Dysautonomia and activity in the early stroke recovery period.

Maintaining cerebral perfusion in the early stages of recovery after stroke is paramount. Autoregulatory function may be impaired during this period leaving cerebral perfusion directly reliant on intravascular volume and blood pressure (BP) with increased risk for expanding cerebral infarction during periods of low BP and hemorrhagic transformation during BP elevations. We suspected that dysautonomia is common during the acute period related to both pre-existing vascular risk factors and potentially independent of such conditions. Thus, we sought to understand the state of the science specific to dysautonomia and acute stroke. The scoping review search included multiple databases and key terms related to acute stroke and dysautonomia. The team employed a rigorous review process to identify, evaluate, and summarize relevant literature. We additionally summarized common clinical approaches used to detect dysautonomia at the bedside. The purpose of this scoping review is to understand the state of the science for the identification, treatment, and impact of dysautonomia on acute stroke patient outcomes. There is a high prevalence of dysautonomia among persons with stroke, though there is significant variability in the type of measures and definitions used to diagnose dysautonomia. While dysautonomia appears to be associated with poor functional outcome and post-stroke complications, there is a paucity of high-quality evidence, and generalizability is limited by heterogenous approaches to these studies. There is a need to establish common definitions, standard measurement tools, and a roadmap for incorporating these measures into clinical practice so that larger studies can be conducted.

The Johns Hopkins Activity and Mobility Promotion Program: A Framework to Increase Activity and Mobility Among Hospitalized Patients.

BACKGROUND: Greater mobility and activity among hospitalized patients has been linked to key outcomes, including decreased length of stay, increased odds of home discharge, and fewer hospital-acquired morbidities. Systematic approaches to increasing patient mobility and activity are needed to improve patient outcomes during and following hospitalization. PROBLEM: While studies have found the Johns Hopkins Activity and Mobility Promotion (JH-AMP) program improves patient mobility and associated outcomes, program details and implementation methods are not published. APPROACH: JH-AMP is a systematic approach that includes 8 steps, described in this article: (1) organizational prioritization; (2) systematic measurement and daily mobility goal; (3) barrier mitigation; (4) local interdisciplinary roles; (5) sustainable education and training; (6) workflow integration; (7) data feedback; and (8) promotion and awareness. CONCLUSIONS: Hospitals and health care systems can use this information to guide implementation of JH-AMP at their institutions.

A sensitive LC-MS/MS method for isomer separation and quantitative determination of 51 pyrrolizidine alkaloids and two tropane alkaloids in cow's milk.

1,2-Unsaturated pyrrolizidine alkaloids (PA), their corresponding N-oxides (PANO), and tropane alkaloids (TA) are toxic secondary plant metabolites. Their possible transfer into the milk of dairy cows has been studied in feeding trials; however, only few data on the occurrence of these toxins in milk are available. In this study, the development of a sensitive analytical approach for the simultaneous detection and quantification of a broad range of 54 PA/PANO as well as of the TA atropine and scopolamine in milk of dairy cows is presented. The method optimisation focused on sensitivity and separation of PA/PANO isomers. Milk samples were extracted using liquid-liquid extraction with aqueous formic acid and n-hexane, followed by a cation-exchange solid-phase extraction for purification. Reversed phase liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis was performed using alkaline solvent conditions. Validation proved low limits of detection and quantification of 0.005 to 0.054 µg/L and of 0.009 to 0.123 µg/L, respectively. For 51 of the 54 tested PA/PANO and both TA, the recovery rates ranged from 64 to 127% with repeatability (RSDr) values below 15% at concentration levels of 0.05 and 0.50 µg/L and below 8% at a concentration level of 3.00 µg/L. Only three PANO did not match the validation criteria and were therefore regarded as semiquantitative. The final method was applied to 15 milk samples obtained from milk vending stations at farms and from local marketers in Bavaria, Germany. In three of the milk samples, traces of PA were detected.

Association between ambulatory status and call bell use in hospitalized patients-A retrospective cohort study.

AIM: Characterize the relationship between patient ambulatory status and in-hospital call bell use. BACKGROUND: Although call bells are frequently used by patients to request help, the relationship between physical functioning and call bell use has not been evaluated. METHODS: Retrospective cohort study of 944 neuroscience patients hospitalized in a large academic urban medical centre between April 1, 2014 and August 1, 2014. We conducted multiple linear regression analyses with number of daily call bells from each patient as the primary outcome and patients' average ambulation status as the primary exposure variable. RESULTS: The mean number of daily call bell requests for all patients was 6.9 (6.1), for ambulatory patients 5.6 (4.8), and for non-ambulatory patients, it was 7.7 (6.6). Compared with non-ambulatory patients, ambulatory patients had a mean reduction in call bell use by 1.7 (95% CI 2.5 to -0.93, p < .001) calls per day. In a post hoc analysis, patients who could walk >250 feet had 5 fewer daily call bells than patients who were able to perform in-bed mobility. CONCLUSION: Ambulatory patients use their call bells less frequently than non-ambulatory patients. IMPLICATIONS FOR NURSING MANAGEMENT: Frequent use of call bells by non-ambulatory patients can place additional demands on nursing staff; patient mobility status should be considered in nurse workload/patient assignment.

Towards improving hospital workflows: An evaluation of resources to mobilize patients.

AIM: To characterize resources to safely mobilize different types of hospitalized patients. BACKGROUND: Current approaches to determine nurse-patient ratios do not always include information regarding the specific demands of patients who require extra resources to mobilize. Workflows must be designed with knowledge of resource requirements to integrate patient mobility into the daily nursing team care plan. METHODS: Nurse-led mobility sessions were evaluated on two adult hospital units, which consisted of nurse-patient encounters focused on patient mobility only. The resources assessed for each session were time-to-mobilize patient, time-to-document, need for additional staff support, and the need for assistive devices. Mobility sessions were also categorized by patient ambulation status, level of mobility limitations (low, medium and high) and diagnosis. RESULTS: In 212 total mobility sessions, the median time-to-mobilize and time-to-document were 7.75 and 1.27 min, respectively. Additional staff support was required for 87% and 92% of patients with medium and high mobility limitations, respectively. All patients with low mobility limitations ambulated, and only 14% required additional staff. Ambulating patients with high mobility limitations was the most time-intensive (median 12.55 min). Ambulating stroke patients required one additional staff and an assistive device in 92% and 69% of the sessions, respectively. CONCLUSION: This study describes the resources associated with mobilizing inpatients with different levels of mobility impairments and diagnoses. IMPLICATIONS FOR NURSING MANAGEMENT: These results could assist nursing management with facilitating appropriate daily nurse-patient ratios and justify the need for assistive devices and staff support to safely mobilize patients.

Increasing patient mobility through an individualized goal-centered hospital mobility program: A quasi-experimental quality improvement project.

BACKGROUND: Hospital-acquired functional decline due to decreased mobility has negative impacts on patient outcomes. Current nurse-directed mobility programs lack a standardized approach to set achievable mobility goals. PURPOSE: We aimed to describe implementation and outcomes from a nurse-directed patient mobility program. METHOD: The quality improvement mobility program on the project unit was compared to a similar control unit providing usual care. The Johns Hopkins Mobility Goal Calculator was created to guide a daily patient mobility goal based on the level of mobility impairment. FINDINGS: On the project unit, patient mobility increased from 5.2 to 5.8 on the Johns Hopkins Highest Level of Mobility score, mobility goal attainment went from 54.2% to 64.2%, and patients exceeding the goal went from 23.3% to 33.5%. All results were significantly higher than the control unit. DISCUSSION: An individualized, nurse-directed, patient mobility program using daily mobility goals is a successful strategy to improve daily patient mobility in the hospital.

Using a Real-Time Location System for Assessment of Patient Ambulation in a Hospital Setting.

OBJECTIVE: To assess the feasibility of using an infrared-based Real-Time Location System (RTLS) for measuring patient ambulation in a 2-minute walk test (2MWT) by comparing the distance walked and the Johns Hopkins Highest Level of Mobility (JH-HLM) score to clinician observation as a criterion standard. DESIGN: Criterion standard validation study. SETTING: Inpatient, university hospital. PARTICIPANTS: Patients (N=25) in an adult neuroscience/brain rescue unit. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: RTLS and clinician-reported ambulation distance in feet, and JH-HLM score on an 8-point ordinal scale. RESULTS: The RTLS ambulation distance for the 25 patients in the 2MWT was between 68 and 516ft. The mean difference between clinician-reported and RTLS ambulation distance was 8.4±11.7ft (2.7%±4.6%). The correlation between clinician-reported and RTLS ambulation distance was 97.9% (P<.01). The clinician-reported ambulation distance for 2 patients was +100ft and -99ft compared with the RTLS distance, implying clinician error in counting the number of laps (98ft). The correlation between the RTLS distance and clinician-reported distance excluding these 2 patients is 99.8% (P<.01). The accuracy of the RTLS for assessment of JH-HLM score for all 25 patients was 96%. The average patient speed obtained from RTLS data varied between 0.4 and 3.0mph. CONCLUSIONS: The RTLS is able to accurately measure patient ambulation and calculate JH-HLM for a 2MWT when compared with clinician observation as the criterion standard.

Takotsubo cardiomyopathy: a case report and literature review.

Takotsubo cardiomyopathy, "broken heart syndrome", is a well-known diagnosis in adults; however, this entity remains rare and is not well represented in the paediatric population. This report illustrates a case of takotsubo cardiomyopathy in a premature neonate with a brief discussion of the condition.

Comparison of Clock Test Deficits Between Elderly Patients With Early and Late Onset Depression.

To compare clock test deficits in elderly patients with early onset depression (EOD) and late onset depression (LOD), we assessed 32 elderly healthy controls (HCs), 26 patients with EOD, and 27 patients with LOD with the clock drawing test (CDT), clock setting test, clock reading test, and the Tübingen Clock Questionnaire testing semantic memory about clock times. There was no significant difference in depression severity between patients with EOD and LOD. Patients with LOD had significantly lower scores on the CDT than patients with EOD and HCs. Semantic memory impairment concerning minute hand functionality was highly correlated with CDT performance and was significantly different between the EOD and the LOD groups. It can be suggested that significant differences in cognitive impairment severity between patients with EOD and LOD can be detected with CDT. Semantic memory impairment concerning minute hand functionality might affect CDT test results in elderly patients with depression.

Pyrrolizidine alkaloids and tropane alkaloids in milk samples from individual dairy farms of the German federal states of Bavaria and Schleswig-Holstein.

1,2-Dehydro-pyrrolizidine alkaloids (PA), their corresponding N-oxides (PANO) and tropane alkaloids (TA), are toxic plant metabolites. If plant material, containing these toxins, is present in the feed of dairy cows these toxins can be transferred into milk. Here, milk was sampled directly from dairy farms in the German federal states of Bavaria and Schleswig-Holstein in 2020-2022 in order to investigate a possible contamination of milk at the production stage. In total, 228 milk samples were analysed for 54 PA/PANO and two TA by a sensitive LC-ESI-MS/MS method. In addition, a subset of milk samples (n = 85) was independently analysed for TA by a cooperating laboratory for verification. PA/PANO were found in 26 samples (11%) with a low median sum content of the contaminated samples of 0.024 µg/L. The highest level of contamination was 5.6 µg/L. Senecionine-, lycopsamine- and heliotrine-type PA/PANO were detected. In four samples (1.8%), atropine was determined up to 0.066 µg/L. The toxin levels in the milk samples hardly contributed to the total daily exposure. These data are first-time results on contamination rates and levels occurring in milk from individual dairy farms, based on a large sample number.

Dose-response study on the transfer of pyrrolizidine alkaloids from a tansy ragwort extract (Jacobaea vulgaris Gaertn.) to bovine milk.

Ragworts like tansy ragwort (J. vulgaris Gaertn., syn. Senecio jacobaea L.) contain hepatotoxic and cancerogenic pyrrolizidine alkaloids (PA) and their corresponding pyrrolizidine alkaloid N-oxides (PANO). Due to increasing spread of ragworts (Jacobaea spp.) PA/PANO may pose a health risk to animals and humans consuming contaminated feed and food. Therefore, the aim of the present study was to investigate the transfer of individual PA/PANO originating from a well-defined PA/PANO extract into the milk of dairy cows. For this objective, 16 German Holstein cows were assigned to four treatment groups (n = 4) in a 28-day dose-response study. Administration into the reticulorumen was performed daily by gavage after the morning milking. Three groups received different amounts of the J. vulgaris extract resulting in a PA/PANO exposure of 0.47, 0.95, or 1.91 mg PA/PANO/kg body weight/day, respectively. Furthermore, a control group received molasses to account for the sugar content of the used PA/PANO extract. While the composition of the PA/PANO extract was more diverse, the PA/PANO pattern in milk was dominated by the PA in their free base form. It was shown that mainly PA considered stable in the rumen environment were transferred into the milk. The main compounds in milk were jacoline (74.3 ± 2.4% of the PA/PANO sum), jaconine (11.2 ± 1.3%), and jacobine (7.2 ± 0.6%) with concentrations up to 29.7, 4.65 µg/l, or in the highest exposed group, 3.44 µg/l. There was no dose-dependent effect on the total PA/PANO transfer rate into the milk. The average transfer rate was 0.064 ± 0.005% of the administered content.

Organization and Implementation of a Stroke Center in Panamá, a Model for Implementation of Stroke Centers in Low and Middle Income Countries.

Background: Stroke is the second leading cause of death and disability worldwide. Stroke centers have become a central component of modern stroke services in many high-income countries, but their feasibility and efficacy in low, middle, and emerging high-income countries are less clear. Also, despite the availability of international guidelines, many hospitals worldwide do not have organized clinical stroke care. We present a methodology to help hospitals develop stroke centers and review quality data after implementation. Objectives: To describe and compare demographics, performance, and clinical outcomes of the Pacífica Salud, Hospital Punta Pacífica (PSHPP) stroke center during its first 3 years 2017-2019. Methods: Pacífica Salud, Hospital Punta Pacífica was organized to implement protocols of care based on the best practices by international guidelines and a quality improvement process. The methodology for implementation adapts a model for translating evidence into practice for implementation of evidence-based practices in medicine. This is a retrospective study of prospectively collected quality data between March of 2017 to December of 2019 for patients admitted to PSHPP with primary diagnosis stroke. Data collected include demographics, clinical data organized per the Joint Commission's STK Performance Measures, door to needle, door to groin puncture, 90 day modified Rankin Score, and hemorrhagic complications from IV thrombolysis and mechanical thrombectomy (MT). Primary outcome: year over year proficiency in documenting performance measures. Secondary outcome: year over year improvement. Results: A total of 143 patients were admitted for acute ischemic stroke, TIA, or hemorrhagic stroke. Of these, 36 were admitted in 2017, 50 in 2018, and 57 in 2019. Performance measure proficiency increased in the year-over-year analysis as did the total number of patients and the number of patients treated with IV thrombolysis and MT. Conclusions: We present the methodology and results of a stroke program implementation in Panamá. This program is the first in the country and in Central America to achieve Joint Commission International (JCI) certification as a Primary Stroke Center (PSC). We postulate that the dissemination of management guidelines is not sufficient to encourage the development of stroke centers. The application of a methodology for translation of evidence into practice with mentorship facilitated the success of this program.

Consolidated Melting Gel Coatings on AZ31 Magnesium Alloy with Excellent Corrosion Resistance in NaCl Solutions: An Interface Study.

Magnesium alloys, with a density two-thirds that of aluminum, are very attractive for the industry. However, these alloys are extremely susceptible to corrosion in the presence of aggressive electrolytes such as NaCl solutions. Here, we designed hybrid coatings obtained by the consolidation of organically modified polysilsesquioxanes called "melting gels" for the corrosion protection of AZ31 magnesium alloy in NaCl solutions. The main focus was to study the interaction between coatings and substrate and the influence of the coating thickness on the final properties. Micro-scratch tests, adhesion by tape tests, confocal Raman microscopy, SEM-EDS, and ToF-SIMS indicate good adhesion of coatings based on the interaction of melting gels and substrate. These measurements indicate the presence of the Si-O-Mg bonds between the substrate and coatings. Electrochemical results show very low current densities (10-13 A cm-2) without any breakdown potential and impedance values of 1010 Ω cm2.

Toward a Common Language for Measuring Patient Mobility in the Hospital: Reliability and Construct Validity of Interprofessional Mobility Measures.

Background: The lack of common language among interprofessional inpatient clinical teams is an important barrier to achieving inpatient mobilization. In The Johns Hopkins Hospital, the Activity Measure for Post-Acute Care (AM-PAC) Inpatient Mobility Short Form (IMSF), also called "6-Clicks," and the Johns Hopkins Highest Level of Mobility (JH-HLM) are part of routine clinical practice. The measurement characteristics of these tools when used by both nurses and physical therapists for interprofessional communication or assessment are unknown. Objective: The purposes of this study were to evaluate the reliability and minimal detectable change of AM-PAC IMSF and JH-HLM when completed by nurses and physical therapists and to evaluate the construct validity of both measures when used by nurses. Design: A prospective evaluation of a convenience sample was used. Methods: The test-retest reliability and the interrater reliability of AM-PAC IMSF and JH-HLM for inpatients in the neuroscience department (n = 118) of an academic medical center were evaluated. Each participant was independently scored twice by a team of 2 nurses and 1 physical therapist; a total of 4 physical therapists and 8 nurses participated in reliability testing. In a separate inpatient study protocol (n = 69), construct validity was evaluated via an assessment of convergent validity with other measures of function (grip strength, Katz Activities of Daily Living Scale, 2-minute walk test, 5-times sit-to-stand test) used by 5 nurses. Results: The test-retest reliability values (intraclass correlation coefficients) for physical therapists and nurses were 0.91 and 0.97, respectively, for AM-PAC IMSF and 0.94 and 0.95, respectively, for JH-HLM. The interrater reliability values (intraclass correlation coefficients) between physical therapists and nurses were 0.96 for AM-PAC IMSF and 0.99 for JH-HLM. Construct validity (Spearman correlations) ranged from 0.25 between JH-HLM and right-hand grip strength to 0.80 between AM-PAC IMSF and the Katz Activities of Daily Living Scale. Limitations: The results were obtained from inpatients in the neuroscience department of a single hospital. Conclusions: The AM-PAC IMSF and JH-HLM had excellent interrater reliability and test-retest reliability for both physical therapists and nurses. The evaluation of convergent validity suggested that AM-PAC IMSF and JH-HLM measured constructs of patient mobility and physical functioning.

Obtaining Thickness-Limited Electrospray Deposition for 3D Coating.

Electrospray processing utilizes the balance of electrostatic forces and surface tension within a charged spray to produce charged microdroplets with a narrow dispersion in size. In electrospray deposition, each droplet carries a small quantity of suspended material to a target substrate. Past electrospray deposition results fall into two major categories: (1) continuous spray of films onto conducting substrates and (2) spray of isolated droplets onto insulating substrates. A crossover regime, or a self-limited spray, has only been limitedly observed in the spray of insulating materials onto conductive substrates. In such sprays, a limiting thickness emerges, where the accumulation of charge repels further spray. In this study, we examined the parametric spray of several glassy polymers to both categorize past electrospray deposition results and uncover the critical parameters for thickness-limited sprays. The key parameters for determining the limiting thickness were (1) field strength and (2) spray temperature, related to (i) the necessary repulsive field and (ii) the ability for the deposited materials to swell in the carrier solvent vapor and redistribute charge. These control mechanisms can be applied to the uniform or controllably-varied microscale coating of complex three-dimensional objects.

29Si NMR and SAXS investigation of the hybrid organic-inorganic glasses obtained by consolidation of the melting gels.

This study is focused on structural characterization of hybrid glasses obtained by consolidation of melting gels. The melting gels were prepared in molar ratios of methyltriethoxysilane (MTES) and dimethyldiethoxysilane (DMDES) of 75%MTES-25%DMDES and 65%MTES-35%DMDES. Following consolidation, the hybrid glasses were characterized using Raman, 29Si and 13C Nuclear Magnetic Resonance (NMR) spectroscopies, synchrotron Small Angle X-Ray Scattering (SAXS) and scanning electron microscopy (SEM). Raman spectroscopy revealed the presence of Si-C bonds in the hybrid glasses and 8-membered ring structures in the Si-O-Si network. Qualitative NMR spectroscopy identified the main molecular species, while quantitative NMR data showed that the ratio of trimers (T) to dimers (D) varied between 4.6 and 3.8. Two-dimensional 29Si NMR data were used to identify two distinct types of T3 environments. SAXS data showed that the glasses are homogeneous across the nm to micrometer length scales. The scattering cross section was one thousand times lower than what is expected when phase separation occurs. The SEM images show a uniform surface without defects, in agreement with the SAXS results, which further supports that the hybrid glasses are nonporous.

Experience with community-based amphotericin B infusion therapy.

STUDY OBJECTIVES: To identify the types and frequencies of adverse events associated with community-based amphotericin B infusion therapy. A second objective was to validate the effectiveness of a monitoring system, based on guidelines from the Infectious Diseases Society of America (IDSA). DESIGN: Retrospective medical record review. SETTING: Outpatient clinic at a tertiary care center. PATIENTS: One hundred five patients who received amphotericin B therapy from a home care provider between January 1997 and July 2002. MEASUREMENTS AND MAIN RESULTS: A total of 113 courses of amphotericin B formulations were administered: liposomal amphotericin B, 41 courses (36%), amphotericin B deoxycholate, 31 courses (27%), amphotericin B lipid complex, 31 courses (27%), and amphotericin B colloidal dispersion, 3 courses (3%); an additional 7 courses consisted of sequential therapy with two different formulations. Nephrotoxicity was associated with 46 (41%) courses, electrolyte abnormalities with 40 (35%) courses, venous access device complications with 12 (11%) courses, and infusion reactions with 13 (12%) courses. Nephrotoxicity occurred most frequently in adults aged 60 years or older, solid organ transplant recipients, and those receiving concomitant cyclosporine. Only two (12%) of 17 courses in children younger than 13 years were associated with nephrotoxicity. Thirteen of all 113 courses resulted in patients requiring hospital admission due to their adverse events. Monitoring of electrolyte, serum creatinine, and blood urea nitrogen levels 2 or 3 times/week was adequate for identifying these events. CONCLUSION: Significant rates of adverse events occurred in patients who received community-based amphotericin B infusion therapy. A monitoring system based on IDSA guidelines was effective in facilitating the detection and management of these adverse events.

Cerebral venous sinus thrombosis in a neonate with homozygous prothrombin G20210A genotype.

We describe a 7-day-old infant who presented with extensive cerebral venous sinus thrombosis (CVST) and was found to be homozygous for the prothrombin G20210A gene mutation. No other known risk factors for thrombosis were identified.