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Indiana University-Purdue University Indianapolis (IUPUI) / Hospital readmission is of growing importance in the healthcare industry because of associated patient and system costs, impact to the quality of patient care, and hospital Medicare payment penalties. The increasing interest in sepsis readmission prevention has highlighted the uniqueness of severe sepsis or septic shock survivors. The results of this study provide insight into the relationship between index hospital length of stay (LOS) and 30-day readmissions for older adults (> 65 years) who discharged home from an index hospital with a principle or secondary discharge diagnosis of severe sepsis or septic shock. The purpose of this study was to investigate the relationship between index hospital LOS and 30-day readmissions in older adults (> 65 years) whose expected primary payer was Medicare and who discharged home with a principle or secondary diagnosis of severe sepsis or septic shock. Data used to answer the proposed research questions consisted of older adult discharge records from the 2014 Nationwide Readmissions Database (NRD), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Differences in 30-day readmissions between older adult age groups, gender, and older adult location were examined. The number of days to readmission since discharge was evaluated for the subset of older adults with a readmission. Approximately 15.6% of older adults were readmitted within 30 days of their discharge. Readmissions were statistically different based on the older adult’s age, gender, and LOS. Location did not have a significant effect on readmissions. Mean LOS among readmitted older adults was 10.1 days. Analysis indicates that an older adult’s LOS had a significant effect on readmissions, although models performed poorly. Findings suggest that there are certain factors that can predict older adults who are at risk for being readmitted after being discharged with a principle or secondary discharge diagnosis of severe sepsis or septic shock.

<p>Dhurrin is a cyanogenic glucoside (CG), an important compound that can interplay with primary and secondary metabolism in sorghum. Dhurrin metabolism contributes to insect resistance, growth, nitrogen (N) metabolism, drought tolerance, and safety for animal consumption when used as a forage. Through chemical mutagenesis with ethyl methanesulfonate (EMS), a mutation in the gene encoding CYP79A1 (<i>cyp79a1</i>), the first enzyme in the biosynthetic pathway of dhurrin, was discovered that inhibits the production of dhurrin. The acyanogenic phenotype of this mutant could be a major benefit in reducing the risk of hydrogen cyanide (HCN) toxicity within animals; however, understanding the effects of inhibiting dhurrin biosynthesis is important in understanding metabolic tradeoffs that could occur. This dissertation describes research to assess impacts and tradeoffs of the dhurrin-free trait on susceptibility to Fall Armyworm [<i>Spodoptera frugiperda</i> (J.E. Smith)] (FAW) feeding, seedling growth, effects on post-flowering drought tolerance, cold stress and utilization as a forage. Insect susceptibility and seedling growth were examined using near-isogenic lines (NILs) within the greenhouse utilizing non-destructive phenotyping technologies for green plant area and in the field comparing total leaf area and dry weight. Post-flowering drought stress was induced within a greenhouse, growth chamber, and field environments. The <i>cyp79a1 </i>mutation was tested in NILs, a near-isogenic backcross (NIBC) population, and near-isogenic hybrids (NIH), to understand the impacts of the <i>cyp79a1 </i>mutation<i> </i>on the stay-green trait. Palatability as forage was examined by comparing the feeding preference of ruminant animals with multiple conventional hybrids and an experimental hybrid carrying the <i>cyp79a1</i> mutation. This preference was also examined using a set of NILs varying in the <i>cyp79a1 </i>mutation<i>. </i> Safety was assessed in preference trials by testing for HCN release before grazing. To further our understanding of the benefits of sorghum as a forage, the dhurrin-free experimental hybrid was compared to seven conventional hybrids as a dry product. The dry sorghum product was tested for the release of HCN and dhurrin content. Lastly, the effects of low temperatures and frost were assessed for their effects on the production of dhurrin in cyanogenic and dhurrin-free sorghum genotypes. </p> <p>Overall, the biosynthesis of dhurrin had a significant effect on the deterrence of FAW and on the growth of sorghum seedlings. Dhurrin-free lines were more susceptible to FAW feeding but also exhibited a significantly higher growth rate. Dhurrin-free lines and hybrids only exhibited a slight increase in susceptibility to post-flowering drought stresses with only one dhurrin-free hybrid discovered to senesce faster than its wild-type NIH. Comparisons of the effects of dhurrin biosynthesis on stay-green in a NIBC population in Tx642 (B35), one of the most important sources of the stay-green trait, did not show any variation in chlorophyll concentration (CC) and normalized difference vegetation index (NDVI). Analyses of the impact of dhurrin on palatability as a forage showed that ewes preferred grazing on the dhurrin-free hybrids and NILs, showing that the ewes were able to detect the presence or absence of dhurrin while feeding. Experiments to assess the safety and stability of dhurrin in dried plant material demonstrated that dhurrin content did not change during drying and HCN was released after rehydration. Furthermore, high levels of HCN were immediately released when rumen fluid was added to dried plant materials containing dhurrin; however, no detectable HCN was released from dhurrin-free genotypes. Finally, sorghum plants exposed to freezing temperatures exhibited an increase in dhurrin content in conventional sorghum hybrids while no detectable dhurrin was noted within <i>cyp79a1 </i>mutants. </p> <p>Taken together, these studies demonstrate pleiotropic effects for the <i>cyp79a1 </i>mutation. Dhurrin-free genotypes were more susceptible to insect herbivory and may be slightly more susceptible to post-flowering drought within the hybrids; however, these genotypes exhibited higher seedling growth rates, feeding preference by ewes, no release of HCN in fresh or dry plant material, and frost did not cause an increase in dhurrin content.</p>

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This project attempted to understand better the relationship between social support and women's commitment to an abusive relationship for the purpose of informing social support interventions. This study was not an intervention; instead, it sought to examine the processes linking receipt of helpful forms of social support from naturally occurring sources with women's commitment and stay/leave decisions. Specifically, it was hypothesized that relationship satisfaction and quality alternatives would mediate the relationship between received social support types (e.g., nondirective support, positive social exchange, tangible assistance, and directive guidance) and battered women's feelings of commitment. Fifty-one battered women living in domestic violence shelters participated in the present study. Women completed the Revised Conflict Tactics Scale (CTS-2), Inventory of Socially Supportive Behaviors (ISSB), and Investment Model Scale (IMS) along with other measures designed for this study. Results showed that battered women who received more resources and services (i.e., tangible assistance) endorsed lesser commitment to their abusive relationships; however, other dimensions of social support such as showing concern, giving advice, and spending time in recreational activities were unrelated to commitment. Further, neither relationship satisfaction nor quality alternatives mediated the relationship between support and commitment; however, relationship satisfaction and quality alternatives demonstrated expected relationships with women's commitment. Potential design limitations as well as clinical and research implications are discussed. / Ph. D.

Yes / IMPORTANCE Patients undergoing emergency laparotomy have high mortality, but few studies exist to improve outcomes for these patients. OBJECTIVE To assess whether a collaborative approach to implement a 6-point care bundle is associated with reduction in mortality and length of stay and improvement in the delivery of standards of care across a group of hospitals. DESIGN, SETTING, AND PARTICIPANTS The Emergency Laparotomy Collaborative (ELC) was a UK-based prospective quality improvement study of the implementation of a care bundle provided to patients requiring emergency laparotomy between October 1, 2015, and September 30, 2017. Participants were 28 National Health Service hospitals and emergency surgical patients who were treated at these hospitals and whose data were entered into the National Emergency Laparotomy Audit (NELA) database. Post-ELC implementation outcomes were compared with baseline data from July 1, 2014, to September 30, 2015. Data entry and collection were performed through the NELA. INTERVENTIONS A 6-point, evidence-based care bundle was used. The bundle included prompt measurement of blood lactate levels, early review and treatment for sepsis, transfer to the operating room within defined time goals after the decision to operate, use of goal-directed fluid therapy, postoperative admission to an intensive care unit, and multidisciplinary involvement of senior clinicians in the decision and delivery of perioperative care. Change management and leadership coaching were provided to ELC leadership teams. MAIN OUTCOME AND MEASURES Primary outcomes were in-hospital mortality, both crude and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) risk-adjusted, and length of stay. Secondary outcomes were the changes after implementation of the separate metrics in the care bundle. RESULTS A total of 28 hospitals participated in the ELC and completed the project. The baseline group included 5562 patients (2937 female [52.8%] and a mean [range] age of 65.3 [18.0-114.0] years), whereas the post-ELC group had 9247 patients (4911 female [53.1%] and a mean [range] age of 65.0 [18.0-99.0] years). Unadjusted mortality rate decreased from 9.8% at baseline to 8.3% in year 2 of the project, and so did risk-adjusted mortality from a baseline of 5.3% to 4.5% post-ELC. Mean length of stay decreased from 20.1 days during year 1 to 18.9 days during year 2. Significant changes in 5 of the 6 metrics in the care bundle were achieved. CONCLUSIONS AND RELEVANCE A collaborative approach using a quality improvement methodology and a care bundle appeared to be effective in reducing mortality and length of stay in emergency laparotomy, suggesting that hospitals should adopt such an approach to see better patient outcomes and care delivery performance. / This study was funded by The Health Foundation, United Kingdom, as part of a Scaling Up Award.

Bakgrund: Idag beräknas bristen på sjuksköterskor uppgå till 5,9 miljoner sjuksköterskor globalt, ensiffra som väntas stiga. Att sjuksköterskor lämnar sina arbetsplatser beror på flera faktorer. Hög arbetsbelastning, etisk stress och bristande ledarskap är några exempel. Detta leder till brist på god omvårdnad och bristande patientsäkerhet.  Syfte: Syftet med studien var att undersöka vad som påverkar sjuksköterskors intention att stanna på sin arbetsplats.  Metod: En kvalitativ litteraturstudie baserad på data från 10 originalartiklar genomfördes, och analyserades med en tematisk innehållsanalys.  Resultat: Tre teman och åtta subteman identifierades. Individuella faktorer innehöll subteman: Privatliv, Klinisk erfarenhet och Ekonomiska faktorer. Det andra temat, Tillfredställelse i arbetet med subteman Professionsstolthet, omvårdnadsfokus och utmanande utveckling. Slutligen Mellanmänskliga relationer, vilken beskrev vikten av Omsorgsfullt ledarskap och Kollegial sammanhållning.  Slutsats: Sjuksköterskor behöver en stabil organisation och en miljö där de tillåts arbeta efter deras professionella autonomi, möjlighet till utveckling, ett gott ledarskap och goda relationer med kollegor. Vidare finns det likheter mellan sjuksköterskors intention att stanna och intentionen att lämna, men även viktiga skillnader. Ytterligare forskning kring detta samband förelsås. Detta för att bidra till god omvårdnad och en säker vård för patienterna. / Background: The global nursing shortage is estimated to 5,9 million nurses. Nurses are leaving their workplaces and the profession. This relates to several factors, for example, high workload, moral distress, and lack of good leadership which contributes to lack of proper nursing care and poor patient safety.   Aim: The aim of this study was to examine what affect nurses’ intention to stay in their workplace.  Method: A literature review of qualitative data was conducted from ten original articles, and was analysed using a qualitative thematic analysis approach.  Results: Three themes and eight subthemes were identified. Individual factors containing subthemes: personal life, clinical experience and financial factors. The second theme was Work satisfaction including subthemes professional pride, nursing care and challenging growth. The last theme was Interpersonal relationships describing the importance of caring leadership and collegial support.  Conclusion: Nurses´ need stable organisations, good leadership, collegial support and being allowed to use their expertise and professional autonomy. There are many similarities between nurses’ intention to stay and intention to leave, but also important differences. Further research investigating these differences are recommended to improve nurses’ work environment.