Grady Memorial Hospital, frequently referred to as Grady Hospital or simply Grady, is the public hospital for the city of Atlanta. It is the tenth-largest public hospital in the United States, and one of the busiest Level I trauma centers in the country. Historical segregation of its hospital units meant that it was also called "The Gradys," a name that still surfaces among elderly Atlanta residents, especially African-Americans. It is the flagship of the Grady Health System..
BACKGROUND:Determination of death by neurologic criteria (DNC) relies on clinical examination, provided no confounding conditions affect reliability. Current guidelines require patients to be free of confounders before neurologic testing but do not specify how these confounders should be assessed or managed. This lack of specificity may lead to variability in practice and uncertainty in protocol implementation. The objective of this study was to review institutional protocols for DNC determination across hospitals in the United States and evaluate how they address medication confounders and the role of ancillary testing. METHODS:To further explore variability observed in our initial national survey sent to the Neurocritical Care Society membership, we conducted a follow-up study requesting exact DNC protocol language from respondents willing to provide additional details. Participants submitted protocol excerpts related to medication confounders, ancillary testing, reversal agents, and practitioner responsibilities, which were de-identified and analyzed using artificial intelligence (AI)-assisted qualitative theme extraction with subsequent investigator review for accuracy. RESULTS:Responses were obtained from 18 of 23 U.S. institutions (78%), nearly all of which were urban centers with neurology and neurocritical care services. Analysis identified several recurring themes. Protocols consistently emphasized pharmacokinetic clearance strategies, most commonly the use of elimination half-lives, drug levels, and toxicology screening, to exclude medication confounders. Ancillary testing was generally reserved for situations in which clinical examination could not be safely performed and was often discouraged as a substitute for drug clearance. Reversal agents were infrequently addressed and, when included, were typically described as optional. Additional variability was observed in patient-specific considerations, practitioner responsibilities, and the presence of supporting drug appendices. CONCLUSION:Institutional DNC protocols demonstrate substantial variability in how medication confounders are assessed, despite most sites requiring medication review. These findings highlight the need for clearer, evidence-based protocols to ensure reliable DNC determinations in the presence of potential medication confounders.
AIMS:The social drivers of diabetic foot disease (SDDFD) impact ulcer incidence and outcomes, but how is relatively unknown. We aimed to build a conceptual model positing how three SDDFD-poverty, insurance, and government assistance-influence outcomes for patients with diabetic foot ulcers. MATERIALS AND METHODS:To inform the model, we conducted a scoping review of studies linking poverty, insurance, and/or government assistance with diabetic foot ulcer outcomes using Levac and colleagues' 6-stage framework, the Preferred Reporting Items for Systematic Review and Meta-analysis extension for scoping reviews, and the SPIDER tool. We searched PubMed, CINAHL, and Embase for original research articles set in the United States and published between 1 January 2005 and 7 November 2025. We excluded those published in a language other than English, case reports, abstracts, and studies of other SDDFD. RESULTS:Data from 35 included studies informed our conceptual model, depicting a complex causal pathway between SDDFD and outcomes, often mediated by healthcare system factors and moderated by patients' abilities to adhere to healthcare recommendations. Multidisciplinary teams might ameliorate the risk of amputations associated with poverty, lack of insurance, or qualifying for government assistance. Additionally, the model highlights reinforcing feedback loops, both positive and negative. CONCLUSION:Our model can be used to inform mediation and moderation analyses and help avoid collider-conditioning bias during statistical analyses. It can help identify potential points of intervention within the healthcare system for those working to dampen the negative effects of SDDFD on outcomes.
Abstract Introduction For decades, multidisciplinary pediatric care has required specialized knowledge and different competency training than adult care. In a large urban, ABA and ACS verified burn and Level 1 Trauma center which primarily handles adult care, the Burn Center is the only unit that admits pediatric patients for both burn and trauma care. Planned expansion of the unit with associated new staff hiring required an assessment and update of current pediatric education programs. Additionally, retention of a new RN Pediatric Specialist role within the Emergency Services Division allowed for the support of cross-service collaboration. Methods A review of existing pediatric coursework was performed to identify gaps, and adult learning theory was utilized to optimize the educational environment. Standard lecture format has been updated to accommodate visual, auditory, and kinesthetic learning styles. Both high and low fidelity simulation is utilized from the beginning of the course to promote active learning. A didactic portion covers burn specific knowledge where staff and facilitators are encouraged to share their experience caring for pediatric patients on the unit, helping connect the “why” behind the education. Speakers include the unit Pharmacist, Social Worker, Child Life Specialist, and Behavioral Health Therapist, who educate on their specific roles during the care of pediatric patients. All courses have pre-class and post-class surveys; these were utilized by the authors to continue to modify the course. Results 32 staff have participated in this education program since the restructuring process. 100% of participants have reported being either “satisfied or very satisfied" by this program. Particularly, pre-assignment of the online modules ahead of time with the option for asynchronous learning has been a significant satisfier. Nursing simulation education was also a significant source of positive responses. Conclusions Infrequent but highly stressful scenarios in medicine can be attributed to the intersection of subspecialty care; in this scenario burn care and pediatric care. Applying adult learning theory can potentially lower the cognitive load for learners; while this cohort of learners were not tested for knowledge retention, their self-reported satisfaction with the course suggests they identified the course as filling perceived gaps. Multi-modal education and consistent practice is paramount to keeping providers skilled in delivering the best care to this patient population. Applicability of Research to Practice Focused, multimodal, and specialized education is important for nurses to be prepared to take care of all patients, especially as part of a team that cares for pediatric patients in an adult hospital. Engaging learners with instructors and each other creates a robust forum for problem solving and improved understanding. Funding for the study N/A.
PURPOSE OF REVIEW:This review provides an updated overview of anesthetic considerations for malpresentation and multiple gestation. Key topics include analgesia for external cephalic version (ECV), labor analgesia for vaginal delivery in malpresentation and multiple gestation, anesthetic considerations for cesarean delivery in these scenarios, and management of postpartum hemorrhage risk. RECENT FINDINGS:Neuraxial analgesia improves both maternal comfort and procedural success during ECV for malpresentation. Neuraxial labor analgesia facilitates safer vaginal delivery in multiple gestation pregnancies. Cesarean delivery for multiple gestation carries an increased risk of uterine atony, with higher oxytocin requirements (ED 90 > 4 IU) compared with singleton pregnancies. SUMMARY:Anesthesiologists should maintain vigilance and readiness for rapid intervention when caring for patients with malpresentation and/or multiple gestation. Persistent gaps exist between recent evidence and routine clinical practice; therefore, implementation studies and multidisciplinary consensus guidelines are warranted.
