Intensive Care Unit Decision-Making in Uncertain and Stressful Conditions Part 2: Cognitive Errors, Debiasing Strategies, and Enhancing Critical Thinking.

Diagnostic errors are considered a blind spot of health care delivery and occur in up to 15% of patient cases. Cognitive failures are a leading cause of diagnostic error and often occur as a result of overreliance on system 1 thinking. This narrative review describes why diagnostic errors occur by shedding additional light on systems 1 and 2 forms of thinking, reviews literature on debiasing strategies in medicine, and provides a framework for teaching critical thinking in the intensive care unit as a strategy to promote learner development and minimize cognitive failures.

Community Assessment of Extreme Heat Preparedness in Milwaukee, Wisconsin.

BACKGROUND: This article describes the first Community Assessment for Public Health Emergency Response (CASPER) rapid needs assessment project to be conducted in Wisconsin. The project focused on extreme heat preparedness. METHODS: Fifteen teams conducted household surveys in 30 census blocks in the city of Milwaukee, Wisconsin. RESULTS: Survey results indicated that the majority of households were unaware of the location of a nearby cooling center. Although the vast majority of households reported some form of air conditioning in their house, over half felt too hot inside their home sometimes, most of the time, or always. DISCUSSION: The community partnerships ensured that this project was conducted with local partner input and that the data could be used to inform extreme heat response.

Taking Action With Data: Improving Environmental Public Health at the Community Level.

CONTEXT: The Wisconsin Environmental Public Health Tracking Program (Wisconsin Tracking) compiles and provides data on health endpoints and related environmental exposures as a resource to local health departments, tribes, academia, and other stakeholders. The goal of providing these data is that stakeholders use them to develop projects that improve environmental health in their communities-that is, moving from "data to action." OBJECTIVE: To encourage use of Wisconsin Tracking data, we developed a minigrants program and issued a funding opportunity to local health departments and tribes. The opportunity requested proposals for small projects using our data, with the goal of making public health improvements in those communities. Wisconsin Tracking evaluated the minigrants program after its completion. DESIGN/SETTING: Eight local health departments in Wisconsin were awarded up to $10 500 to develop and implement projects over a 9-month period. METHODS: Wisconsin Tracking created a funding opportunity announcement requiring utilization of our data to develop projects by local health departments in Wisconsin. We reviewed and scored applications, evaluating proposals on a range of criteria. During the 9-month project period, Wisconsin Tracking staff members provided a variety of technical assistance to grantees. An evaluation of the overall program followed. RESULTS: Funded communities used Wisconsin Tracking data to improve public health infrastructure, leverage partnerships, establish new initiatives, respond to emergencies, improve communication with stakeholders and residents, and make a variety of public health improvements in their communities. CONCLUSIONS: Efforts to increase use of our data catalyzed development of small-scale environmental health projects. This minigrants program was successful at building relationships between local health departments and Wisconsin Tracking, increasing awareness of Wisconsin Tracking data and resources, and contributing to numerous documented public health improvements throughout Wisconsin.

Heat Vulnerability Index Mapping for Milwaukee and Wisconsin.

CONTEXT: Extreme heat waves elevate the population's risk for heat-related morbidity and mortality, specifically for vulnerable groups such as older adults and young children. In this context, we developed 2 Heat Vulnerability Indices (HVIs), one for the state of Wisconsin and one for the Milwaukee metropolitan area. OBJECTIVE: Through the creation of an HVI, state and local agencies will be able to use the indices as a planning tool for extreme heat events. DESIGN: Data used for the HVIs were grouped into 4 categories: (1) population density; (2) health factors; (3) demographic and socioeconomic factors; and (4) natural and built environment factors. These categories were mapped at the Census block group level. MAIN OUTCOME MEASURES: Unweighted z-score data were used to determine index scores, which were then mapped by quantiles ranging from "high" to "low" vulnerability. RESULTS: Statewide, Menominee County exhibited the highest vulnerability to extreme heat. Milwaukee HVI findings indicated high vulnerability in the city's inner core versus low vulnerability along the lakeshore. CONCLUSION: Visualization of vulnerability could help local public health agencies prepare for future extreme heat events.

Occurrence of Amblyomma americanum (Acari: Ixodidae) and Human Infection With Ehrlichia chaffeensis in Wisconsin, 2008-2015.

Because of the increasing incidence of human ehrlichiosis in Wisconsin, we assessed reports of human infections by Ehrlichia chaffeensis and the distribution of its vector, the lone star tick (Amblyomma americanum (L.)). From 2008 through 2015, 158 probable and confirmed human cases of E. chaffeensis infections were reported to the Wisconsin Department of Health Services. Five cases without travel history outside of Wisconsin were confirmed as E. chaffeensis by polymerase chain reaction. Surveillance for the vector occurred from 2008 through 2015 and was based on active and passive methods, including examination of white-tailed deer, collections from live-trapped small mammals, submissions of ticks removed from wild and domestic animals through the Wisconsin Surveillance of Animals for Ticks (SWAT) program, digital or physical submissions by the public to the University of Wisconsin Insect Diagnostic or Medical Entomology laboratories, and active tick dragging. More than 50 lone star ticks (46 adults, 6 nymphs, and 1 larva) were identified. Lone star ticks were more commonly found in south central Wisconsin, particularly in Dane County, where discovery of more than one life stage in a single year indicates possible establishment.

Alcohol-attributable deaths and years of potential life lost--11 States, 2006-2010.

Excessive alcohol consumption, the fourth leading preventable cause of death in the United States, resulted in approximately 88,000 deaths and 2.5 million years of potential life lost (YPLL) annually during 2006-2010 and cost an estimated $223.5 billion in 2006. To estimate state-specific average annual rates of alcohol-attributable deaths (AAD) and YPLL caused by excessive alcohol use, 11 states analyzed 2006-2010 data (the most recent data available) using the CDC Alcohol-Related Disease Impact (ARDI) application. The age-adjusted median AAD rate was 28.5 per 100,000 population (range = 50.9 per 100,000 in New Mexico to 22.4 per 100,000 in Utah). The median YPLL rate was 823 per 100,000 (range = 1,534 YPLL per 100,000 for New Mexico to 634 per 100,000 in Utah). The majority of AAD (median = 70%) and YPLL (median = 82%) were among working-age (20-64 years) adults. Routine monitoring of alcohol-attributable health outcomes, including deaths and YPLL, in states could support the planning and implementation of evidence-based prevention strategies recommended by the Community Preventive Services Task Force to reduce excessive drinking and related harms. Such strategies include increasing the price of alcohol, limiting alcohol outlet density, and holding alcohol retailers liable for harms related to the sale of alcoholic beverages to minors and intoxicated patrons (dram shop liability).

In situ generation of cell-laden porous MMP-sensitive PEGDA hydrogels by gelatin leaching.

Proteolytically degradable poly(ethylene) glycol (PEG) hydrogels have been investigated as tissue engineering scaffolds; however, cell invasion and tissue regeneration are limited by the rate of cell-mediated degradation due to the small mesh size of the resultant crosslinked network. Gelatin leaching is combined with photopolymerization to form porous matrix-metalloproteinase (MMP)-sensitive PEG scaffolds under cytocompatible conditions in the presence of cells. Gelatin leaching allows control over pore size and porosity through selectivity of gelatin bead particle size and porogen loading, respectively. Increases in porogen loading lead to increased porosity, decreased compressive modulus and degradation time, and enhanced proliferation of encapsulated vascular smooth muscle cells.

MMP-sensitive PEG diacrylate hydrogels with spatial variations in matrix properties stimulate directional vascular sprout formation.

The spatial presentation of immobilized extracellular matrix (ECM) cues and matrix mechanical properties play an important role in directed and guided cell behavior and neovascularization. The goal of this work was to explore whether gradients of elastic modulus, immobilized matrix metalloproteinase (MMP)-sensitivity, and YRGDS cell adhesion ligands are capable of directing 3D vascular sprout formation in tissue engineered scaffolds. PEGDA hydrogels were engineered with mechanical and biofunctional gradients using perfusion-based frontal photopolymerization (PBFP). Bulk photopolymerized hydrogels with uniform mechanical properties, degradation, and immobilized biofunctionality served as controls. Gradient hydrogels exhibited an 80.4% decrease in elastic modulus and a 56.2% decrease in immobilized YRGDS. PBFP hydrogels also demonstrated gradients in hydrogel degradation with degradation times ranging from 10-12 hours in the more crosslinked regions to 4-6 hours in less crosslinked regions. An in vitro model of neovascularization, composed of co-culture aggregates of endothelial and smooth muscle cells, was used to evaluate the effect of these gradients on vascular sprout formation. Aggregate invasion in gradient hydrogels occurred bi-directionally with sprout alignment observed in the direction parallel to the gradient while control hydrogels with homogeneous properties resulted in uniform invasion. In PBFP gradient hydrogels, aggregate sprout length was found to be twice as long in the direction parallel to the gradient as compared to the perpendicular direction after three weeks in culture. This directionality was found to be more prominent in gradient regions of increased stiffness, crosslinked MMP-sensitive peptide presentation, and immobilized YRGDS concentration.

Private drinking water quality in rural Wisconsin.

Between July 1, 2007, and December 31, 2010, Wisconsin health departments tested nearly 4,000 rural drinking water supplies for coliform bacteria, nitrate, fluoride, and 13 metals as part of a state-funded program that provides assistance to low-income families. The authors' review of laboratory findings found that 47% of these wells had an exceedance of one or more health-based water quality standards. Test results for iron and coliform bacteria exceeded safe limits in 21% and 18% of these wells, respectively. In addition, 10% of the water samples from these wells were high in nitrate and 11% had an elevated result for aluminum, arsenic, lead, manganese, or strontium. The high percentage of unsafe test results emphasizes the importance of water quality monitoring to the health of nearly one million families including 300,000 Wisconsin children whose drinking water comes from a privately owned well.

Heat-related fatalities in Wisconsin during the summer of 2012.

BACKGROUND: The hottest year on record for the contiguous United States was 2012. July 2012 ranked as Wisconsin's fourth warmest July, which has profound implications for heat-related mortality. METHODS: We conducted a case series of 27 heat-related fatalities in Wisconsin during summer 2012. Data from death certificates supplemented by coroner reports were analyzed to characterize factors that increase vulnerability to heat-related fatality. RESULTS: The 2012 heat-related fatalities occurred in both urban and rural counties. All cases had 1 or more known risk factors: 100% lacked functioning residential air conditioning; 70% were over age 65; 75% had a cardiovascular disease; and 52% had a mental health condition. Of the 14 cases with a mental health condition, half were known to be taking psychotropic medication. None of the decedents had been in air conditioning immediately prior to death, and 8 (36%) had been using fans. CONCLUSIONS: Air conditioning is known to be a strong protective factor in preventing heat-related deaths whereas fans have not been shown to be significantly protective across all exposure situations. Prevention efforts should stress reducing social isolation by encouraging checks by friends, neighbors, or police. Prevention messages should also warn patients on psychotropic medications that the medication could increase their risk of heat-related illness or fatality.