Communicating do-not-resuscitate orders with a computer-based system

BACKGROUND: Do-not-resuscitate (DNR) orders for critically ill patients are frequently miscommunicated between attending physicians, house staff, and nurses. A computer-based system was developed to improve the communication of a procedure-specific DNR order form. METHODS: Concordance of understanding of patients' DNR status was measured with the use of unstructured DNR orders (period 1), procedure-specific DNR order forms (period 2), and procedure-specific DNR order forms administered with a computer-based communication system (period 3). The 3 components of the DNR order assessed were (1) the clinical events to which the DNR order applied, (2) whether the DNR order withheld all elements of cardiopulmonary resuscitation, and (3) whether other treatments were to be withheld. RESULTS: For the 147 patients, the computer-based system in period 3 (n = 71) improved concordance for attending physicians and nurses or residents for all 3 of the DNR components compared with period 1 (n = 40) and some of the DNR components compared with period 2 (n = 36). Concordance was "substantial" or "almost perfect" as measured by the K statistic during period 3. The proportion of agreement for the composite of all 3 components of the DNR order increased during each period (P<.001, period 3 vs period 1). Overall agreement between all caregivers for the composite DNR order also improved from period 1 (22.2%) to period 2 (47.8%) and period 3 (61.9%; P<.001 vs period 1). Errors in order entry were detected by physicians because of the computer system and corrected in 9.9% of DNR orders in period 3. Progress note documentation of DNR status did not improve during period 3. The procedures of period 3 were considered acceptable by the physician and nursing staff. CONCLUSION: A computer-based system combined with a procedure-specific DNR order form improves communication of patients' DNR status in a critical care setting.     

Infective endocarditis complicated with rapidly progressive glomerulonephritis: a case report

Despite a general national decline in criminal activities in the 1990s, juvenile criminal offenses continue to increase, (including violent, property, and delinquency acts). In addition increased numbers of children are being held in juvenile jails. It is all but impossible for pediatric health providers to think that "their patients" and "their practices" are immune from the epidemic of crime that affects and is caused by "just kids."     

Modelling the dynamics of the tilt-casting process and the effect of the mould design on the casting quality

All titanium alloys are highly reactive in the molten condition and so are usually melted in a water-cooled copper crucible to avoid contamination using processes such as Induction Skull Melting (ISM). These provide only limited superheat which, coupled with the surface turbulence inherent in most conventional mould filling processes, results in entrainment defects such as bubbles in the castings. To overcome these problems, a novel tilt-casting process has been developed in which the mould is attached directly to the ISM crucible holding the melt and the two are then rotated together to achieve a tranquil transfer of the metal into the mould. From the modelling point of view, this process involves complex three-phase flow, heat transfer and solidification. In this paper, the development of a numerical model of the tilt-casting process is presented featuring several novel algorithm developments introduced into a general CFD package (PHYSICA) to model the complex dynamic interaction of the liquid metal and melting atmosphere. These developments relate to the front tracking and heat transfer representations and to a casting-specific adaptation of the turbulence model to account for an advancing solid front. Calculations have been performed for a 0.4 m long turbine blade cast in a titanium aluminide alloy using different mould designs. It is shown that the feeder/basin configuration has a crucial influence on the casting quality. The computational results are validated against actual castings and are used to support an experimental programme. Although fluid flow and heat transfer are inseparable in a casting, the emphasis in this paper will be on the fluid dynamics of mould filling and its influence on cast quality rather than heat transfer and solidification which has been reported elsewhere.     

Effect of argon pressure on the optical properties of sputtered solar selective surfaces

The influence of argon gas pressure (0.15-40 Pa) on the refractive indices n,k of dc planar-magnetron reactively sputtered cermet and amorphous semiconductor films has been investigated for a layer thickness of approximately 50 nm. Stainless steel-carbon and amorphous hydrogenated carbon layers with relatively low index n and stainless steel-silicon and amorphous hydrogenated silicon layers with relatively high index n are examined with a view to solar selective surface applications. The development of structural porosity with associated reduction in n for layers deposited at high argon pressure significantly improves the solar absorptance of surfaces incorporating stainless steel-silicon or amorphous hydrogenated silicon layers.     

Determination of IgG1 and IgG3 SARS-CoV-2 Spike Protein and Nucleocapsid Binding—Who Is Binding Who and Why?

The involvement of immunoglobulin (Ig) G3 in the humoral immune response to SARS-CoV-2 infection has been implicated in the pathogenesis of acute respiratory distress syndrome (ARDS) in COVID-19. The exact molecular mechanism is unknown, but it is thought to involve this IgG subtype’s differential ability to fix, complement and stimulate cytokine release. We examined the binding of convalescent patient antibodies to immobilized nucleocapsids and spike proteins by matrix-assisted laser desorption/ionization–time of flight (MALDI-ToF) mass spectrometry. IgG3 was a major immunoglobulin found in all samples. Differential analysis of the spectral signatures found for the nucleocapsid versus the spike protein demonstrated that the predominant humoral immune response to the nucleocapsid was IgG3, whilst for the spike protein it was IgG1. However, the spike protein displayed a strong affinity for IgG3 itself, as it would bind from control plasma samples, as well as from those previously infected with SARS-CoV-2, similar to the way protein G binds IgG1. Furthermore, detailed spectral analysis indicated that a mass shift consistent with hyper-glycosylation or glycation was a characteristic of the IgG3 captured by the spike protein.     

An enterprise modelling CASE tool and data schema requirements for the selection of software support

This paper describes a prototype CASE tool which has been implemented to support the selection of software applications. It is argued that information structures are invariably linked to the operation of the enterprise and can, therefore, be used as a powerful basis both for the suitability assessment and selection of candidate software applications. A structured methodology for the modelling of the enterprise operation and development of information requirements is first outlined to establish the application domain of the CASE tool. The functionality of the CASE tool is subsequently described, showing how aspects of the enterprise are captured in terms of organization, functionality, resource and information. It will be demonstrated how the information structures, captured by the CASE tool, are subsequently developed into a schema and used for the evaluation of a suitable software application.     

In vitro evaluation of spray‐dried chitosan microspheres crosslinked with pyromellitic dianhydride for oral colon‐specific delivery of protein drugs

Chitosan microspheres have been prepared using a spray‐drying method, and crosslinked with pyromellitic dianhydride. The chemical structure of the modified chitosan was characterized by FTIR spectroscopy and solid state 13C NMR analysis. The particle size and morphology of the crosslinked chitosan were investigated. These microspheres were evaluated for colon‐specific delivery of bovine serum albumin (BSA) as a model protein drug. The results indicate that the drug was released as follows: 37.1 ± 2.8% after 2 h in SGF, 73.1 ± 4.8% after 8 h (2 h in SGF+ 6 h in SIF), and 80.9 ± 4.1% after 12 h in SCF. The effect of β‐glucosidase on the drug release was also examined. The encapsulation efficiency was decreased from 88.4 ± 3.1% to 62.8 ± 2.9%, with increasing BSA concentration. Loading capacity was significantly increased from 6.3 ± 0.3% to 41.8 ± 4.1% by increasing the initial BSA concentration. © 2014 Wiley Periodicals, Inc. J. Appl. Polym. Sci. 2014 , 131, 40514.     

SARS-CoV-2 Spike Protein Binding of Glycated Serum Albumin—Its Potential Role in the Pathogenesis of the COVID-19 Clinical Syndromes and Bias towards Individuals with Pre-Diabetes/Type 2 Diabetes and Metabolic Diseases

The immune response to SARS-CoV-2 infection requires antibody recognition of the spike protein. In a study designed to examine the molecular features of anti-spike and anti-nucleocapsid antibodies, patient plasma proteins binding to pre-fusion stabilised complete spike and nucleocapsid proteins were isolated and analysed by matrix-assisted laser desorption ionisation–time of flight (MALDI-ToF) mass spectrometry. Amongst the immunoglobulins, a high affinity for human serum albumin was evident in the anti-spike preparations. Careful mass comparison revealed the preferential capture of advanced glycation end product (AGE) forms of glycated human serum albumin by the pre-fusion spike protein. The ability of bacteria and viruses to surround themselves with serum proteins is a recognised immune evasion and pathogenic process. The preference of SARS-CoV-2 for AGE forms of glycated serum albumin may in part explain the severity and pathology of acute respiratory distress and the bias towards the elderly and those with (pre)diabetic and atherosclerotic/metabolic disease.