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We present a quantitative methodology for assessing how well an organization's budgetary resource plan aligns to its enterprise goals. We determine priority weights based on a hierarchical strategy-to-task analytic structure (Kent, 1989). For our example application in the United States Air Force, the hierarchy aggregates program elements to systems to mission areas to enterprise goals. The weighted sum of funding provides our measure of budget alignment to enterprise goals for any proposed budget. Given this measure, we select the budget that maximizes achievement of any single goal using a greedy algorithm and any list of prioritized enterprise goals using preemptive goal programming. We examine tradeoffs between enterprise goals by altering funding levels in a given budget for program elements that affect one of the goals. We conduct additional sensitivity analysis by altering our goal priorities and evaluating how the reordered goals affect the optimal solution and illuminate the budget decision trade space. [ABSTRACT FROM AUTHOR]

Objective: We sought to establish the significance of querying chronic rhinosinusitis (CRS) patients about their past CRS-related oral antibiotic and corticosteroid usage by determining the association between these metrics and patients' quality of life (QoL).Study Design: Cross-sectional study.Methods: A total of 157 patients with CRS were prospectively recruited. CRS-specific QoL was measured using the 22-item Sinonasal Outcome Test (SNOT-22). General health-related QoL was measured using the EuroQoL five-dimensional questionnaire visual analog scale. Associations were sought between these measures of QoL and frequency of CRS-related oral antibiotic and corticosteroid usage reported by the participants in the prior 3 and 12 months.Results: More frequent antibiotic and corticosteroid use was significantly associated with worse CRS-specific and general health-related QoL, whether querying medication use over the prior 3 months or over the prior 12 months (P < 0.001 in all cases). The effect size of CRS-related antibiotic use during the prior 3 months on CRS-specific QoL (SNOT-22 score) was significantly greater than for use during the prior 12 months. However, there was no other statistically significant difference in effect size for association between QoL and CRS-related antibiotic or corticosteroid use in the prior 3 months versus prior 12 months. These results were independent of the presence or absence of polyps.Conclusion: More frequent past CRS-related oral antibiotic and corticosteroid use, regardless of time period queried (3 months or 12 months) is associated with significant decrease in CRS-specific and general health-related QoL. CRS-related systemic medication use is an important indicator of CRS patients' QOL that easily can be queried and utilized in both clinical and research settings.Level Of Evidence: 2c. Laryngoscope, 128:37-42, 2018. [ABSTRACT FROM AUTHOR]

In recent years, there has been a push to improve and standardize the quality of clinical care delivered. This has led to marked efforts across institutions to invest in quality improvement (QI) as a part of daily practice. “Problem-solving, Root cause analysis, Improvement Science, and Monitoring” (PRISM) is a model used to detail a stepwise approach to QI in a way that can be easily followed, sustained, and eventually integrated into an organization’s learning system. This model is being used to improve the efficiency of our emergency department admissions process. The various tools that are a part of PRISM are discussed in detail here. Frontline team members have been educated about PRISM and are now engaged and leading improvement efforts within our organization. In short, PRISM has provided the common QI language for our transformation toward becoming a leader in patient- and family-centered care. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to describe the range and types of medical and traumatic conditions encountered in land search and rescue operations in New Zealand. Methods Twenty months (May 2010 to December 2011) of land search and rescue operations were analyzed. Data on medical and traumatic conditions were extracted from the New Zealand Police search and rescue database. Results During the period audited, New Zealand Police coordinated 1490 land-based search and rescue operations, from which 611 persons fulfilled the study inclusion criteria. Males accounted for 60.5% of the subjects, and a trauma-related injury was the most commonly encountered condition (37.3% of all). The lower limb was the most commonly injured body site, and most injuries occurred as the result of a slip or fall. Medical conditions were recorded in 11.6% of operations and included a wide spread of conditions, with cardiovascular events being seen most frequently. Hypothermia was diagnosed in 9.3% of all operations, and fatalities made up 5.6% of the sample. Thirty percent of all operations were for persons with cognitive impairment who had wandered away from their usual place of residence. These were almost entirely urban searches and concentrated in districts with large populations. Conclusions Search and rescue personnel are exposed to a broad range of medical and traumatic conditions. In New Zealand, they include preexisting cognitive impairment that results in persons lost in urban environments. Notwithstanding this, many subjects will also need to be managed in remote, resource-limited environments for extended periods. First aid training and field equipment should reflect these demands. [ABSTRACT FROM AUTHOR]

Objective: Pulmonary hypertension may complicate surgical correction of congenital heart defects, resulting in increased morbidity and mortality. We have previously shown that plasma levels of the nitric oxide precursors citrulline and arginine drop precipitously after congenital cardiac surgery and that oral citrulline supplementation may be protective against the development of pulmonary hypertension. In this study, we assessed the safety and pharmacokinetic profile of intravenous citrulline as a potential therapy for postoperative pulmonary hypertension. Methods: The initial phase of this investigation was a dose-escalation study of intravenously administered citrulline in infants and children undergoing one of five congenital cardiac surgical procedures (phase 1). The primary safety outcome was a 20% drop in mean arterial blood pressure from the baseline pressure recorded after admission to the intensive care unit. Based on our previous work, the target circulating plasma citrulline trough was 80 to 100 μmol/L. Each patient was given two separate doses of citrulline: the first in the operating room immediately after initiation of cardiopulmonary bypass and the second 4 hours later in the pediatric intensive care unit. Stepwise dose escalations included 50 mg/kg, 100 mg/kg, and 150 mg/kg. After model-dependent pharmacokinetic analysis, we enrolled an additional 9 patients (phase 2) in an optimized dosing protocol that replaced the postoperative dose with a continuous infusion of citrulline at 9 mg/(kg·h) for 48 hours postoperatively. Results: The initial stepwise escalation protocol (phase 1) revealed that an intravenous citrulline dose of 150 mg/kg given after initiation of cardiopulmonary bypass yielded a trough level of in the target range of approximately 80 to 100 μmol/L 4 hours later. The postoperative dose revealed that the clearance of intravenously administered citrulline was 0.6 L/(h·kg), with a volume of distribution of 0.9 L/kg and estimated half-life of 60 minutes. Because of the short half-life, we altered the protocol to replace the postoperative dose with a continuous infusion of 9 mg/(kg·h). An additional 9 patients were studied with this continuous infusion protocol (phase 2). Mean plasma citrulline levels were maintained at approximately 125 μmol/L, with a calculated clearance of 0.52 L/(h·kg). None of the 17 patients studied had a 20% drop in mean arterial blood pressure from baseline. Conclusions: In this first report of the use of intravenous citrulline in humans, we found citrulline to be both safe and well tolerated in infants and young children undergoing congenital cardiac surgery. Because of the rapid clearance, the optimal dosing regimen was identified as an initial bolus of 150 mg/kg given at the initiation of cardiopulmonary bypass, followed 4 hours later by a postoperative infusion of 9 mg/(kg·h) continued up to 48 hours. Using this regimen, plasma arginine, citrulline, and nitric oxide metabolite levels were well maintained. Intravenous citrulline needs to be studied further as a potential therapy for postoperative pulmonary hypertension. [Copyright &y& Elsevier]