The growing presence of electronic anesthesia record keeping and perioperative informatics systems is contributing to a database of valuable information that can significantly improve patient care and patient outcomes. Efforts such as the National Surgical Quality Improvement Project and the Surgical Care Improvement Project have analyzed quality measures that directly correlate to patient outcomes. Several of these quality indicators are influenced by the performance of anesthesia providers’ activities in the perioperative period. These programs promote timely administration of preoperative antibiotics. One of their guidelines states that preoperative antibiotic should be given within an hour prior to surgical incision. Surgical site infections are the most common postoperative complication. Reducing postoperative complications can reduce health care costs, and postoperative morbidity and mortality rates. The purpose of this project was to utilize an electronic feedback mechanism to improve anesthesia providers’ documentation of timely preoperative antibiotic administration. Electronic feedback reminders in the form of screensaver dashboards displaying updated departmental timely antibiotic percentage metrics for the day, the past week, and the past month were displayed for 16 weeks. Text messages were delivered once a week for 6 weeks showing an anesthesia providers’ prior average one week on time antibiotic along with an equivalent department on time average. The measures were effective in improving the documentation of timely antibiotic administration.

Background: Emerging evidence suggests that interactive CE activities will have the most effect in terms of knowledge and practice. Using technology to provide interactivity via computer-based applications is as effective an educational strategy as traditional education formats. Methods: A randomized controlled trial was conducted to test the effectiveness and satisfaction of educational activities provided within an online community of practice(CoP) on nurse practitioner (NP) knowledge and practice behavior. The online interactive website combined certified continuing education, professional forum, Ask-the-Experts, national guideline links, patient education tools, and professional resources. A Two-Group Control Group design was used. Study participants were assessed on knowledge and practice behavior prior to and after the six month study. Results: A sample of 66 NPs was randomly assigned to an online education only control group (n=33) or a CoP group (n=33). NPs in both groups had similar pretest knowledge assessment scores: 46% (control) vs. 49% (CoP), and pretest clinical vignette scores: 51%(control) vs. 57% (CoP). After the intervention, there was no significant increase in the posttest scores of the CoP group at 6 months compared with the posttest scores of the control group (knowledge assessment: 67% vs. 60%, p =.17; clinical vignettes: 67% vs. 74%, p =.28). Conclusions: The pilot test did not demonstrate that the intervention (CoP access) had a more positive effect on knowledge or clinical performance than access to online CE activities alone. It did however confirm the effectiveness of online education in improving knowledge.

La résonance magnétique nucléaire (RMN) est désormais devenue une technique spectroscopique incontournable à de nombreux domaines de la science et de la médecine. Cependant, elle est limitée par une faible sensibilité en raison d'une polarisation nucléaire insuffisante, définie par la différence des populations entre les niveaux d'énergie impliqués, ce qui résulte à des temps expérimentaux assez longs. Cet inconvénient peut être compensé en transférant l’énorme polarisation des électrons non appariés aux spins nucléaires à l'aide d'une irradiation par micro-ondes à basse température - une méthode connue sous le nom de polarisation nucléaire dynamique (DNP). Sami Jannin et ses collègues ont récemment combiné la méthode de polarisation croisée (CP) avec la DNP, à des températures très basses, afin de polariser plus rapidement les noyaux de faible γ en transférant la polarisation des électrons aux protons et ensuite aux noyaux de faible γ, comme le carbone-13. Cette thèse démontre que l'efficacité de cette méthode peut être améliorée en arrêtant l'irradiation par micro-ondes pendant quelques centaines de millisecondes avant la CP. En effectuant ces expériences, la polarisation du carbone-13 de l'acétate de sodium [1-¹³C] peut monter jusqu'à 64% avec une constante de temps d'accumulation de polarisation très courte de 160 s. L'échantillon hyperpolarisé peut ensuite être rapidement dissous pour obtenir un signal RMN amplifié à l'état liquide et à la température ambiante. Cette méthode a été développée par Ardenkjaer-Larsen et ses collègues en 2003 et est connue sous le nom de polarisation nucléaire dynamique par dissolution (D-DNP). Elle peut fournir une amplification du signal d'un facteur jusqu'à quatre ordres de grandeur. La combinaison de la D-DNP avec les techniques de CP peut être utilisée pour créer des états de longue durée de vie (LLS) dans des molécules deutériées comme l'éthanol-d6 et le DMSO-d6. Ces états peuvent avoir des durées de vie beaucoup plus longues que l'aimantation conventionnelle de Zeeman. Ces états peuvent être détectés indirectement via des multiplets asymétriques dans les spectres RMN du carbone-13 en solution, à température ambiante après dissolution, via les couplages scalaires entre le carbone-13 et les noyaux du deutérium. Ces LLS résultent du déséquilibre des populations entre les représentations irréductibles des groupes de symétrie des molécules deutériées étudiées. Dans cette thèse, nous avons étudié les LLS dans les groupes CD₂ et CD₃. Les durées de vie de ces LLS peuvent dépasser les temps de relaxation T₁(²H) des noyaux de deutérium par un facteur jusqu'à 20 (dépendant de la dynamique moléculaire) et peuvent être observées par la décroissance de l'asymétrie du multiplet du carbone-13. Ces observations peuvent élargir les applications de la DNP en ajoutant le noyau de ²H à la liste des observables possibles / Nowadays, Nuclear Magnetic Resonance (NMR) has become an inevitable spectroscopic technique that can be applied in many fields of science and medicine. However it is limited by low sensitivity due to the low nuclear polarization, defined by the difference of populations between the energy levels involved, thus leading to long experimental times. This drawback can be overcome by using the huge polarization of unpaired electrons compared to nuclear spins and its transfer to nuclear spins at low temperatures (using microwave irradiation) to achieve a large nuclear magnetization - a method know as dynamic nuclear polarization (DNP). Sami Jannin and co-workers have recently combined the cross-polarization (CP) method with DNP at very low temperatures to polarize low γ nuclei faster by transferring the electron polarization to protons and then to low γ nuclei like ¹³C. This thesis demonstrates that the efficiency of the CP method can be improved by switching the microwave irradiation off for a few hundred milliseconds prior to CP. By performing these microwave gating experiments, ¹³C polarizations for sodium [1-¹³C]acetate as high as 64% could be achieved with a polarization build-up time constant as short as 160 s. The hyperpolarized sample can subsequently be rapidly dissolved to achieve NMR signal enhancement in the liquid state at ambient temperature. This method has been developed by Ardenkjaer-Larsen and co-workers in 2003 and became known as dissolution-dynamic nuclear polarization (D-DNP). It can provide signal enhancements by a factor of up to four orders of magnitude in liquid state at room temperature. Combining D-DNP with CP techniques from ¹H to ¹³C can be used to create to create long-lived states (LLS) in deuterated molecules like ethanol-d₆ and DMSO-d₆, which can have much longer life times than conventional Zeeman magnetization. These LLS can be detected indirectly via the asymmetric multiplets in ¹³C NMR spectra in solution state at room temperature after dissolution due to scalar couplings between ¹³C and ²H. These LLS result from population imbalances between spin manifolds of distinct irreducible representations of the relevant symmetry groups of the investigated deuterated moities. In this thesis we have investigated LLS in CD₂ and CD₃ groups. Lifetimes of these LLS can exceed the spin-lattice relaxation times T₁(²H) of deuterium nuclei by a factor up to 20 (depending on the underlying molecular dynamics) and can be obtained by monitoring the decay of the asymmetry of the ¹³C multiplet. These observations can expend the scope of DNP by adding ²H nucleus to the list of possible observables.

The purpose of this project was to improve support for victims of domestic violence. To that end, this project developed an evidence-based program to provide information about domestic violence including safe and confidential ways to seek assistance, rights as cohabiting intimate partners, and the resources available to community members. Several approaches were used to develop, validate, and plan for implementation and evaluation of this program, which was developed for 3 sites in Broward and Miami-Dade counties where the project is situated. The program logic model and the social ecological model, including the individual, relationship, community, and societal levels, were used to guide this project. In addition, scholarly works from 2000 to 2013 were selected from ProQuest, CINAHL, Ebscohost, Medline, and Ovid Nursing Journals to develop this program in collaboration with an interdisciplinary team of 7 community stakeholders including a physician, advanced practice nurse, law enforcement officer, pastor, and 3 recovery center directors with knowledge in these areas. Content validation involved incorporating feedback from the project team. The target population for the project includes women and men aged 18 or higher who have experienced domestic violence, homelessness, and drug addiction. Community operationalization of the initiative will be facilitated by implementation and evaluation plans developed as part of this project. The project includes community education that may help organize events and campaigns, increase domestic violence awareness among community members, and influence policy regarding issues pertaining to domestic violence.

<p>Insulin release from single islets of Langerhans is pulsatile. The secretory activities of the islets in the pancreas are coordinated resulting in plasma insulin oscillations. Nutrients amplitude-regulate the insulin pulses without influencing their frequency. Diabetic patients show an abnormal plasma insulin pattern, but the cause of the disturbance remains to be elucidated. Ithe present thesis the influence of the cytoplasmic calcium concentratio([Ca²⁺]_i) and cell metabolism on pulsatile insulin release was examined in single islets of Langerhans from <i>ob/ob</i>-mice. Glucose stimulation of insulin release involves closure of ATP-sensitive K⁺ channels (K_ATP channels), depolarization, and Ca²⁺ influx in β-cells. In the presence of 11 mM glucose, pulsatile insulin secretion occurs in synchrony with oscillations i[Ca²⁺]_i. When [Ca²⁺]_i is low and stable, e.g. under basal conditions, low amplitude insulin pulses are still observed. When [Ca²⁺]_i is elevated and non-oscillating, e.g. when the β-cells are depolarized by potassium, high amplitude insulin pulses are observed. The frequency of the insulin pulses under these conditions is similar to that observed when [Ca²⁺]_i oscillations are present. By permanently opening or closing the K_ATP channels with diazoxide or tolbutamide, respectively, it was investigated if glucose can modulate pulsatile insulin secretion when it does not influence the channel activity. Under these conditions, [Ca²⁺]_i remained stable whereas the amplitude of the insulin pulses increased with sugar stimulation without change in the frequency. Metabolic inhibition blunted but did not prevent the insulin pulses. The results indicate that oscillations in metabolism can generate pulsatile insulin release when [Ca²⁺]_i is stable. However, under physiological conditions, pulsatile secretion is driven by oscillations in metabolism and [Ca²⁺]_i, acting in synergy.</p>

Insulin release from single islets of Langerhans is pulsatile. The secretory activities of the islets in the pancreas are coordinated resulting in plasma insulin oscillations. Nutrients amplitude-regulate the insulin pulses without influencing their frequency. Diabetic patients show an abnormal plasma insulin pattern, but the cause of the disturbance remains to be elucidated. Ithe present thesis the influence of the cytoplasmic calcium concentratio([Ca2+]i) and cell metabolism on pulsatile insulin release was examined in single islets of Langerhans from ob/ob-mice. Glucose stimulation of insulin release involves closure of ATP-sensitive K+ channels (KATP channels), depolarization, and Ca2+ influx in β-cells. In the presence of 11 mM glucose, pulsatile insulin secretion occurs in synchrony with oscillations i[Ca2+]i. When [Ca2+]i is low and stable, e.g. under basal conditions, low amplitude insulin pulses are still observed. When [Ca2+]i is elevated and non-oscillating, e.g. when the β-cells are depolarized by potassium, high amplitude insulin pulses are observed. The frequency of the insulin pulses under these conditions is similar to that observed when [Ca2+]i oscillations are present. By permanently opening or closing the KATP channels with diazoxide or tolbutamide, respectively, it was investigated if glucose can modulate pulsatile insulin secretion when it does not influence the channel activity. Under these conditions, [Ca2+]i remained stable whereas the amplitude of the insulin pulses increased with sugar stimulation without change in the frequency. Metabolic inhibition blunted but did not prevent the insulin pulses. The results indicate that oscillations in metabolism can generate pulsatile insulin release when [Ca2+]i is stable. However, under physiological conditions, pulsatile secretion is driven by oscillations in metabolism and [Ca2+]i, acting in synergy.

Submitted by Wilson Nobre Filho (wilson.nobre@fgv.br) on 2013-07-16T21:54:48Z No. of bitstreams: 1 Dissertacao de Mestrado – Wilson Nobre 2013.pdf: 2816404 bytes, checksum: bd330cdfccbdec4ced5db374509a28bc (MD5) / Approved for entry into archive by Suzinei Teles Garcia Garcia (suzinei.garcia@fgv.br) on 2013-07-17T12:24:17Z (GMT) No. of bitstreams: 1 Dissertacao de Mestrado – Wilson Nobre 2013.pdf: 2816404 bytes, checksum: bd330cdfccbdec4ced5db374509a28bc (MD5) / Made available in DSpace on 2013-07-17T13:33:14Z (GMT). No. of bitstreams: 1 Dissertacao de Mestrado – Wilson Nobre 2013.pdf: 2816404 bytes, checksum: bd330cdfccbdec4ced5db374509a28bc (MD5) Previous issue date: 2013-06-18 / Este trabalho visa identificar práticas de design thinking (DT), isto é, as abordagens características da disciplina do design para criação de inovações, que possam ser incorporadas ao processo de desenvolvimento de novos produtos (DNP). Cinco dessas práticas – abordagem centrada em pessoas, estilo de trabalho colaborativo, pensar fazendo, visualização e combinação de abordagens divergente e convergente – foram analisadas por meio do estudo de caso em profundidade de três empresas polares: um escritório profissional de design, uma empresa de produtos para cuidados pessoais e um fabricante de ferramentas profissionais. A discussão teórica apoiou-se em autores de DNP e de DT que estudaram a evolução desses campos em gerações de maturidade, trazendo também visões bem recentes que apontam para a relevância das mudanças em curso. Entre os achados da pesquisa, observou-se que o modelo de gestão e a estrutura organizacional – orientada por projetos com times multifuncionais ou por processos com estrutura funcional – tem influência na adoção das práticas de DT. Outro achado, esse menos evidente, mostrou que a forma como a empresa se relaciona com clientes e usuários, guarda semelhança com a forma como trata seus profissionais de DNP. Uma descoberta interessante é a função moderadora do alinhamento de propósitos entre empresa e colaborador, para a adoção dessas práticas. Como contribuição ao campo de estudo, apresenta-se um diagrama de cinco gerações de evolução da oferta de novos produtos (ONP), termo utilizado para incorporar não só os produtos com inovações desenvolvidas e de propriedade da empresa focal, mas também aquelas desenvolvidas pelos próprios usuários e as inovações construídas nas redes sociais e oferecidas pela empresa focal. / This work aims to identify practices in design thinking (DT), that is, the approaches that characterize the discipline of design to create innovations, that can be brought into the process of new product development (NPD). Five of these practices–—people-centered approach, collaborative work style, thinking by doing, visualization and combining divergent and convergent approaches–—were analyzed by means of in-depth case study of three selected companies: a professional design office, a company of personal care products and a manufacturer of professional tools. The theoretical discussion was based on authors in NPD and DT fields that have studied the evolution of these fields in generations of maturity, also shedding light on new visions that underscore the relevance of the changes underway. Among the findings of the research, it was observed that the management model and organizational structure–—project-oriented with cross-functional teams or process-oriented with functional structure–—influences the adoption of DT practices. A less obvious finding showed that the way a company connects with customers and users is clearly tied in with the way it treats its NPD employees. An interesting finding is the moderating role of alignment of purpose between company and employee, for the adoption of these practices. As a contribution to the research field, this work presents a five generation diagram of the evolution of new products offering (NPO), a term used to incorporate not only the products with innovations developed and owned by the focal firm, but also those developed by the users and innovations constructed in social networks and distributed by the focal firm.

Diabetes is a condition that is primarily self-managed and lifestyle modifications such as diet, exercise, and weight management are necessary to reduce morbidity and mortality. Motivation to implement lifestyle modifications through self management is an integral part of disease management and studies have shown group medical visits are more effective than individual appointments in this patient population. The purpose of this project was to develop, implement and evaluate an evidencebased group medical visit program for up to a maximum of 8 adult patients with type 2 diabetes in a family practice setting for six months. Seven participants with abnormal A1C results accepted the invitation to attend group medical visits. Here surrounded by peers with the same diagnosis, they were able to learn and discuss methods to self manage their type 2 diabetes. At the conclusion post survey results indicate positive change in some lifestyle behaviors and improvement with hemoglobin A1C. However there was no improvement in weight management. A cost analysis reveals group medical visits may generate a small profit when compared to individual visits. Group medical visits may offer an effective means to motivate patients to make lifestyle change to reduce risk.

Current procedures for cleaning anesthesia airway equipment have been reported to be ineffective. The potential for cross-contamination from some airway equipment to a patient has been documented in several studies. In order to prevent potential infections, it should be ascertained as to why all anesthesia providers are not using disposable laryngoscope blades. The purpose of this evidence based project is to determine the perceptions of anesthesia providers regarding the use of disposable laryngoscope blades. Their frequency of use, their evaluation of ease of use, and any complications encountered when using the disposable blade before and after an in-service program designed to increase the use of disposable blades will be determined. Once Institutional Review Board (IRB) approval and written consent were obtained, anesthesia providers were asked to complete an anonymous one page questionnaire on their knowledge and practice regarding disposable laryngoscope blades. Immediately following the completion of the questionnaire, participants were given an investigator developed article to read. Participants completed the same anonymous questionnaire 3 months following the pre-intervention questionnaire. Inventory of the disposable laryngoscope blades were collected at the start of the project, at one month, and then again at three months. A total of 12 anesthesia providers participated in the evidence based practice project. An increased number of providers stated that they felt disposable laryngoscope blades were easy to use at the completion of the project and there was an increased use of disposable laryngoscope blades. At post-intervention, anesthesia providers described performance (25%) as their reason for not using the disposable laryngoscope blade which was down from the start of the project (60%). A single proportion Z-Test showed that the 23% increase in use of disposable laryngoscope blades after the intervention was statistically significant (Z=2.046, p=0.041). This evidence based project has shown that despite initial apprehension, a change in practice was evident after dissemination of the best and most recent clinical evidence regarding laryngoscope blades which should translate to improved patient outcomes.

The incidence and prevalence of overweight and obese children in the United States is a serious health concern since the complications of childhood obesity can have serious and long-term effects: cardiovascular disease, sleep apnea, type 2 diabetes, neurological disease, and pulmonary disease. Parental modeling and nutritional education focusing on the obese/overweight child’s parents has been shown as an effective strategy for improving nutritional outcomes of the recommended servings of fruits and vegetables in children from five to ten years of age. Outcomes of this study and targeted nutritional modeling included increasing vegetable and fruit consumption of the parent by at least one fruit and vegetable serving per day post-intervention through nutritional education. The project purpose was to measure the impact of a parent-focused nutritional educational intervention that increases fruit and vegetable consumption in the parents of obese and overweight children. While the study indirectly measured a nutrition education intervention aimed at children via their parents, no children were included in this project. Parents (N = 93) of obese/overweight children were provided nutritional and modeling education over three months. A participation rate of 14% (N = 13) was achieved. The majority of the parents were single African American mothers between 18 and 25 years old with one or two children living in the household, an average income less than $10,000 per year, and some college or technical education. This project used a pre-and post-test design to measure the effectiveness of a nutritional educational intervention. A descriptive analysis of the participants was computed. Differences in the pre-and post-test scores on the parental dietary modeling questionnaire and the food frequency questionnaire were analyzed. Results showed a significant increase in fruit and vegetable consumption (p < .05). The majority of the increase was due to improved fruit consumption. There was also an increase in parental modeling awareness. Parents’ understanding of the importance of parental modeling had an impact on nutritional selection of their own fruit and vegetable intake.