Optimal Assessment Tool Research Articles

Frailty Scores and Their Utility in Older Patients with Cardiovascular Disease.

The world’s population is ageing, resulting in more people with frailty receiving treatment for cardiovascular disease (CVD). The emergence of novel interventions, such as transcatheter aortic valve implantation, has also increased the proportion of older patients being treated in later stages of life. This increasing population burden makes the assessment of frailty of utmost importance, especially in patients with CVD. Despite a growing body of evidence on the association between frailty and CVD, there is no consensus on the optimal frailty assessment tool for use in clinical settings. Previous studies have shown limited concordance between validated frailty instruments. This review evaluates the evidence on the utility of frailty assessment tools in patients with CVD, and the effect of frailty on different outcomes measured.

One-Size-Fits All: A Scalable Solution to Formal Telemedicine Provider Training to Support the COVID-19 Pandemic Response.

Introduction: Formalized training in telemedicine addresses barriers to provider adoption and engagement and assures a level of competence for independent practice. We previously developed a blended-model training program, customizable according to role and specialty; this method of training was not feasible in the pandemic response. We describe the development and implementation of a multi- and interdisciplinary telemedicine provider training program enabling the rapid scaling of telemedicine at our institution.Methods: An existing curriculum was pared down to a 1-h session delivered synchronously, covering the foundational components of telemedicine practice. Supplemental materials were available for asynchronous learning via the hospital intranet. Completion of training was required of all clinicians who practice telemedicine.Results: We conducted 35 sessions for 1,070 providers over 12 weeks. Attendees included clinicians across numerous roles and specialties. Additional resources were created and available through the Telemedicine Virtual Handbook and housed in specific toolkits.Discussion: Telemedicine training is necessary for consistent, competent practice of telemedicine in pediatrics. We describe a training process that can be easily replicated and rapidly deployed to providers of telemedicine across roles and disciplines. Combining a mandatory and brief synchronous provider training session with a repository of online resources creates a foundation for consistent practice, while allowing for more individualized resources accessible on demand. Standardized telemedicine training followed by mechanisms for ongoing professional practice evaluation allow institutions to ensure consistent and competent practice of telemedicine. Further study is needed to determine the best modality for training, and optimal assessment tools according to professional role.

Assessing the thrombosis risk of peripherally inserted central catheters in cancer patients using Caprini risk assessment model: a prospective cohort study.

There was no optimal risk assessment tool to stratify the risk of peripherally inserted central catheter-related venous thromboembolism (PICC-RVT) in cancer patients. We currently use the Caprini risk assessment model for thrombotic risk assessment, but no evidence exists on the effectiveness of Caprini in such patients. This study was to assess the validity of the Caprini in Chinese cancer patients with PICCs. We conducted a prospective study of 468 participants. Following calculating the Caprini score, color Doppler ultrasonography was performed every 7 days for 3 weeks to confirm PICC-RVT. There was a correlation between PICC-RVT and the Caprini score. Compared with scores of 5, the risk was 2.089-fold greater (95% CI 1.165-3.743, P = 0.012) in patients with a score of 6 and 7, and 7.156-fold greater (95% CI 3.157-16.217, P < 0.001) in patients with scores ≥8. The area under the receiver-operating characteristic curve was 0.636 (95% CI 0.590-0.680; P < 0.001). 6 was the best cutoff point for Caprini, with a sensitivity of 0.76 and a specificity of 0.44. The Caprini can be used for high-risk screening of the PICC-RVT in cancer patients, and classification of the highest risk level using a score of 6 can be more clinically significant compared to 5 as recommended. The results provide evidence for the practitioner's early use of the Caprini to assess the thrombotic risk in patients with PICCs and take timely prevention measures. But pharmacological prevention should be considered seriously for its low specificity.

Identifying risks for severity of neurological symptoms in Hungarian West Nile virus patients

BackgroundWest Nile virus (WNV) infections have become increasingly prevalent in certain European countries, including Hungary. Although most human infections do not cause severe symptoms, in approximately 1% of cases WNV infections can lead to severe WNV neuroinvasive disease (WNND) and death. The goal of our study was to assess the neurological status changes of WNV –infected patients admitted to inpatient care and to identify potential risk factors as underlying reasons for severe neurological outcome.MethodsWe conducted a retrospective chart review of 66 WNV-infected patients from four Hungarian medical centers. Patients’ neurological status at hospital admission and at two follow-up intervals (1st follow-up, within 60–90 days and 2nd follow-up, within 150–180 days, after hospital discharge) were assessed. All of the 66 patients in the initial sample had some type of neurological symptoms and 56 patients were diagnosed with WNND. The modified Rankin Scale (mRS) and the West Nile Virus Neurological Index (WNV-N Index), a scoring system designed for the purpose of this study, were used for neurological status assessment. Patients were dichotomized into two categories, “moderately severe” and “severe” based on their neurological status. Descriptive analysis for sample description, stratified analysis for calculation of odds ratio (OR) and logistic regression for continuous input variables, were performed.ResultsThe average number of days between the onset of neurological symptoms and hospital admission (the neurological symptom interval) was 6.01 days. Complications during the hospital stay arose in almost a fifth of the patients (18.2%) and 5 patients died. Each day’s increase in the neurological symptom interval significantly increased the risk for developing a severe neurological status following hospital admission (0.799-fold and 0.688-fold, based on the WNV-N Index and mRS, respectively). Patients’ age, comorbidity, presence of complications and symptoms of malaise, and gait uncertainty were shown to be independent risk factors for severe neurological status.ConclusionsTimely hospital admission of patients with neurological symptoms as well as risk assessment by clinicians - possibly with an optimal assessment tool for estimating neurological status- could improve the neurological outcome of WNV-infected patients.

T Scores, FRAX, Frailty Phenotype, Falls, and Its Relationship to Fractures in Patients on Maintenance Hemodialysis.

Background:Despite the magnitude of fracture and the consequences in patients receiving hemodialysis, optimal risk assessment tools in this population are not well explored. Frailty and falls—known risk factors for fracture in chronic kidney disease (CKD) and non-CKD populations—are common in patients receiving hemodialysis (HD) therapy. While the relationship between T scores in relation to fractures in patients receiving HD is recognized, there is a paucity of data to the additional contributions of fracture assessment tool (FRAX), frailty status, and falls in its relationship with fracture.Objectives:To evaluate the clinical utility of adding FRAX, frailty status, and falls to T scores at the femoral neck to determine whether it enhances fracture discrimination in patients on maintenance HD.Design:A cross-sectional observational study.Setting:Two main dialysis units in Regina, Saskatchewan, Canada.Patients:A total of 109 patients on maintenance HD at two dialysis units from January 1, 2017, to December 31, 2018, were included in the study.Measurements:Fracture (the main outcome) was documented based on the review of medical charts, self-recall, and additionally vertebral fractures were identified by an x-ray. Areal bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA). FRAX score was calculated using an online algorithm based on 11 clinical risk factors. We calculated the FRAX score for hip fracture and major osteoprotoic fracture with and without the inclusion of BMD. Frailty was assessed using the Fried criteria, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), and questionnaires for physical activity and self-perceived exhaustion. Patients were enquired about the history and frequency of falls.Methods:A total of 131 patients underwent frailty assessments at the two dialysis units during the dialysis treatment. Following frailty assessments, they were referred for DXA scans and upon receipt of the results undertook FRAX questionnaires. They were additionally sent for lumbar x-rays and contacted for a history of falls. Association between the BMD-T score, FRAX, frailty status, falls, with fracture were examined with sequential multivariable logistic regression models. Differences were considered statistically significant at P values <.05.Results:A total of 109 patients were included in the data analysis. The composite of fracture occurred in 37.6% of patients. About 59.3% were identified as frail, and 29% of the participants had at least one fall in the last year. On multivariate regression analysis, each lower standard deviation (SD) in femoral neck T score was associated with 48% higher odds of fracture (odds ratio [OR] = 1.48; 95% confidence interval [CI] 1.20-1.68, P = .005). With the inclusion for FRAX scores (hip), the OR for fracture remained significant at 1.38 (OR = 1.38, 95% CI 1.04-1.63, P = .043). The addition of frailty status and history of falls did not further improve the model. Low T score and FRAX were both independent risk factors in patients on HD therapy.Limitations:This is a single-center study with a small sample size which limits the generalizability of the findings. Due to the cross-sectional study, associations identified may be difficult to interpret.Conclusions:Both BMD measurements by DXA and FRAX are useful tools to assess fracture in patients receiving HD. The addition of frailty status and history of falls is not associated with fractures in this population. Larger prospective studies are needed to determine whether the inclusion of frailty and falls to the conventional models will improve fracture assessment in the population receiving HD.Trial Registration:The study was not registered on a publicly accessible registry as it did not involve health care intervention on human participants.

Patient-reported functional outcomes in a cohort of hand and foot sarcoma survivors treated with limb sparing surgery and radiation therapy.

Describe patient-reported functional outcomes for hand and foot sarcoma survivors treated with limb-sparing surgery and radiation therapy (LSS + RT). Fifty-four patients with hand/wrist and foot/ankle sarcomas treated with LSS + RT from 1991 to 2015 were identified. Survivors≥18 years old without subsequent amputation completed self-assessed functional surveys: Toronto upper extremity salvage score (TESS-UE) and Michigan hand outcomes (MHQ) surveys for hand; TESS lower extremity (TESS-LE) and Foot and Ankle Outcomes (FAOS) surveys for foot. Scoring scales: 0-100, MHQ and TESS; -26 to 56 and 25-59, FAOS core and shoe comfort, respectively. Higher scores denote superior function. Five-year local tumor control was 88%. Fourteen of 24hand (58%) and 14/18 foot (78%) survivors completed surveys. Mean TESS-UE and MHQ scores were 89.4 and 72.8, respectively. Mean TESS-LE, core FAOS, and shoe comfort scores were 92.4, 46.19, and 53.1, respectively. No factors correlated with outcomes. TESS-UE and MHQ scores strongly correlated (r = .87). TESS-LE and FAOS scores were associated with a poor correlation (r = .02 and r = .69). The largest patient-reported functional outcomes analysis for hand and foot sarcoma survivors treated with LSS + RT demonstrates excellent local tumor control and acceptable functional outcomes. Further exploration of optimal functional assessment tools is needed given the potential scope differences.

Prognostic prediction models and clinical tools based on consensus to support patient prioritization for clinical pharmacy services in hospitals: A scoping review.

Identifying patients at high risk of adverse medication-related outcomes for targeted clinical pharmacy services is essential in hospital pharmacy. Models and predictive tools to prioritize patients are available to the clinical pharmacy services for hospital use. To describe and assess prognostic models and predictive tools used to identify inpatients at risk of adverse medication-related outcomes. We searched in Medline, Lilacs, Cochrane, CINAHL, Embase, Scopus and Web of Science, databases of theses and dissertations, and the references of the selected studies. The screening was carried out by two independent researchers. Cross-sectional studies, prospective or retrospective cohort studies, and case-control studies were eligible for inclusion. The studies addressed the development or validation of predictive models and clinical prioritization tools based on expert opinion to identify inpatients at risk of adverse medication-related outcomes. 25 studies were included, 13 of which were prognostic prediction models, seven were instrument development using the consensus method, and five were validation. The outcome events were drug-related problems (9), adverse drug reactions (8), adverse drug events (6), and medication errors (2). Most studies targeted adult patients (14), eight had older adult patients, one had obstetric patients, and others had pediatric patients. External validation was performed after the development study in three studies. The predictive model with a low risk of bias was the Medicines Optimisation Assessment Tool. Limited details on the method of expert involvement and the number of experts were identified in four studies. The development of patient prioritization tools to optimize pharmacotherapy by clinical pharmacy services is a complex process. The predictive models and tools analyzed are limited in their development and validation process, hindering their effective use in prioritizing patients by the clinical pharmacy services. The development of additional prognostic prediction models for drug-related problems is a priority.

Diagnostic Performance of Delirium Assessment Tools in Critically Ill Patients: A Systematic Review and Meta-Analysis.

Critical care nurses are in the best position to detect and monitor delirium in critically ill patients. Therefore, an optimum delirium assessment tool with strong evidence should be identified with critical care nurses to perform in the daily assessment. To evaluate and compare the diagnostic performance of delirium assessment tools in diagnosing delirium in critically ill patients. We searched five electronic databases including the Cochrane Library, PubMed, Embase, CINAHL, and a Chinese database for eligible diagnostic studies published in English or Mandarin up to December 2018. This diagnostic test accuracy meta-analysis was limited to studies in intensive care unit (ICU) settings, using the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a standard reference to test the accuracy of delirium assessment tools. Eligible studies were critically appraised by two investigators independently. The summary of evidence was conducted for pooling and comparing diagnostic accuracy by a bivariate random effects meta-analysis model. The pooled sensitivities and specificities, summary receiver operating characteristic curve (sROC), the area under the curve (AUC), and diagnostic odds ratio (DOR) were calculated and plotted. The possibility of publication bias was assessed by Deeks' funnel plot. We identified and evaluated 23 and 8 articles focused on CAM-ICU and ICDSC, respectively. The summary sensitivities of 0.85 and 0.87, and summary specificities of 0.95 and 0.91 were found for CAM-ICU and ICDSC, respectively. The AUC of the CAM-ICU was 0.96 (95% CI, 0.94-0.98), with DOR at 99 (95% CI, 55-177). The AUC of the ICDSC was 0.95 (95% CI, 0.92-0.96), and the DOR was 65 (95% CI, 27-153). CAM-ICU demonstrated higher diagnostic test accuracy and is recommended as the optimal delirium assessment tool. However, the results should be interpreted with caution due to the between-study heterogeneity of this diagnostic test accuracy meta-analysis.

Identification of Frailty and Its Risk Factors in Elderly Hospitalized Patients from Different Wards: A Cross-Sectional Study in China.

ObjectivesTo survey the difference of frailty prevalence in elderly inpatients amongdifferent wards; to compare the diagnostic performance of five frailty measurements (Clinical Frailty Scale [CFS], FRAIL, Fried, Edmonton, Frailty Index [FI]) in identifying frailty; and to explore the risk factors of frailty in elderly inpatients.Participants and methodsThis was a cross-sectional study including 1000 inpatients (mean age 75.2±6.7 years, 51.5% male; 542, 229, and 229 patients from cardiology, non-surgical, and surgical wards, respectively) in a tertiary hospital from September 2018 to February 2019. We applied the combined index to integrate the five frailty measurements mentioned above as the gold standard of frailty diagnosis. Multivariate logistic regression models were used to determine the independent risk factors of frailty.ResultsFrailty prevalence was 32.3% (Fried), 36.2% (CFS), 19.2% (FRAIL), 25.2% (Edmonton), 35.1% (FI) in all patients. The frailty was more common in non-surgical wards, regardless of the frailty assessment tools used (non-surgical wards: 27.5% to 51.5%; cardiology ward: 14.9% to 29.3%; surgical wards: 18.8% to 41.9%). CFS≥5 showed a sensitivity of 94.1% and a specificity of 85.2% for all patients. FI≥0.25 showed a sensitivity of 94.8% and a specificity of 87.0% for all patients. Age [odds ratio (OR) = 1.089, P<0.001], education level (OR = 0.782, P=0.001), heart rate (OR = 1.025, P<0.001), albumin (OR = 0.911, P=0.002), log D-dimer (OR = 2.940, P<0.001), ≥5 comorbidities (OR = 2.164, P=0.002), and ≥5 medications (OR = 2.819, P<0.001) were independently associated with frailty in all participants.ConclusionFrailty is common among elderly inpatients, especially in non-surgical wards. CFS is a preferred screening tool and FI may be an optimal assessment tool. Old age, low educational level, fast heart rate, low albumin, high D-dimer, ≥5 comorbidities, and polypharmacy are independent risk factors of frailty in elderly hospitalized patients.

Evaluation of optimal psoriasis assessment tool incorporating both clinical measures and patient-reported outcomes for the treatment of moderate-to-severe plaque psoriasis

Evaluation of optimal psoriasis assessment tool incorporating both clinical measures and patient-reported outcomes for the treatment of moderate-to-severe plaque psoriasis

Optimal assessment tools in assessing breast surgery: patient reported outcome measures (PROMs) vs. objective measures.

Improving the health-related quality of life (HRQoL) of patients is the fundamental aim of aesthetic breast surgery and its importance is increasingly recognised in breast cancer-related surgery. There has been growing acceptance of the value of assessing physical, psychological and social well-being through patient reported outcome measures (PROMs). It is important to consider the role of PROMs in relation to objective measures to ensure that the optimal assessment tools are selected when assessing outcomes in breast surgery. A narrative review was conducted of published articles identified on Ovid Medline by searching the terms: patient reported outcome measures, quality of life (QoL), functional outcomes, aesthetic outcomes, complications and breast surgery. Reference lists were also examined to find relevant articles not detected through the search. Survival and mortality are outcomes of immense importance in breast surgery that are not suitable for assessment through PROMs and should be measured objectively. Post-operative complication rates and markers of their severity are most appropriately assessed using objective measures, however, patients may provide valuable insights into the impact complications have on their QoL. All current assessment tools for assessing aesthetic outcome have inherent limitations, and thus it is likely that both subjective and objective measures are required to comprehensively assess aesthetic outcomes in breast surgery. Physical dysfunction can be assessed objectively, however, PROMs may better evaluate physical well-being, reflecting the real-life implications of a change in function. Psychological and social well-being is irrefutably personal in nature and best assessed through PROMs. There is no one optimal assessment tool for assessing breast surgery outcomes. Utilising a combination of PROMs and objective measures is necessary to accurately and comprehensively evaluate the impact and effectiveness of surgical breast interventions.

A hybrid DMST model for pitch optimization and performance assessment of high-solidity straight-bladed vertical axis wind turbines

Straight-bladed vertical axis wind turbines (SBVAWTs) with a fixed pitch are subject to continuous variation in wind attack angle, which leads to low power generation. Variable pitch techniques are thus required to tackle the problem, but a proper analytical tool for pitch optimization and performance assessment must first be determined. This study thus aims to find a proper analytical tool for high-solidity SBVAWTs of low operational speeds for real-world applications. The applicability of the double-disk multiple stream-tube (DMST) model, a mainstream tool for analyzing moderate-solidity SBVAWTs and optimal pitch angles, is first examined for high-solidity SBVAWTs using measurement data obtained from wind tunnel tests. The complex flow field around a high-solidity SBVAWT is found to make current DMST models’ predictions unsatisfactory. A hybrid DMST model, using the attack angle-dynamic aerodynamic force coefficient relationship, is then proposed. The proposed hybrid DMST model predicts the aerodynamic forces acting on the blades with greater accuracy than those from current DMST models. Based on the proposed hybrid DMST model, a method of determining optimal pitch angles is developed and applied to the high-solidity SBVAWT. The results show that the novel method has the potential to significantly enhance power generation in high-solidity SBVAWTs.

541 Evaluation of optimal psoriasis assessment tool (OPAT) incorporating both clinical and patient-reported outcomes for treatment of moderate-to-severe plaque psoriasis

Psoriasis Area and Severity Index (PASI) is not used in routine clinical practice due to complexity and time. A simpler assessment measure more predictive of patients’ (pt) quality of life and sensitive to changes in symptom severity and pt assessment is needed. We evaluate OPAT’s potential as an alternative to PASI, based on simple and relevant clinical measures and pt outcomes correlated with PASI and Dermatology Life Quality Index. Using 3 integrated UNCOVER trials, intent-to-treat pts (N=3863) were randomized to ixekizumab (IXE) 80 mg every weeks (wks) (Q2W) or every 4 wks (Q4W) after 160-mg starting dose, placebo, or etanercept 50 mg Q2W (UNCOVER-2,-3) to Wk 12. Correlations were computed for clinical measures (BSA; worst-scaling, -erythema, and -thickness) and pt-reported measures (skin pain, itch, Pt’s Global Assessment) with PASI and DLQI at baseline (BL) and Wks 4, 8, 12 (PASI) and 4, 12 (DLQI). Regressions were run on PASI and DLQI at BL and Wk 12 using covariates BSA and pt assessments. At BL and Wks 4, 8, 12, strong correlations were found (PASI *BSA r=0.72 to 0.78), and PASI and BSA with each symptom severity and worst sum of severity measures (r=0.82 to 0.90). DLQI correlations with simple patient-assessed measures were higher than with PASI and increased over time. At Wk 12, regression analysis revealed higher correlation of PASI and BSA combined with pt assessments (R=0.912 to 0.915) than with BSA alone (r=0.78). For DLQI, correlations with these same combined measures were even stronger (R=0.75 to 0.78) than BSA alone (r=0.31). The best subset models were 2-variable models, including BSA and 1 pt assessment. OPAT is a simple alternative to PASI and can be derived using 1 to 2 pt assessments that have modest correlation with PASI and strong correlation with DLQI. OPAT can be used in real-world clinical practice via a simple, digital tool.

Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists’ input to prevent medication-related problems

BackgroundMedicines optimisation is a key role for hospital pharmacists, but with ever-increasing demands on services, there is a need to increase efficiency while maintaining patient safety.ObjectiveTo develop a prediction tool,...

Sleep after TBI: How the TBI Model Systems have advanced the field.

Identification and management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Recent meta-analyses highlight sleep disturbance and sleep disorders following TBI (Mathias & Alvaro, 2012). Improving the recognition and treatment of sleep disorders in TBI should be a central focus of rehabilitation. The Traumatic Brain Injury Model System (TBIMS) has created an infrastructure allowing multi-center investigations into sleep dysfunction in those who have had a moderate to severe TBI and received inpatient rehabilitation. This paper will describe the 1) infrastructure used to advance sleep dysfunction/disorders research following TBI, 2) preliminary findings from these studies, and 3) repository of data which can be accessed for secondary analyses by investigators outside of the TBIMS infrastructure. Two internal mechanisms allow investigators at TBIMS sites to collaborate on projects of shared interest: Research Modules and Special Interest Groups (SIG). To date, five studies have resulted from the TBIMS collaborative process focusing on insomnia, circadian disruption, and sleep apnea. Future directions for the SIG include continued development of available knowledge and understanding of the multidimensional factors that contribute to TBI-related sleep disturbance, optimal assessment tools, effectiveness of available treatments, and treatment compliance in this population.

Rapid screening of IgG quality attributes – effects on Fc receptor binding

The interactions of therapeutic antibodies with fragment crystallizable γ (Fcγ) receptors and neonatal Fc receptors (FcRn) are measured in vitro as indicators of antibody functional performance. Antibodies are anchored to immune cells through the Fc tail, and these interactions are important for the efficacy and safety of therapeutic antibodies. High‐throughput binding studies on each of the human Fcγ receptor classes (FcγRI, FcγRIIa, FcγRIIb, FcγRIIIa, and FcγRIIIb) as well as FcRn have been developed and performed with human IgG after stress‐induced modifications to identify potential impact in vivo. Interestingly, we found that asparagine deamidation (D‐N) reduced the binding of IgG to the low‐affinity Fcγ receptors (FcγRIIa, FcγRIIb, FcγRIIIa, and FcγRIIIb), while FcγRI and FcRn binding was not impacted. Deglycosylation completely inhibited binding to all Fcγ receptors, but showed no impact on binding to FcRn. On the other hand, afucosylation only impacted binding to FcγRIIIa and FcγRIIIb. Methionine oxidation at levels below 7%, multiple freeze/thaw cycles and short‐term thermal/shake stress did not influence binding to any of the Fc receptors. The presence of high molecular weight species, or aggregates, disturbed measurements in these binding assays; up to 5% of aggregates in IgG samples changed the binding and kinetics to each of the Fc receptors. Overall, the screening assays described in this manuscript prove that rapid and multiplexed binding assays may be a valuable tool for lead optimization, process development, in‐process controls, and biosimilarity assessment of IgGs during development and manufacturing of therapeutic IgGs.

Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to improve patient outcomes. Protocol for an observational study

IntroductionMedicines optimisation is a key role for hospital pharmacists, but with ever-increasing demands on services there is a need to increase efficiency while maintaining patient safety. The aim of this...

Understanding Interrater Reliability and Validity of Risk Assessment Tools Used to Predict Adverse Clinical Events.

This article will describe how to assess interrater reliability and validity of risk assessment tools, using easy-to-follow formulas, and to provide calculations that demonstrate principles discussed. Clinical nurse specialists should be able to identify risk assessment tools that provide high-quality interrater reliability and the highest validity for predicting true events of importance to clinical settings. Making best practice recommendations for assessment tool use is critical to high-quality patient care and safe practices that impact patient outcomes and nursing resources. Optimal risk assessment tool selection requires knowledge about interrater reliability and tool validity. The clinical nurse specialist will understand the reliability and validity issues associated with risk assessment tools, and be able to evaluate tools using basic calculations. Risk assessment tools are developed to objectively predict quality and safety events and ultimately reduce the risk of event occurrence through preventive interventions. To ensure high-quality tool use, clinical nurse specialists must critically assess tool properties. The better the tool's ability to predict adverse events, the more likely that event risk is mediated. Interrater reliability and validity assessment is relatively an easy skill to master and will result in better decisions when selecting or making recommendations for risk assessment tool use.

Evaluation of CO2 Low Salinity Water-Alternating-Gas for enhanced oil recovery

Low Salinity Waterflooding (LSW) is an emerging attractive enhanced oil recovery (EOR) method because of its oil recovery performance and relatively simple, environmentally friendly implementation, when compared with conventional high salinity waterflooding and EOR approaches. More importantly, another advantage of LSW is that it can be integrated with other EOR methods (in hybrid LSW processes), i.e. chemical or miscible gas flooding. The merits of combining LSW with CO2 injection is investigated in this paper, and a novel EOR method, Low Salinity Water Alternating CO2 (CO2 LSWAG), is proposed. CO2 LSWAG injection promotes the synergy of the mechanisms underlying these methods which further enhances oil recovery and overcomes the late production problems frequently encountered in conventional WAG. CO2 LSWAG has been evaluated in both one-dimensional and full-field scale with positive results compared with conventional high salinity WAG.To investigate the advantages of CO2 LSWAG, a comprehensive ion exchange model associated with geochemical processes has been implemented and coupled to the multi-phase multi-component flow equations in an equation-of-state compositional simulator. 1D simulation of different CO2 LSWAG schemes are first conducted to understand the combined effects of solubility of CO2 in brine, dissolution of carbonate minerals, ion exchange, and wettability alteration. CO2 LSWAG performance is then evaluated on a field scale through an integrated workflow that includes geological modeling, multi-phase multi component reservoir flow modeling and process optimization. The simulation results indicate that CO2 LSWAG has the highest oil recovery compared to conventional high salinity waterflood, high salinity WAG, continuous CO2 flooding, and low salinity waterflood. A number of geological realizations are generated to assess the geological uncertainty effect, in particular clay distribution uncertainties, on CO2 LSWAG efficiency. CO2 LSWAG injection strategies are optimized by identifying key WAG parameters. Finally, CO2 LSWAG is evaluated in the full field scale for a North Sea reservoir and the simulation results shows that CO2 LSWAG yields about 4.5% incremental OOIP compared to the conventional high salinity WAG.The proposed workflow demonstrates the synergy between CO2 WAG and LSW. Built in a robust reservoir simulator, it serves as a powerful tool for screening, design, optimization, and uncertainty assessment of the process. CO2 LSWAG is a promising EOR technique as it not only combines the benefits of CO2 injection and low salinity water floods but also promotes the synergy between these processes through the interactions between geochemical reactions associated with CO2 injection, ion exchange process, and wettability alteration. This paper demonstrates the merits of this process through modeling, optimization and uncertainty assessment.

Hyperlactemia Predicts Surgical Mortality in Patients Presenting With Acute Stanford Type-A Aortic Dissection.

Inspired by the limited facility of the Penn classification, the authors aimed to determine a rapid and optimal preoperative assessment tool to predict surgical mortality after acute Stanford type-A aortic dissection (AAAD) repair. Patients who underwent an attempted surgical repair of AAAD were determined using a de-identified single institution database. The charts of 144 patients were reviewed retrospectively for preoperative demographics and surrogates for disease severity and malperfusion. Bivariate analysis was used to determine significant (p≤0.05) predictors of in-hospital and 1-year mortality, the primary endpoints. Receiver operating characteristic curve generation was used to define optimal cut-off values for continuous predictors. Single center, level 1 trauma, university teaching hospital. The study included 144 cardiac surgical patients with acute type-A aortic dissection presenting for surgical correction. Surgical repair of aortic dissection with preoperative laboratory samples drawn before patient transfer to the operating room or immediately after arterial catheter placement intraoperatively. The study cohort comprised 144 patients. In-hospital mortality was 9%, and the 1-year mortality rate was 17%. Variables that demonstrated a correlation with in-hospital mortality included an elevated serum lactic acid level (odds ratio [OR] 1.5 [1.3-1.9], p<0.001), a depressed ejection fraction (OR 0.91 [0.86-0.96], p = .001), effusion (OR 4.8 [1.02-22.5], p = 0.04), neurologic change (OR 5.3 [1.6-17.4], p = 0.006), severe aortic regurgitation (OR 8.2 [2.0-33.9], p = 0.006), and cardiopulmonary resuscitation (OR 6.8 [1.7-26.9], p = 0.01). Only an increased serum lactic acid level demonstrated a trend with 1-year mortality using univariate Cox regression (hazard ratio 1.1 [1.0-1.1], p = 0.006). Receiver operating characteristic analysis revealed optimal cut-off lactic acid levels of 6.0 mmol/L and 6.9 mmol/L for in-hospital and 1-year mortality, respectively. Lactic acidosis, ostensibly as a surrogate for systemic malperfusion, represents a novel, accurate, and easily obtainable preoperative predictor of short-term mortality after attempted AAAD repair. These data may improve identification of patients who would not benefit from surgery.