual complexity of DF which affects the complexity of the GIT microbiota. Here, we review the literature comparing results of fermentation of purified DF substrates, with whole plant foods. There are strong indications that the more complex and varied the diet (and its ingredients), the more complex and varied the GIT microbiota is likely to be. Therefore, it is proposed that as the DF fermentability resulting from this complex microbial population has such profound effects on human health in relation to diet, it would be appropriate to include DF fermentability in its characterization-a functional approach of immediate relevance to nutrition.

Effects of communication styles on marital satisfaction and distress of parents of pediatric cancer patients: a prospective longitudinal study.

OBJECTIVE: The aim of this study was to examine the longitudinal effects of communication styles on marital satisfaction and distress of parents of children treated for cancer. METHODS: Marital dissatisfaction (Maudsley Marital Questionnaire), intimacy, avoidance, destructive and incongruent communication (Communication Skills Inventory) and psychological distress (General Health Questionnaire) were assessed in 115 parents of pediatric cancer patients shortly after diagnosis (T1) and 5 years later (T2). RESULTS: Only mothers' marital dissatisfaction increased significantly over time. No gender differences in dissatisfaction were found. Mothers had a significantly higher lack of intimacy score than fathers. All T1 communication styles were significantly univariately related to fathers' and mothers' T2 marital dissatisfaction, while not to T2 distress. Mothers' T1 marital dissatisfaction accounted for 67% and fathers' for 12% in the explained variance of T2 dissatisfaction. T1 destructive communication uniquely affected fathers' T2 marital dissatisfaction and T1 avoidant communication that of mothers. CONCLUSIONS: Five years after cancer diagnosis in their children, the quality of parents' marital relationships seemed largely unchanged. Parents' use of communication skills at diagnosis appeared to have limited effect on their marital dissatisfaction and no effect on their distress 5 years later. While avoidant communication seemed indicative of mothers' marital distress, fathers' seemed affected by destructive communication.

Primary Care Triple P for parents of NICU graduates with behavioral problems: a randomized, clinical trial using observations of parent-child interaction.

BACKGROUND: Preterm-born or asphyxiated term-born children show more emotional and behavioral problems at preschool age than term-born children without a medical condition. It is uncertain whether parenting intervention programs aimed at the general population, are effective in this specific group. In earlier findings from the present trial, Primary Care Triple P was not effective in reducing parent-reported child behavioral problems. However, parenting programs claim to positively change child behavior through enhancement of the parent-child interaction. Therefore, we investigated whether Primary Care Triple P is effective in improving the quality of parent-child interaction and increasing the application of trained parenting skills in parents of preterm-born or asphyxiated term-born preschoolers with behavioral problems. METHODS: For this pragmatic, open randomized clinical trial, participants were recruited from a cohort of infants admitted to the neonatal intensive care units of two Dutch hospitals. Children aged 2-5 years, with a gestational age <32 weeks and/or birth weight <1500 g and children with a gestational age 37-42 weeks and perinatal asphyxia were included. After screening for a t-score ≥60 on the Child Behavior Checklist, children were randomly assigned to Primary Care Triple P (n = 34) or a wait-list control group (n = 33). Trial outcomes were the quality of parent-child interaction and the application of trained parenting skills, both scored from structured observation tasks. RESULTS: There was no effect of the intervention on either of the observational outcome measures at the 6-month trial endpoint. CONCLUSIONS: Primary Care Triple P, is not effective in improving the quality of parent-child interaction nor does it increase the application of trained parenting skills in parents of preterm-born or asphyxiated term-born children with behavioral problems. Further research should focus on personalized care for these parents, with an emphasis on psychological support to reduce stress and promote self-regulation. TRIAL REGISTRATION: Netherlands National Trial Register NTR2179 . Registered 26 January 2010.

Using lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose".

BACKGROUND: Virginia Mason Medical Center (Seattle) employed the Lean concept of Jidoka (automation with a human touch) to plan for and deploy bar code medication administration (BCMA) to hospitalized patients. METHODS: Integrating BCMA technology into the nursing work flow with minimal disruption was accomplished using three steps ofJidoka: (1) assigning work to humans and machines on the basis of their differing abilities, (2) adapting machines to the human work flow, and (3) monitoring the human-machine interaction. Effectiveness of BCMA to both reinforce safe administration practices and reduce medication errors was measured using the Collaborative Alliance for Nursing Outcomes (CALNOC) Medication Administration Accuracy Quality Study methodology. Trained nurses observed a total of 16,149 medication doses for 3,617 patients in a three-year period. RESULTS: Following BCMA implementation, the number of safe practice violations decreased from 54.8 violations/100 doses (January 2010-September 2011) to 29.0 violations/100 doses (October 2011-December 2012), resulting in an absolute risk reduction of 25.8 violations/100 doses (95% confidence interval [CI]: 23.7, 27.9, p < .001). The number of medication errors decreased from 5.9 errors/100 doses at baseline to 3.0 errors/100 doses after BCMA implementation (absolute risk reduction: 2.9 errors/100 doses [95% CI: 2.2, 3.6,p < .001]). The number of unsafe administration practices (estimate, -5.481; standard error 1.133; p < .001; 95% CI: -7.702, -3.260) also decreased. CONCLUSION: As more hospitals respond to health information technology meaningful use incentives, thoughtful, methodical, and well-managed approaches to technology deployment are crucial. This work illustrates how Jidoka offers opportunities for a smooth transition to new technology.

Mathematical accuracy of Aztec land surveys assessed from records in the Codex Vergara.

Land surveying in ancient states is documented not only for Eurasia but also for the Americas, amply attested by two Acolhua-Aztec pictorial manuscripts from the Valley of Mexico. The Codex Vergara and the Códice de Santa María Asunción consist of hundreds of drawings of agricultural fields that uniquely record surface areas as well as perimeter measurements. A previous study of the Codex Vergara examines how Acolhua-Aztecs determined field area by reconstructing their calculation procedures. Here we evaluate the accuracy of their area values using modern mathematics. The findings verify the overall mathematical validity of the codex records. Three-quarters of the areas are within 5% of the maximum possible value, and 85% are within 10%, which compares well with reported errors by Western surveyors that postdate Aztec-Acolhua work by several centuries.

Understanding older adults' motivators and barriers to participating in organized programs supporting exercise behaviors.

Little is known about older adults' perceptions of organized programs that support exercise behavior. We conducted semi-structured interviews with 39 older adults residing in King County, Washington, who either declined to join, joined and participated, or joined and then quit a physical activity-oriented program. We sought to explore motivators and barriers to physical activity program participation and to elicit suggestions for marketing strategies to optimize participation. Two programs supporting exercise behavior and targeting older persons were the source of study participants: Enhance(®)Fitness and Physical Activity for a Lifetime of Success. We analyzed interview data using standard qualitative methods. We examined variations in themes by category of program participant (joiner, decliner, quitter) as well as by program and by race. Interview participants were mostly females in their early 70s. Approximately half were non-White, and about half had graduated from college. The most frequently cited personal factors motivating program participation were enjoying being with others while exercising and desiring a routine that promoted accountability. The most frequent environmental motivators were marketing materials, encouragement from a trusted person, lack of program fees, and the location of the program. The most common barriers to participation were already getting enough exercise, not being motivated or ready, and having poor health. Marketing messages focused on both personal benefits (feeling better, social opportunity, enjoyability) and desirable program features (tailored to individual needs), and marketing mechanisms ranged from traditional written materials to highly personalized approaches. These results suggest that organized programs tend to appeal to those who are more socially inclined and seek accountability. Certain program features also influence participation. Thoughtful marketing that involves a variety of messages and mechanisms is essential to successful program recruitment and continued attendance.