An Education Initiative Concerning Lead in an Arkansas Community: Results from Pre- and Post-Surveys

The Arkansas People Participating in Lead Education (APPLE) Program is a collaborative effort between six Arkansas state, national and community organizations to provide lead awareness, training, and municipal legislation to needy communities in Arkansas. Under this program, APPLE organized and hosted well-designed, hands-on, and effective “call to action” lead awareness workshops for parents and community members in 10 needy communities over a 2 year period. Pre- and post-surveys were given to community members to access knowledge, attitudes and effectiveness of lead workshop activities, with demographic and another 13 and 11 questions on pre- and post-surveys, respectively. There were 709 adult attendees across the 10 workshop (Many children also attended.), with 460 completing pre-surveys, and 199 completed post-survey. Post-surveys were limited to four cities. The majority of those who completed surveys were African-American, reported as 78% on pre-surveys, with the majority also being parents (61%) and females. Although, 71% reported knowing that lead paint was bad for their health, more than 60% reported knowing little about lead exposure, and another 25% did not know the age of their residence. On the post-surveys, the majority of respondents found the workshop to be pleasant and informative (98%), while 45% had changed something in their lives to prevent lead exposure for a child and another 53% planned to make a change to prevent lead exposure for a child.     

Pedestrian injuries in children: who is most at risk?

INTRODUCTION

This study evaluates the demographics of paediatric pedestrian injuries with the aim of identifying the group of children who is most vulnerable and the risk factors for major trauma (MT).

METHODS

Data was extracted from the integrated trauma system of a regional paediatric referral hospital. All paediatric cases involving road traffic accidents from January 2011 to December 2013 were studied. Demographics, injury mechanism, treatment and outcome were evaluated. Patients were categorised as MT or non-MT (NMT) based on their Injury Severity Score, admission to the intensive care unit, type of surgery (e.g. life/limb-saving) and death. Data analysis was done using nonparametric tests and Fisher’s exact test.

RESULTS

A total of 261 children were admitted for pedestrian injuries during the study period. The median age was ten years (range 14 months–16 years) and the median weight was 42.4 (range 8.6–93.7) kg. Half (i.e. 50.2%) of the children were primary-schoolers. The majority of the accidents occurred on roads (i.e. 83.1%), between 12 pm and 6 pm (i.e. 52.8%). Among the 261 children, 177 (67.8%) were unaccompanied by an adult at the time of the accident; 17 (6.5%) children sustained MT, while 244 (93.5%) suffered NMT. MT patients were more likely to have lost consciousness (p < 0.001) and been flung (p = 0.001).

CONCLUSION

Most paediatric pedestrian injuries involved primary-schoolers walking home from school unaccompanied by adults. This information should inform future road safety campaigns. Being flung and loss of consciousness predicted MT in children who sustained pedestrian injuries.     

Computational protein design enables a novel one-carbon assimilation pathway

We describe a computationally designed enzyme, formolase (FLS), which catalyzes the carboligation of three one-carbon formaldehyde molecules into one three-carbon dihydroxyacetone molecule. The existence of FLS enables the design of a new carbon fixation pathway, the formolase pathway, consisting of a small number of thermodynamically favorable chemical transformations that convert formate into a three-carbon sugar in central metabolism. The formolase pathway is predicted to use carbon more efficiently and with less backward flux than any naturally occurring one-carbon assimilation pathway. When supplemented with enzymes carrying out the other steps in the pathway, FLS converts formate into dihydroxyacetone phosphate and other central metabolites in vitro. These results demonstrate how modern protein engineering and design tools can facilitate the construction of a completely new biosynthetic pathway.Novel strategies are needed to address current challenges in energy storage and carbon sequestration. One approach is to engineer biological systems to convert one-carbon compounds into multicarbon molecules such as fuels and other high value chemicals. Many synthetic pathways to produce value-added chemicals from common feedstocks, such as glucose, have been constructed in organisms that lack one-carbon anabolic pathways, such as Escherichia coli or Saccharomyces cerevisiae (1–3); however, despite considerable effort, it has been difficult to introduce heterologous one-carbon fixing pathways into these organisms (4). Likely problems include the inherent complexity, environmental sensitivity, inefficiency, or unfavorable chemical driving force of naturally occurring one-carbon metabolic pathways (5).An optimal pathway for one-carbon utilization in common synthetic biology platforms would be (i) composed of a minimal number of enzymes, (ii) linear and disconnected from other metabolic pathways, (iii) thermodynamically favorable with a significant driving force at most or all steps, and (iv) capable of functioning in a robust manner under both aerobic and anaerobic conditions (5). A pathway with these properties could enable the assimilation of one-carbon molecules as the sole carbon source for the production of fuels and chemicals. Although no such pathway is known in nature, the established electrochemical reduction of carbon dioxide to formate under ambient temperatures and pressures in neutral aqueous solutions provides an attractive starting point for a one-carbon fixation pathway (5–8).We describe the computational design of an enzyme that catalyzes the carboligation of three one-carbon molecules into a single three-carbon molecule. This enzyme enables the construction of a new pathway, the formolase pathway, in which formate is converted into the central metabolite dihydroxyacetone phosphate (DHAP; Fig. 1). The use of computational protein design to reengineer catalytic activities opens up the pathway design space beyond that available based on existing enzymes.Open in a separate windowFig. 1.Overview of formolase pathway reactions. (A) Benzaldehyde lyase couples two benzaldehydes into benzoin through an acyloin addition reaction. (B) Acetyl-CoA synthase (ACS) catalyzes the ATP-dependent conversion of acetate into acyl-CoA. (C) Acetaldehyde dehydrogenase (ACDH) catalyzes the NADH-dependent reduction of acetyl-CoA to acetaldehyde. (D) Conversion of formate to dihydroxyacetone phosphate (DHAP) by the formolase pathway. To generate reducing equivalents in the cell, formate is oxidized by formate dehydrogenase (FDH) to produce CO₂ and NADH (stage 1). To use formate as a carbon source, activation (stage 2) and carbon-carbon coupling (stage 3) to form dihydroxyacetone (DHA) are carried out by the enzymes ACS, ACDH, and formolase (FLS). DHA is phosphorylated to DHAP, a glycotic intermediate by a dihydroxyacetone kinase (DHAK) (stage 4). The novel enzyme functions identified here are underlined.     

Designing and Evaluating an Interactive Multimedia Web-Based Simulation for Developing Nurses’ Competencies in Acute Nursing Care: Randomized Controlled Trial

BackgroundWeb-based learning is becoming an increasingly important instructional tool in nursing education. Multimedia advancements offer the potential for creating authentic nursing activities for developing nursing competency in clinical practice.ObjectiveThis study aims to describe the design, development, and evaluation of an interactive multimedia Web-based simulation for developing nurses’ competencies in acute nursing care.MethodsAuthentic nursing activities were developed in a Web-based simulation using a variety of instructional strategies including animation video, multimedia instructional material, virtual patients, and online quizzes. A randomized controlled study was conducted on 67 registered nurses who were recruited from the general ward units of an acute care tertiary hospital. Following a baseline evaluation of all participants’ clinical performance in a simulated clinical setting, the experimental group received 3 hours of Web-based simulation and completed a survey to evaluate their perceptions of the program. All participants were re-tested for their clinical performances using a validated tool.ResultsThe clinical performance posttest scores of the experimental group improved significantly (P<.001) from the pretest scores after the Web-based simulation. In addition, compared to the control group, the experimental group had significantly higher clinical performance posttest scores (P<.001) after controlling the pretest scores. The participants from the experimental group were satisfied with their learning experience and gave positive ratings for the quality of the Web-based simulation. Themes emerging from the comments about the most valuable aspects of the Web-based simulation include relevance to practice, instructional strategies, and fostering problem solving.ConclusionsEngaging in authentic nursing activities using interactive multimedia Web-based simulation can enhance nurses’ competencies in acute care. Web-based simulations provide a promising educational tool in institutions where large groups of nurses need to be trained in acute nursing care and accessibility to repetitive training is essential for achieving long-term retention of clinical competency.     

Are clinical documents optimised for patient safety? A critical analysis of patient safety outcomes using the EDA error model

Iatrogenic errors and patient safety in clinical processes are an increasing concern. The quality of process information in hardcopy or electronic form can heavily influence clinical behaviour and decision making errors. Little work has been undertaken to assess the safety impact of clinical process planning documents guiding the clinical actions and decisions. This paper investigates the clinical process documents used in elective surgery and their impact on latent and active clinical errors. Eight clinicians from a large health trust underwent extensive semi-structured interviews to understand their use of clinical documents, and their perceived impact on errors and patient safety. Samples of the key types of document used were analysed. Theories of latent organisational and active errors from the literature were combined with the EDA semiotics model of behaviour and decision making to propose the EDA Error Model. This model enabled us to identify perceptual, evaluation, knowledge and action error types and approaches to reducing their causes. The EDA error model was then used to analyse sample documents and identify error sources and controls. Types of knowledge artefact structures used in the documents were identified and assessed in terms of safety impact. This approach was combined with analysis of the questionnaire findings using existing error knowledge from the literature. The results identified a number of document and knowledge artefact issues that give rise to latent and active errors and also issues concerning medical culture and teamwork together with recommendations for further work.     

A review of Medicare expenditure in Australia for psychiatric consultations delivered in person and via videoconference

We examined the activity (services recorded) and cost (benefits paid) of reimbursement associated with telepsychiatry services in the Australian public health-care sector. We reviewed the activity and costs administered through the government's Medicare Benefits Schedule (MBS) from July 2002 to June 2011. During this nine-year-period, almost 14 million psychiatric consultations were funded through Medicare at a cost of $1.6 billion. Of these, 8003 were telepsychiatry consultations which cost $934,000, i.e. the video consultations subgroup represented 0.06% of all psychiatric consultations provided and 0.06% of the total cost to the government for these services. Despite telepsychiatry being a widely reported and successful example of telehealth internationally, the uptake of telepsychiatry in Australia has been slow.     

A pharmacist-managed cardiovascular risk-reduction clinic for individuals experiencing serious mental illness

ObjectivesThis retrospective analysis sought to: (1) characterize a cardiovascular risk-reduction clinic (CVRRC) patient population with serious mental illness (SMI); (2) analyze clinical outcomes of CVRRC patients over a 2-year period; and (3) compare outcomes for individuals prescribed different antipsychotic treatments in the CVRRC patient population over a 2-year period.Evaluation methodsIn 2016, A pharmacist-managed CVRRC was implemented within a primary care clinic for patients with SMI. The CVRRC operates under a collaborative practice agreement allowing the pharmacist to initiate and change medications and order laboratory tests. Baseline data collected included demographic information, referring provider, tobacco use, and 10-year atherosclerotic cardiovascular disease risk. Data collected at subsequent visits included date of visit, A1C, estimated average glucose (eAG), blood pressure, weight, body mass index, low-density lipoprotein cholesterol, non–high-density lipoprotein cholesterol, statin and dose, tobacco use, amount smoked, and current antipsychotic treatment. Number of times that treatment for diabetes was initiated or intensified by the pharmacist or primary care provider was also collected.Impact of innovationA total of 101 patients were referred to the CVRRC over the 2-year period. Of these, 81 (80.2%) had at least 1 subsequent visit and were included in the A1C analysis. CVRRC patients had a statistically significant improvement in A1C over time. Mean A1C decreased by an increment of 0.06% for each month increase in follow-up time (P < 0.0001). There was no significant difference in A1C values between patients on different antipsychotic treatments (P = 0.74).ConclusionThe pharmacist-managed CVRRC demonstrated beneficial outcomes for individuals diagnosed with diabetes and SMI. Results provide promising evidence supporting future larger studies to confirm these findings. Considering the morbidity and mortality disparities for individuals with SMI, health care organizations should consider similar models to improve diabetes outcomes.     

Extended high cut‐off haemodialysis for myeloma cast nephropathy in Auckland, 2008–2012

Myeloma cast nephropathy contributes to high morbidity and early mortality associated with the development of end‐stage renal disease. Treatment with extended high cut‐off haemodialysis coupled with novel anti‐myeloma therapies enables significant reduction of serum‐free light chains and has been shown to improve renal outcomes. In this case series, medical records of 6 patients who received high cut‐off haemodialysis for biopsy‐proven cast nephropathy were retrospectively reviewed. Patients received a total of 344 hours of high cut‐off haemodialysis and concurrent chemotherapy. Only 50% became dialysis independent following treatment. One patient who achieved sustained remission remained dialysis dependent. The added benefit of high cut‐off haemodialysis in the light of novel anti‐myeloma therapies requires further evaluation.     

C5-Alkyl-2-methylurea-Substituted Pyridines as a New Class of Glucokinase Activators

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