We present a complementary approach to real-time optimization (RTO) for maximizing the operating profit of an existing chemical plant without requiring a model-updating procedure, which is cumbersome and which may not necessarily improve the model. The proposed optimization methodology is based on an analogy between steady-state operation periods in process operation and iterations in numerical optimization. This analogy is also used by optimization-based run-to-run (RtR) control for batch processes. The process measurements are utilized to correct the gradient information used in optimization computations, resulting in better operating conditions. The plant operation is an integral part of the optimization, and this necessitates certain modifications to the optimization algorithm that we use (feasible sequential quadratic programming). The methodology is tested with a CSTR process and is shown to be robust in the presence of substantial model-plant mismatch.

IMPORTANCE Children raised in settings with lower parental socioeconomic status are at increased risk for neuropsychological disorders. However, to date, the association between socioeconomic status and fetal brain development remains poorly understood.OBJECTIVE To determine the association between parental socioeconomic status and in vivo fetal brain growth and cerebral cortical development using advanced, 3-dimensional fetal magnetic resonance imaging. DESIGN, SETTING, AND PARTICIPANTSThis cohort study of fetal brain development enrolled 144 healthy pregnant women from 2 low-risk community obstetrical hospitals from 2012 through 2019 in the District of Columbia. Included women had a prenatal history without complications that included recommended screening laboratory and ultrasound studies. Exclusion criteria were multiple gestation pregnancy, known or suspected congenital infection, dysmorphic features of the fetus, and documented chromosomal abnormalities. T2-weighted fetal brain magnetic resonance images were acquired. Each pregnant woman was scanned at up to 2 points in the fetal period. Data were analyzed from June through November 2020. EXPOSURES Parental education level and occupation status were documented. MAIN OUTCOMES AND MEASURES Regional fetal brain tissue volume (for cortical gray matter, white matter, cerebellum, deep gray matter, and brainstem) and cerebral cortical features (ie, lobe volume, local gyrification index, and sulcal depth) in the frontal, parietal, temporal, and occipital lobes were calculated. RESULTS Fetal brain magnetic resonance imaging studies were performed among 144 pregnant women (median [interquartile range] age, 32.5 [27.0-36.1] years) with gestational age from 24.0 to 39.4 weeks; 75 fetuses (52.1%) were male, and 69 fetuses (47.9%) were female. Higher parental education level was associated with significantly increased volume in the fetal white matter

Introduction: Hemorrhage is the leading cause of preventable death in pediatric trauma patients. Timely blood administration is associated with improved outcomes in children and adults. This study aimed to identify delays to transfusion and improve the time to blood administration among injured children. Methods: A multidisciplinary team identified three activities associated with blood transfusion delays during the acute resuscitation of injured children. To address delays related to these activities, we relocated the storage of un-crossmatched blood to the emergency department (ED), created and disseminated an intravenous access algorithm, and established a nursing educator role for resuscitations. We performed comparative and regression analyses to identify the impact of these factors on the timeliness and likelihood of blood administration. Results: From January 2017 to June 2021, we treated 2159 injured children and adolescents in the resuscitation area, 54 (2.5%) of whom received blood products in the ED. After placing a blood storage refrigerator in the ED, we observed a centerline change that lowered the adjusted time-to-blood administration to 17 minutes (SD 11), reducing the time-to-blood administration by 11 minutes (β = −11.0, 95% CI = −22.0 to −0.9). The likelihood of blood administration was not changed after placement of the blood refrigerator. We observed no reduction in time following the implementation of the intravenous access algorithm or a nursing educator. Conclusions: Relocation of un-crossmatched blood storage to the ED decreased the time to blood transfusion. This system-based intervention should be considered a strategy for reducing delays in transfusion in time-critical settings.

Background There are well‐documented racial and ethnic disparities in treatment and perioperative outcomes for patients with adolescent idiopathic scoliosis. Aims We hypothesize that the implementation of a coordinated care pathway for pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may be associated with a reduction in racial and ethnic disparities in perioperative outcomes. Methods This is a retrospective pre‐ and post‐test cohort study of patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution between July 1, 2013 and August 5, 2019. We implemented a coordinated care pathway in March 2015. Patient demographics included age, race, ethnicity, weight, gender, insurance status, ASA class, time between the date surgery was ordered and the date surgery occurred, degree of scoliosis, and the number of spinal levels fused. The primary outcome was length of stay. The secondary outcomes included transfusion rates, pain scores, and postoperative complications. Multivariable regression models compared outcome medians across race/ethnicity. Disparities were defined as the difference in adjusted outcomes by race/ethnicity. Results Four hundred twenty‐four patients underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution (116 prepathway and 308 postpathway). The median length of stay of Black patients was 1.0 day (95% CI: 0.4, 1.5; p = .006) longer than White patients prepathway. Prepathway patients who self‐identified as Other had a 1.2 (95% CI: 0.5, 1.9; p = .004) higher median average pain score on postoperative day 1 compared with White patients. On postoperative day 2, patients who identified as Other had 2.0 (95% CI: 0.8, 3.2; p = .005) higher pain score compared with White patients prepathway. Postpathway, there were no significant differences in outcomes by race/ethnicity. Conclusions Our study supports the hypothesis that use of a coordinated care pathway is associated with a reduction in racial and ethnic disparities in length of stay and pain scores in pediatric patients undergoing posterior spinal fusion.

Introduction: Accurate and timely documentation of pediatric early warning scores (PEWS) by the bedside nurse into the electronic health record (EHR) is important to promote early identification of patients in stages of deterioration. Through the implementation of a PEWS calculator embedded in the EHR, we hope to improve the accuracy of the recorded score and reduce the time between vital sign collection and final documentation in the EHR. Methods: Identification of the highest PEWS value in the 24 hours before all unplanned transfers or rapid response activations without a transfer occurred between the period November 1, 2013, through December 31, 2016. The accuracy of the calculated cardiac or respiratory subscore based on heart rate or the respiratory rate at the time of PEWS calculation was determined. We tracked the calculation of the time to chart via the difference between nursing documentation of PEWS compared to vital sign collection. Before September 3, 2015, PEWS was calculated mentally by the bedside nurse; afterward, the nurse entered the unique PEWS features into the EHR, and the EHR automatically calculated PEWS. Results: This study evaluated 2,409 PEWS scores, 1,411 before and 998 after initiation of the PEWS calculator. Accuracy before the EHR calculator was 71%, and the median time to document was 55 minutes. Following the implementation of the calculator, no scores were incorrectly calculated too low, and the median time to document was 20 minutes. Conclusions: Transition to an EHR-based PEWS calculator eliminated inaccurately low PEWS values and reduced time to document.