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The sensemaking theory is extended via the incorporation of lifeworld influences on organizational practices, delineated through a dialectical method. Strengths and weaknesses of the concept are discussed, and implications for further research are included.

Relationships among health care costs, social support, and occupational stress are investigated. Health care cost data were collected over two years for 260 working individuals. Multiple regression analyses were used to control for initial health care costs, age, and gender in predicting later costs; independent variables were stress, strain, social support, and their interactions. Main effects and interactions each accounted for significant proportions of the variance in various health care costs. [ABSTRACT FROM AUTHOR]

Brad Gilbreath [*] Abstract In this paper we attempt to bridge the gap between theory and practice by developing the concept of 'resourceful sensemaking'. [1] Resourceful sensemaking is the ability [...]

Objectives: Noise is one of the most common exposures, and occupational noise-induced hearing loss (NIHL) is highly prevalent. In addition to NIHL, noise is linked to numerous non-auditory health effects. The Occupational Safety and Health Administration (OSHA) maintains the Integrated Management Information System (IMIS) database of compliance-related measurements performed in various industries across the USA. The goal of the current study was to describe and analyse personal noise measurements available through the OSHA IMIS, identifying industries with elevated personal noise levels or increasing trends in worker exposure over time.Methods: Through a Freedom of Information Act request, we obtained OSHA's noise measurements collected and stored in IMIS between 1979 and 2013 and analysed permissible exposure limit (PEL) and action level (AL) criteria measurements by two-digit industry code.Results: The manufacturing industry represented 87.8% of the 93 920 PEL measurements and 84.6% of the 58 073 AL measurements. The highest mean noise levels were found among the agriculture, forestry, fishing and hunting industry for PEL (93.1 dBA) and the mining, quarrying and oil and gas extraction group for AL (93.3 dBA). Overall, measurements generally showed a decreasing trend in noise levels and exceedances of AL and PEL by year, although this was not true for all industries.Conclusions: Our results suggest that, despite reductions in noise over time, further noise control interventions are warranted both inside and outside of the manufacturing industry. Further reductions in occupational noise exposures across many industries are necessary to continue to reduce the risk of occupational NIHL. [ABSTRACT FROM AUTHOR]

Importance: Current treatments for long-term prophylaxis in hereditary angioedema have limitations.Objective: To assess the efficacy of lanadelumab, a fully human monoclonal antibody that selectively inhibits active plasma kallikrein, in preventing hereditary angioedema attacks.Design, Setting, and Participants: Phase 3, randomized, double-blind, parallel-group, placebo-controlled trial conducted at 41 sites in Canada, Europe, Jordan, and the United States. Patients were randomized between March 3, 2016, and September 9, 2016; last day of follow-up was April 13, 2017. Randomization was 2:1 lanadelumab to placebo; patients assigned to lanadelumab were further randomized 1:1:1 to 1 of the 3 dose regimens. Patients 12 years or older with hereditary angioedema type I or II underwent a 4-week run-in period and those with 1 or more hereditary angioedema attacks during run-in were randomized.Interventions: Twenty-six-week treatment with subcutaneous lanadelumab 150 mg every 4 weeks (n = 28), 300 mg every 4 weeks (n = 29), 300 mg every 2 weeks (n = 27), or placebo (n = 41). All patients received injections every 2 weeks, with those in the every-4-week group receiving placebo in between active treatments.Main Outcome and Measures: Primary efficacy end point was the number of investigator-confirmed attacks of hereditary angioedema over the treatment period.Results: Among 125 patients randomized (mean age, 40.7 years [SD, 14.7 years]; 88 females [70.4%]; 113 white [90.4%]), 113 (90.4%) completed the study. During the run-in period, the mean number of hereditary angioedema attacks per month in the placebo group was 4.0; for the lanadelumab groups, 3.2 for the every-4-week 150-mg group; 3.7 for the every-4-week 300-mg group; and 3.5 for the every-2-week 300-mg group. During the treatment period, the mean number of attacks per month for the placebo group was 1.97; for the lanadelumab groups, 0.48 for the every-4-week 150-mg group; 0.53 for the every-4-week 300-mg group; and 0.26 for the every-2-week 300-mg group. Compared with placebo, the mean differences in the attack rate per month were -1.49 (95% CI, -1.90 to -1.08; P < .001); -1.44 (95% CI, -1.84 to -1.04; P < .001); and -1.71 (95% CI, -2.09 to -1.33; P < .001). The most commonly occurring adverse events with greater frequency in the lanadelumab treatment groups were injection site reactions (34.1% placebo, 52.4% lanadelumab) and dizziness (0% placebo, 6.0% lanadelumab).Conclusions and Relevance: Among patients with hereditary angioedema type I or II, treatment with subcutaneous lanadelumab for 26 weeks significantly reduced the attack rate compared with placebo. These findings support the use of lanadelumab as a prophylactic therapy for hereditary angioedema. Further research is needed to determine long-term safety and efficacy.Trial Registration: EudraCT Identifier: 2015-003943-20; ClinicalTrials.gov Identifier: NCT02586805. [ABSTRACT FROM AUTHOR]

Purpose: An increasing number of patients with end-stage heart failure are supported with left ventricular assist device (LVAD) implantation and must be maintained on a consistent anticoagulation regimen. Pre-emptive extraction of carious teeth in these patients is necessary to prevent seeding of the implanted device and endocarditis. Thus, the objective of this study was to evaluate bleeding complications after minor oral surgery, specifically teeth extractions, in this unique patient population requiring long-term anticoagulation.Materials and Methods: This study was a retrospective single-center review. Adult patients supported on an implanted continuous-flow LVAD from January 1, 2007 to December 31, 2016 were included. Baseline characteristics were collected by retrospective chart review and the institutional LVAD registry. All extractions were performed in the operating room under local anesthesia with moderate sedation or general anesthesia with nasal intubation, and LVAD settings were monitored by a trained perfusionist. Preoperative and postoperative hematology laboratory values, such as hemoglobin and international normalized ratio (INR), were collected by chart review. Continuous variables were presented as mean ± standard deviation and compared using the Student t test. Categorical variables were presented as proportion and percentage and compared using the χ2 test or Fisher exact test as appropriate. Statistical significance was established at a P value less than .05.Results: After screening 798 patients, 32 (4%) were found to have undergone dental extractions after LVAD implantation. The sample was composed of 32 patients with a mean age of 60.13 years and 81.25% were men. The average time from LVAD implantation to extraction was 445.19 ± 1,108.53 days. Average preoperative INR was 1.76 ± 0.47. Preoperative fresh frozen plasma was not administered to any patients. Twenty-eight patients (87.5%) were on Coumadin (warfarin) preoperatively. In 11 of these 28 patients (39.3%), Coumadin was held preoperatively. The average postoperative change in hemoglobin level was -0.79 ± 1.45. Only 1 patient (3%) required postoperative blood transfusion for a hemoglobin level of 7.6 that responded appropriately. There were no reoperations for bleeding.Conclusions: Minor oral surgical procedures can be performed safely for patients being supported on LVAD therapy. With primary closure of the gingiva at the site of extraction, dental extractions can be performed without the full reversal of anticoagulation. [ABSTRACT FROM AUTHOR]

Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery. An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence. The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices. Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population. [Display omitted] [ABSTRACT FROM AUTHOR]

Health care reimbursement models are transitioning from volume-based to value-based models. Value-based models focus on patient outcomes both during the hospital admission and postdischarge. These models place emphasis on cost, quality of care, and coordination of multidisciplinary services. Perioperative physicians are challenged to evaluate traditional practices to ensure coordinated, cost-effective, and evidence-based care. With the Centers for Medicare and Medicaid Services planned introduction of bundled payments for coronary artery bypass graft surgery, cardiovascular anesthesiologists are financially responsible for postdischarge outcomes. In order to meet these patient outcomes, multidisciplinary care pathways must be designed, implemented, and sustained, a process that is challenging at best. This review (1) provides a historical perspective of health care reimbursement; (2) defines value as it pertains to quality, service, and cost; (3) reviews the history of value-based care for cardiac surgery; (4) describes the drive toward optimization for vascular surgery patients; and (5) discusses how programs like Enhanced Recovery After Surgery assist with the delivery of value-based care. [ABSTRACT FROM AUTHOR]

Introduction: The Association of American Medical Colleges' (AAMC) initiative for Core Entrustable Professional Activities for Entering Residency includes as an element of Entrustable Professional Activity 13 to "identify system failures and contribute to a culture of safety and improvement." We set out to determine the feasibility of using medical students' action learning projects (ALPs) to expedite implementation of evidence-based pathways for three common patient diagnoses in the emergency department (ED) setting (Atrial fibrillation, congestive heart failure, and pulmonary embolism). Methods: These prospective quality improvement (QI) initiatives were performed over six months in three Northeastern PA hospitals. Emergency physician mentors were recruited to facilitate a QI experience for third-year medical students for each project. Six students were assigned to each mentor and given class time and network infrastructure support (information technology, consultant experts in lean management) to work on their projects. Students had access to background network data that revealed potential for improvement in disposition (home) for patients. Results: Under the leadership of their mentors, students accomplished standard QI processes such as performing the background literature search and assessing key stakeholders' positions that were involved in the respective patient's care. Students effectively developed flow diagrams, computer aids for clinicians and educational programs, and participated in recruiting champions for the new practice standard. They met with other departmental clinicians to determine barriers to implementation and used this feedback to help set specific parameters to make clinicians more comfortable with the changes in practice that were recommended. All three clinical practice guidelines were initiated at consummation of the students' projects. After implementation, 86% (38/44) of queried ED providers felt comfortable with medical students being a part of future ED QI initiatives, and 84% (26/31) of the providers who recalled communicating with students on these projects felt they were effective. Conclusion: Using this novel technique of aligning small groups of medical students with seasoned mentors, it is feasible for medical students to learn important aspects of QI implementation and allows for their engagement to more efficiently move evidence-based medicine from the literature to the bedside. [ABSTRACT FROM AUTHOR]

Background Perioperative use of angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEis) in patients undergoing cardiac operations remains controversial. The current practice of discontinuing renin-angiotensin-system inhibitors preoperatively may negate their beneficial effects in vulnerable populations, including patients with metabolic syndrome, who exhibit elevated renin-angiotensin system activity. We hypothesized that preoperative ARB use is associated with reduced incidence of postoperative complications, compared with ACEi or no drug, in patients with metabolic syndrome undergoing coronary artery bypass grafting. Methods We used propensity matching to derive a cohort of 1,351 patients from 2,998 who underwent coronary artery bypass grafting based on preoperative use of ARBs, ACEis, or no renin-angiotensin-system inhibitors. Our primary end point was a composite of adverse events occurring within 30 days after the operation: new-onset atrial fibrillation/flutter, arrhythmia requiring cardioversion, perioperative myocardial infarction, acute renal failure, need for dialysis, cerebrovascular accidents, acute respiratory failure, or perioperative death. Results At least one adverse event occurred in 524 (38.8%) of matched cohort patients (1,184 [39.6% of all patients]). Adjusting for European System for Cardiac Operative Risk Evaluation and metabolic syndrome in the matched cohort, preoperative use of ARBs was associated with a lower incidence of adverse events in patients with metabolic syndrome compared with preoperative use of no renin-angiotensin-system inhibitors (odds ratio, 0.43; 95% confidence interval, 0.19 to 0.99) or ACEis (odds ratio, 0.38; 95% confidence interval, 0.16 to 0.88). Conclusions Preoperative use of ARBs, but not ACEis, confers a benefit within 30 days after cardiac operations in patients with metabolic syndrome, suggesting potential efficacy differences of these drug classes in reducing cardiovascular morbidity and death in ambulatory vs surgical patients. [ABSTRACT FROM AUTHOR]