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Fielding an expeditionary prolonged casualty care kit: What we carry matters
No full textIntroduction:Prolonged Casualty Care (PCC) is an extension of Tactical Combat Casualty Care (TCCC), which provides prehospital care when evacuation is delayed and care is resource constrained and suboptimal. Current medical rucksacks are designed to maximize medical equipment, without sustainment items like food, clothing, and essential communication equipment. This leaves limited room for PCC expendable supplies and equipment to expand upon existing TCCC loadouts. The multi-day premise of PCC requires both extended medical and general survival items, for which existing medical kits are poorly suited and not optimized. In this study, we sought to systematically create a Prolonged Field Care Kit (PFAK) capable of providing field medics with medications and equipment adjuncts for PCC as well as a specialized long-range medical rucksack (LMR) to house the PFAK, TCCC, and sustainment items.
Materials and methods:Baseline design elements from conventional rucksacks were obtained and modified to address known limitations. Initial prototypes for the PFAK and LMR were created. These were modified following informal discussions with various and multiple end users from both U.S. conventional and Special Operations Forces. Feedback regarding the second iteration prototype was obtained systematically through written surveys regarding strengths, weaknesses, and potential changes that could be made. Qualitative data were analyzed using MAXQDA software.
Results:Using informal feedback, we deduced that the first PFAK prototype lacked internal compartmentalization and could not accommodate the volume of intravenous fluid needed for PCC. Moreover, the LMR was prone to damage by external factors such as rainwater. The second prototype addressed these flaws and written feedback was obtained from medics (n = 10), nurses (n = 11), and medical doctors (n = 3) on its applicability. Positive feedback received on the second prototype included daypack detachability, overall organization, versatility, and design of the LMR and PFAK. However, most survey participants felt that the LMR was too complex and that its heaviness could limit its field use. After the feedback obtained, the finalized PFAK weighed 18 pounds and had a volume of 30 L. The LMR containing the PFAK and other mixed sustainment and TCCC equipment has a length of 30 inches and weighs 110 pounds with all items intact.
Conclusions:PCC will require thoughtful equipping to enable prehospital providers to manage multiple, potentially complex casualties; existing military medical backpacks are not currently optimized for this scenario. Our group created the first-of-its-kind PFAK, as well as the LMR to house it. The final prototypes of our LMR and PFAK are versatile, well organized, and significantly improve upon current backpack options for PCC. However, field testing and further improvement through qualitative analysis are needed
Exploring the association between patent ductus arteriosus, its management, and acute kidney injury in preterm neonates
No full textObjective: To examine the relationship between Patent Ductus Arteriosus (PDA) and Acute Kidney Injury (AKI) stages in preterm neonates with gestational age \u3c 30 weeks, and to evaluate how different PDA management approaches influence AKI occurrence.Study Design: A Single-center retrospective cohort study conducted at a level 3 NICU between February 2020 and September 2023. All inborn and out–born neonates with gestational age \u3c30 weeks admitted within 72 hours of birth were included. AKI was defined using neonatal-modified Kidney Disease-Improving Global Outcomes (KDIGO) criteria. PDA management strategies were categorized as conservative, pharmacological, or surgical intervention.Results: Of 166 neonates, 79 (47.6%) had PDA and 133 (80.1%) developed AKI. PDA was associated with higher AKI incidence (87.3% vs 73.6%, p=0.026), lower gestational age (GA) (26.7±2.1 vs 27.8±2.0 weeks, p\u3c0.001), lower birth weight (BW) (927.8±285.6 vs 1065.4±348.9g, p=0.005), more delivery room intubations (64.6% vs 48.3%, p=0.042), higher serum creatinine weeks 2-4 (p\u3c0.05), paradoxically higher GFR weeks 2-4 (p\u3c0.01), altered fluid management (higher week 1, p=0.015; lower weeks 3-4, p\u3c0.05), and increased diuretic use (furosemide weeks 1-4, p\u3c0.01; thiazide weeks 2-4, p\u3c0.001). AKI infants had lower maternal age, GA, BW, 1-minute Apgar scores (all p≤0.01), more delivery room interventions (p\u3c0.05), longer mechanical ventilation (p=0.05), and more inotrope use (p=0.02). Stage 2 AKI trended higher with PDA (13.9% vs 5.7%, p=0.08). Coding-based AKI diagnosis was substantially lower than KDIGO criteria (8.4% vs 80.1%).Conclusion: PDA is significantly associated with increased AKI risk in extremely preterm neonates, with altered renal function, fluid management patterns, and increased diuretic requirements. The substantial under-recognition of AKI in clinical practice (8.4% coded vs 80.1% KDIGO-based) highlights the critical need for systematic AKI surveillance and standardized diagnostic criteria implementation in this high-risk population
Baseline characteristics of the U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER): Successful enrollment of a diverse clinical trial cohort at risk for cognitive decline
No full textIntroduction:The U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER) is a 2-year randomized controlled trial of two lifestyle interventions in 2111 older adults at increased risk for cognitive decline.
Methods:Sociodemographic and clinical characteristics and rates of ancillary study participation were described with means and frequencies.
Results:U.S. POINTER successfully enrolled a cohort, ages 60-79 years, which was ethno-racially inclusive (\u3e30% individuals from groups often under-represented in clinical trials with cognitive outcomes) and 18% residing in neighborhoods with moderate or high levels of socioeconomic deprivation. Enrollees were cognitively intact but at increased risk for cognitive decline. Participation in ancillary studies (overall 73%) was uniformly high across sociodemographic groups.
Discussion:The trial cohort meets study goals and provides a basis for assessing multidomain lifestyle intervention effects on cognitive function and other health outcomes that will generalize to large portions of the at-risk US populations.
Gov identifier:NCT00017953.
Highlights:The U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER) enrolled individuals at enhanced risk for cognitive decline. Efforts to engage socio-demographically representative individuals were successful. Four ancillary studies with high rate of recruitment extend scientific impact
Comorbidities, pharmacologic interventions, and mechanical interventions associated with mortality in isolated diastolic left heart failure: Lessons from a national database
No full textBackground:Diastolic heart failure may be noted in paediatric patients with CHD, cardiomyopathy, or malignancies requiring chemotherapy, but the available data are scarce, and often derived from adult trials or based on theoretic or anecdotal evidence.
Methods:Data between 2016 and 2021 were obtained from Pediatric Health Information System database. Patients
Results:Isolated diastolic heart failure comprised 0.5% of critically ill paediatric patients. A total of 121 (5%) experienced mortality among the 2,273 admissions in the final analyses. Milrinone and angiotensin converting enzyme inhibitor were found to be associated with decreased mortality. Increasing age and diuretics were associated with decreased total hospital length of stay in survivors.
Conclusion:In the cohort studied, isolated diastolic left heart failure has a 5% mortality. Several comorbidities and interventions are associated with increased mortality with milrinone and angiotensin converting enzyme inhibitors being associated with decreased risk of mortality. When only admissions with survival to discharge are considered, older age and diuretics are associated with lower total hospital length of stay
Utilization of a Traveling Education Cart to Provide In-Situ Education
No full textPurpose/Rationale: After analyzing safety events and two learning needs assessments, an opportunity for improving cardiovascular and respiratory knowledge was evident. In-situ education was implemented to accommodate competing priorities such as time constraints and patient acuity. The education evaluated learners’ knowledge, skills, and confidence. Synthesis of Evidence: Evidence shows that interactive, simulation-based activities effectively engage learners and enhance critical thinking through application to clinical scenarios. There is also support for implementing a traveling education cart to disseminate information in a concise, flexible small-group format. CINAHL, PubMed, and Google Scholar databases were used to locate 19 references and adopt 6 articles to support this project. Practice Change: The education cart was piloted over 3 months in a 14-bed neuro ICU at a Magnet-designated, comprehensive stroke, teaching hospital. A multi-modal approach included case studies, gamification, discussions, and guided small-group simulations with high-risk, low-volume equipment. One cart featured an interactive activity for recognizing EKG rhythms and managing a defibrillator, while another included a Jeopardy game with hands-on respiratory devices and case study applications for escalating care. Implementation Strategies: The education cart advertisement was shared via email, unit meetings, and in person. A facilitator captured available nurses by rounding at nurse stations twice weekly for 3 months during the day shift. Each week, 1-2 topics were covered based on attendance and prior participation. Teammates scanned a QR code before and after sessions to assess learning and provide feedback, which helped influence future topics. Evaluation: Pre- and post-tests via QR code gathered qualitative and quantitative data. Multiple-choice and short-answer questions assessed knowledge and a 5-point Likert scale measured confidence changes. The EKG cart showed a 25% increase in confidence and an 18.75% improvement in knowledge. The respiratory cart showed 21% knowledge improvement; with one erroneous question removed, this result increased to 44%. Qualitative feedback was overall positive, with comments such as “helpful, necessary, great.” Implications for Practice: Positive results and feedback indicate that the education cart can effectively meet learners\u27 needs with its flexible, brief, and engaging, small-group format. Next steps include partnering with a night shift champion and presenting the data to Professional Governance and hospital educators in other departments to adopt this innovative approach