Costs and Effects of School-Based Licensed Practical Nurses on Elementary Student Attendance and Chronic Absenteeism.

Despite increasing reliance on licensed practical nurses (LPNs) to provide health services in schools, we do not know whether this is a cost-effective prevention strategy against student absenteeism. Therefore, we evaluated the costs and effectiveness of an LPN-based school nursing program for improving attendance and chronic absenteeism at a large, urban school district in the southeastern USA. We first identified a matched set of 46 elementary schools (23 nurse, 23 no-nurse) by using an optimal multilevel matching algorithm based on student- and school-level characteristics. We then conducted a cost-effectiveness analysis on the matched set, using the ingredients method to estimate societal costs and multilevel regression to estimate effects. The results indicated that despite substantial incremental costs of $68,228 per school, the presence of a full-time LPN was associated with at best negligible improvements, and at worst slight disimprovements, in attendance and chronic absenteeism. We recommend a careful review of the theory of change for LPN-based school nursing programs to clarify the specific inputs and activities that are expected to lead to improved student outcomes. Education agencies should develop explicit assignment, training, monitoring, and auditing plans to ensure LPNs are equitably distributed and that their activities are aligned with the theory of change. Education agencies should also explore whether expanded Medicaid billing can reduce their share of the nursing cost burden.

Venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock-A six-year service evaluation.

Only a small number of English hospitals provide postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) and there are doubts about its efficacy and safety. The aim of this service evaluation was to determine local survival rates and report on patient demographics. This was a retrospective service evaluation of prospectively recorded routine clinical data from a tertiary cardiothoracic center in the United Kingdom offering services including cardiac and thoracic surgery, heart and lung transplantation, venovenous extracorporeal membrane oxygenation (VV-ECMO) for respiratory failure, and all types of mechanical circulatory support. In six years, 39 patients were supported with VA-ECMO for refractory postcardiotomy cardiogenic shock (PCCS). We analyzed survival data and looked for associations between survival rates and patient characteristics. The intervention was venoarterial-ECMO in patients with PCCS either following weaning from cardiopulmonary bypass or following a trial of inotropes and intra-aortic balloon counterpulsation on the intensive care unit. 30-day, hospital discharge, 1-year and 2-year survivals were 51.3%, 41%, 37.5%, and 38.5%, respectively. The median (IQR [range]) duration of support was 6 (4-9 [1-35]) days. Nonsurvival was associated with advanced age, shorter intensive care length of stay, and the requirement for postoperative hemofiltration. Reasonable survival rates can be achieved in selected patients who may have been expected to have a worse mortality without VA-ECMO. We suggest postoperative VA-ECMO should be available to all patients undergoing cardiac surgery be it in their own center or through an established pathway to a specialist center.

Restorative Practices: Using local evidence on costs and student outcomes to inform school district decisions about behavioral interventions.

School disciplinary practices affect student academic and life outcomes. Many schools have recently shifted towards the prevention of behavioral disorders rather than the punishment of such disorders, but disciplinary actions are still disproportionately meted out to Black students. We took advantage of a natural experiment in a large school district to investigate the costs and effects of a school-wide intervention based on the principles of restorative justice on suspensions, referrals, and three school climate constructs. The study involved 14 elementary and middle schools, each of which was already implementing Positive Behavioral Interventions and Supports (PBIS). Six of the schools integrated Restorative Practices into their PBIS framework during the first year of the study, whereas the other eight served as comparison schools and implemented the program the following year. We tested a difference-in-difference regression model for each of our five outcomes of interest after 1 year of implementation using Quasi-Poisson models for referrals and suspensions. We found no statistically significant effects on four of the outcomes, either for the overall sample or by racial subgroup. We found negative effects on student-reported personal safety. An additional analysis 1 year later showed that Black students in schools implementing Restorative Practices for 2 years experienced a greater reduction in suspensions than Black students in schools implementing the program for only 1 year. We used the ingredients method to estimate start-up costs and ongoing costs for the first full year of implementation. Our reference case analysis results using a societal perspective, national average prices, and a 3% discount rate were $57,450 per school and $139 per student for the first year of Restorative Practices implementation. These estimates included training costs from the prior year and were incremental to the costs of PBIS, which served as the business-as-usual condition. We compared these costs to those of a number of other behavioral interventions and concluded that Restorative Practices are relatively low cost but may need to be implemented for several years with greater fidelity in order to produce the desired improvements in behavior events and school climate.

Electroconvulsive treatment for a patient with psychotic depression and inclusion body myositis.

A patient with inclusion body myositis (IBM) and psychotic depression required inpatient psychiatric care. The patient's mental and physical health continued to deteriorate despite maximal treatment with medication. After careful consideration and psychiatric, neurological, and anesthetic review, electroconvulsive therapy was initiated. We present, what is to our knowledge, the first documented case of a patient with inclusion body myositis requiring a course of electroconvulsive therapy for psychotic depression.

Simple linear asymmetrical complexes of silver(I): NC-Ag-NH3 and Br-Ag-NH3.

The compounds Ag(CN)(NH(3)) and Ag(Br)(NH(3)) are remarkable in that they form solids containing the simple molecular units NC-Ag-NH(3) and Br-Ag-NH(3), rather than extended solids, and are the first examples of simple linear asymmetric complexes of silver(I).

Surface modification of microspheres with steric stabilizing and cationic polymers for gene delivery.

In this paper, we describe surface modification of poly( D,L-lactide- co-glycolide) (PLG) microspheres, intended for DNA vaccine application, with two functionalities: a steric stabilizing component, provided by poly(vinyl alcohol) (PVA) and a cationic component, aimed at subsequent DNA surface loading. The cationic functionality arises from polycations, such as PEI, poly( L-lysine), trimethyl chitosan, and (dimethylamino)ethyl methacrylate, introduced into the water phase of classical oil-in-water (o/w) solvent evaporation method of PLG microsphere fabrication. By systematic evaluation of production variables, a system was produced with balanced properties in terms of microsphere size appropriate for uptake by antigen presenting (e.g., dendritic) cells, colloidal stability, and relatively high DNA loading. The polycation (PEI) molecular weight and preparation concentration were both found to increase the surface polycation content and DNA binding capacity; however, they lead to an increased tendency for aggregation, particularly when the microsphere size was decreased. DNA loading of almost 100% efficiency was achieved under optimized conditions in physiologically acceptable buffers, resulting in a surface DNA loading appropriate for vaccine purposes. A further increase in surface DNA loading was however associated with an increase in the particles negative potential, indicating the surface presence of DNA charges not neutralized by the polycation and hence potentially not protected from in vivo enzymatic degradation. The internalization of surface-loaded DNA into the target cells was confirmed by monitoring fluorescent DNA after the microspheres were endocytosed by the cells in culture.