bluuebunny/crossref_metadata_2025 huggingface dataset:
Creating a Quality Improvement Course for Undergraduate Medical Education: Practice What You Teach
Authors: Bradham Tamala S. , Sponsler Kelly C. , Watkins Scott C. , Ehrenfeld Jesse M.
Published: May 2018

Problem

More than half of U.S. medical schools have implemented curricula addressing quality improvement (QI); however, the evidence on which pedagogical methods are most effective is limited.

Approach

As of January 2015, students at Vanderbilt University School of Medicine are required to take a QI course consisting of three 1-month-long (4 hours per week) blocks during their third or fourth year, in which student-identified faculty sponsors are paired with highly trained QI professionals from Vanderbilt University Medical Center. The three blocks of the course include didactic instruction using Institute for Healthcare Improvement Open School modules, readings, weekly assignments, and experiential learning activities (i.e., students develop and implement a QI project with two Plan–Do–Study–Act cycles using a systematic approach that employs the principles of improvement science, which they present as a poster on the last day of the third block).

Outcomes

From January 2015 to January 2017, 132 students completed all three blocks, resulting in 110 completed QI projects. On evaluations (distributed after each completed block), a majority of students rated the clinical relevance of the blocks highly (191/273; 70%), agreed the blocks contributed to their development as physicians (192/273; 70%), and reported the blocks motivated them to continue to learn more about QI (168/273; 62%).

Next Steps

The authors have applied QI methods to improve the course and will aim to assess the sustainability of the course by tracking clinical outcomes related to the projects and students’ ongoing involvement in QI after graduation.
Using Assessment Point Accumulation as a Guide to Identify Students at Risk for Interrupted Academic Progress
Authors: Cendán Juan C. , Joledo Oloruntomi , Soborowicz Mary Beth , Marchand Leslie , Selim Basma R.
Published: May 2018

Problem

Interruptions in academic progress (IP) are problematic for students and educational programs alike. Early identification of students at risk for IP, to provide remediation, could be beneficial.

Approach

Considering the clinically familiar pediatric growth curve as a metaphor, researchers hypothesized they could identify students at risk of IP. They organized course-related examination performance data for 518 students in five classes (2013–2014 through 2017–2018), adding students’ percentage scores cumulatively over time. At every examination point, they analyzed the data for dis-tribution and calculated a mean class score. They plotted each student’s accumulated points and accommodated a linear fit. Using the mean of the class as the horizontal axis, students gaining points against the mean show a positive slope; conversely, students losing points reveal a negative slope. The authors compared their findings against students who had faced IP—those who had repeated at least one course or an academic year, or who had left medical school.

Outcomes

Using a receiver operating characteristic approach, the authors identified a slope of −5 as an excellent screening test with 85% accuracy (sensitivity = 82%, specificity = 86%, area under curve = 0.917). Of 38 students facing IP, 25 would have been identified at risk for IP as early as the fifth assessment using a slope of −5.

Next Steps

Given the outcomes of this innovative, inexpensive, highly accurate approach to identifying students at risk of IP, the authors have plans to optimize interventions and to validate the approach at other programs.
The Effect of Combination Pharmacotherapy on Low Back Pain
Authors: Song Liyang , Qiu Pencheng , Xu Jiaqi , Lv Jiawen , Wang Shengyu , Xia Chen , Chen Pengfei , Fan Shunwu , Fang Xiangqian , Lin Xianfeng
Published: May 2018

Objective:

To evaluate the difference between combination pharmacotherapy and monotherapy on low back pain (LBP).

Methods:

We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials databases up to March 14, 2017. Two authors independently extracted the data and assessed the validity of included trials.

Results:

Twelve randomized controlled trials comparing the effect of LBP combination pharmacotherapy to monotherapy or placebo were included. In chronic LBP, combination pharmacotherapy was more effective than placebo in pain relief (P<0.001; standardized mean difference [SMD], −0.50; 95% confidence interval [CI], −0.70 to −0.29; I²=0%) and function improvement (P<0.001; SMD, −0.27; 95% CI, −0.41 to −0.13; I²=0%) and showed improved pain relief compared with monotherapy (P<0.001; SMD, −0.84; 95% CI, −1.12 to −0.56; I²=0%). Combination pharmacotherapy did not outperform monotherapy pain relief and function improvement in acute LBP. In addition, risk of adverse effects of combination pharmacotherapy was much higher compared with placebo (P<0.05; relative risk, 1.80; 95% CI, 1.33-2.42; I²>50%) and monotherapy (P<0.05; relative risk, 1.44; 95% CI, 1.01-2.06; I²>50%) in both settings.

Discussion:

Combination pharmacotherapy is more effective than placebo or monotherapy in the management of pain and disability in chronic LBP, but not in acute LBP. Further, combination pharmacotherapy has a higher risk of adverse effects than placebo and monotherapy.
Acute Procedural Pain in Children
Authors: Kristensen Helle Nygaard , Lundbye-Christensen Søren , Haslund-Thomsen Helle , Graven-Nielsen Thomas , Elgaard Sørensen Erik
Published: May 2018

Introduction:

Hospitalized children often describe needle-related procedures as the worst pain possible and such procedures may be emotionally traumatic. The use of hospital clowns (HCs) related to painful medical procedures in children may offer pain relief, but this has not been systematically evaluated. The objective of this study was to assess the effect of a therapeutic clown in comparison with standard care on the experience of pain in children receiving venipuncture.

Materials and Methods:

A sample of 116 children aged 4 to 15 years consecutively admitted to the hospital was allocated to either the experimental (presence of HC) or control group (standard care) before venipuncture. Self-reported pain after the procedure was assessed using the Faces Pain Scale combined with a 0 to 10 Numerical Rating Scale. Separate analysis was conducted in age groups from 4 to 6 (N=37) and 7 to 15 (N=74) years.

Results:

Without the clown present, the mean pain score (2.7±2.8) was not significantly different between the 2 age groups. Children aged 7 to 15 years had lower pain scores when the clown was present compared with the control group (P=0.025). Children aged 4 to 6 years had higher pain scores with the clown present, although the difference was not statistically significant (P=0.054). Children with pain (N=49) or previous experiences with venipuncture (N=56) did not score pain significantly differently.

Discussion:

Assessing the pain experience of children receiving venipuncture with the presence of an HC indicates a pain relieving effect for children older than 6 years. However, future studies should carefully study the effects on younger children where mixed effects may be present.
In a Spirit of Restoration
Authors: Gorman Geraldine , Singer Rebecca M. , Christmas Erin , Herbstritt Catherine , Miller Layne , Murphy Mary , Shannon Cailan , Wyss Katrina
Published: May 2018

Conditions within jails and prisons are a public health crisis, necessitating critical reform measures. An innovative collaboration between a Midwestern College of Nursing and Cook County Department of Corrections provides students with the opportunity to develop health education for both those detained in the jail and the corrections officers. A phenomenological approach, recognizing the importance of intuitive and cognitive understanding, is offered as a framework for practice in complex environments. Principles of restorative justice provide a bridge between primary, secondary, and tertiary prevention and the nursing practice possible within these institutions of incarceration and the communities to which people return.
Three-dimensional MRI Analysis of Femoral Head Remodeling After Reduction in Patients With Developmental Dysplasia of the Hip
Authors: Tsukagoshi Yuta , Kamada Hiroshi , Kamegaya Makoto , Takeuchi Ryoko , Nakagawa Shogo , Tomaru Yohei , Tanaka Kenta , Onishi Mio , Nishino Tomofumi , Yamazaki Masashi
Published: May 2018

Background:

Previous reports on patients with developmental dysplasia of the hip (DDH) showed that the prereduced femoral head was notably smaller and more nonspherical than the intact head, with growth failure observed at the proximal posteromedial area. We evaluated the shape of the femoral head cartilage in patients with DDH before and after reduction, with size and sphericity assessed using 3-dimensional (3D) magnetic resonance imaging (MRI).

Methods:

We studied 10 patients with unilateral DDH (all female) who underwent closed reduction. Patients with avascular necrosis of the femoral head on the plain radiograph 1 year after reduction were excluded. 3D MRI was performed before reduction and after reduction, at 2 years of age. 3D-image analysis software was used to reconstruct the multiplanes. After setting the axial, coronal, and sagittal planes in the software (based on the femoral shaft and neck axes), the smallest sphere that included the femoral head cartilage was drawn, the diameter was measured, and the center of the sphere was defined as the femoral head center. We measured the distance between the center and cartilage surface every 30 degrees on the 3 reconstructed planes. Sphericity of the femoral head was calculated using a ratio (the distance divided by each radius) and compared between prereduction and postreduction.

Results:

The mean patient age was 7±3 and 26±3 months at the first and second MRI, respectively. The mean duration between the reduction and second MRI was 18±3 months. The femoral head diameter was 26.7±1.5 and 26.0±1.6 mm on the diseased and intact sides, respectively (P=0.069). The ratios of the posteromedial area on the axial plane and the proximoposterior area on the sagittal plane after reduction were significantly larger than before reduction (P<0.01).

Conclusions:

We demonstrated that the size of the reduced femoral head was nearly equal to that of the intact femoral head and that the growth failure area of the head before reduction, in the proximal posteromedial area, was remodeled after reduction.

Level of Evidence:

Level IV—case series.
How Much Will My Child’s Operation Cost? Availability of Consumer Prices From US Hospitals for a Common Pediatric Orthopaedic Surgical Procedure
Authors: Racimo Allison R. , Talathi Nakul S. , Zelenski Nicole A. , Wells Lawrence , Shah Apurva S.
Published: May 2018

Background:

Price transparency allows patients to make value-based health care decisions and is particularly important for individuals who are uninsured or enrolled in high-deductible health care plans. The availability of consumer prices for children undergoing orthopaedic surgery has not been previously investigated. We aimed to determine the availability of price estimates from hospitals in the United States for an archetypal pediatric orthopaedic surgical procedure (closed reduction and percutaneous pinning of a distal radius fracture) and identify variations in price estimates across hospitals.

Methods:

This prospective investigation utilized a scripted telephone call to obtain price estimates from 50 “top-ranked hospitals” for pediatric orthopaedics and 1 “non-top-ranked hospital” from each state and the District of Columbia. Price estimates were requested using a standardized script, in which an investigator posed as the mother of a child with a displaced distal radius fracture that needed closed reduction and pinning. Price estimates (complete or partial) were recorded for each hospital. The number of calls and the duration of time required to obtain the pricing information was also recorded. Variation was assessed, and hospitals were compared on the basis of ranking, teaching status, and region.

Results:

Less than half (44%) of the 101 hospitals provided a complete price estimate. The mean price estimate for top-ranked hospitals ($17,813; range, $2742 to $49,063) was 50% higher than the price estimate for non-top-ranked hospitals ($11,866; range, $3623 to $22,967) (P=0.020). Differences in price estimates were attributable to differences in hospital fees (P=0.003), not surgeon fees. Top-ranked hospitals required more calls than non-top-ranked hospitals (4.4±2.9 vs. 2.8±2.3 calls, P=0.003). A longer duration of time was required to obtain price estimates from top-ranked hospitals than from non-top-ranked hospitals (8.2±9.4 vs. 4.1±5.1 d, P=0.024).

Conclusions:

Price estimates for pediatric orthopaedic procedures are difficult to obtain. Top-ranked hospitals are more expensive and less likely to provide price information than non-top-ranked hospitals, with price differences primarily caused by variation in hospital fees, not surgeon fees.

Level of Evidence:

Level II—economic and decision analyses.
Long‐term Outcomes in Patients With Multiple Myeloma
Authors: Verelst Silvia G.R. , Blommestein Hedwig M. , De Groot Saskia , Gonzalez‐McQuire Sebastian , DeCosta Lucy , de Raad Johan B. , Uyl‐de Groot Carin A. , Sonneveld Pieter
Published: May 2018

Supplemental Digital Content is available in the text
Improving Patient Compliance With Mechanical Venous Thromboembolism Prophylaxis
Authors: Nahar Deepti , Nizam Aaron , Farrow Monique , Restifo Andrea , Nimaroff Michael
Published: May 2018

Venous thromboembolic events (VTE) occurring in the postoperative period are serious yet preventable conditions. Multiple studies have demonstrated that the risk of postoperative VTE can be successfully reduced with mechanical prophylaxis and/or chemoprophylaxis. Patients are often noncompliant with mechanical prophylaxis in the postoperative period. We performed a prospective nonrandomized controlled study to determine if providing an educational pamphlet would increase knowledge and compliance with mechanical VTE prophylaxis. Patients receiving the educational pamphlet were more likely to rate their knowledge of VTE prophylaxis as “very good” when compared to the control group (73.1% vs. 30.2%, p < .001). Patients were also more likely to be compliant with mechanical prophylaxis in the educational group (53.9% vs. 30.2%, p = .014). Our study demonstrated that providing a simple educational pamphlet increased patient knowledge regarding VTE prophylaxis and increased compliance with mechanical prophylaxis.
Blended tube feeding prevalence, efficacy, and safety: What does the literature say?
Authors: Carter Holly , Johnson Kelly , Johnson Teresa W. , Spurlock Amy
Published: May 2018

Background and purpose:

For most of human history, physicians used blended whole foods for patients who are unable to eat by mouth. However, by the 1960s and 1970s, advances in enteral nutrition resulted in the gradual displacement of blenderized tube feedings (BTFs) with commercial formulas. There are advantages and disadvantages to commercial formulas and BTFs. The purpose of this article was to review the literature for the incidence of blended tube feeding use and its safety, efficacy, and implications for clinical practice.

Methods:

A search of the scientific literature in PubMed, CINAHL, Cochrane, ProQuest, and Ovid was conducted using the keywords “blenderized tube feeding” and “blended tube feeding.” Articles were divided into two categories: 1) frequency of use and experiences of BTF in patients or caregivers and health care providers and 2) safety/efficacy studies.

Conclusions:

The literature review shows a rising interest in BTF, with more research on efficacy indicated.

Implications for practice:

The use of BTF is primarily patient or caregiver driven. Blenderized tube feeding requires oversight by health care providers just as commercial formulas. Health care providers should be aware of the use of BTF and the effect it can have on different patient populations regarding content, cost, safety, and efficacy in the clinical and home settings.
Brief report of a novel advanced practice provider–led course for ultrasound novices
Authors: Santos Christan D. , Rose Mariah Q. , Tomlinson Amanda D. , McLaughlin Diane C.
Published: May 2018

Background and purpose:

Formal training for ultrasound use is essential for critical care providers. Despite a national increase in the utilization of advanced practice providers in critical care, ultrasound education is not routinely provided in their training programs. This study describes and evaluates a 1-day advanced care provider (APP)-led course designed to provide fellow APPs with the skills to obtain and evaluate basic ultrasound images.

Methods:

A 15-question pretest was administered via anonymous use of a clicker response system. Participants had didactic lectures followed by hands-on experience with live models and instructor. Posttest was administered after achievement of basic ultrasound views. Postcourse evaluations were also administered.

Conclusions:

Pretest and posttest questions included identifying anatomy, pathology, quantifying cardiac function, and clinical decision making. Scores improved from 58% on the pretest to 78% on the posttest. All participants acknowledged the need for the course and their ability to transfer the course into practice.

Implications for practice:

This course established that APPs can both teach and learn from their peers in a formal setting. In addition, this course demonstrated that an APP-led course with a combined hands-on and didactic approach is an effective method for critical care ultrasound skills acquisition in ultrasound-novice APPs.
Organophosphate insecticide exposure: A clinical consideration of chlorpyrifos regulation
Authors: Curtis Alexa Colgrove , Sattler Barbara
Published: May 2018

Background and purpose:

In March 2017, the Environmental Protection Agency (EPA) reversed course on a proposal to ban the agricultural use of the organophosphate (OP) insecticide chlorpyrifos (CPF). The purpose of this article is to examine the evidence leading to this controversial decision and provide clinically applicable health promotion guidance for nurse practitioners on CPF exposure and risk reduction measures.

Methods:

Environmental Protection Agency documents on CPF regulation and corresponding research referenced within the EPA reports are reviewed. Evidence-based health promotion strategies obtained through PubMed, CINAHL, Center for Disease Control and Prevention, and National Institutes of Health sources are summarized.

Conclusions:

Available data suggest a potential association between CPF exposure and adverse neurodevelopmental outcomes. Particularly vulnerable populations are pregnant women, children younger than two years, and agricultural workers. There may be genetic variability in susceptibility to environmental toxins.

Implications for practice:

Because of the extensive use of the OP CPF in agriculture and other community-based settings throughout the United States, nurse practitioners should be knowledgeable of the evidence regarding CPF exposure and be prepared to provide health promotion guidance to patients in clinical practice. Nurse practitioners should also consider their role in advocacy for healthy environments and the protection of vulnerable populations as it relates to agricultural insecticide exposure.
Impact of the acute care nurse practitioner in reducing the number of unwarranted daily laboratory tests in the intensive care unit
Authors: Jefferson Brian K. , King Joan E.
Published: May 2018

Background:

Frequent laboratory testing may be necessary at times for critically ill patients. However, the practice of indiscriminate laboratory test ordering is common.

Purpose:

The purpose of this quality improvement project was to assess the effectiveness of the acute care nurse practitioner (ACNP) in reducing the number of unwarranted laboratory tests ordered for ICU patients. To determine whether the presence of an ACNP would make a difference, an ACNP was present on daily ICU multidisciplinary rounds to facilitate the discussion of the laboratory testing needs for each patient for the following 24-hour period.

Conclusions:

Eighty-one patients were enrolled in the project, 41 in the comparison and 40 in the intervention group. No significant differences were noted between the two groups. The project demonstrated that although there was an increase in tests ordered for the intervention group, the increase was brought about by an increase in specific individual tests rather than an increase in panels of laboratory tests. A reduction in patient cost was observed for the number of tests ordered. No increase in adverse events was noted.

Implications for Practice:

Acute care nurse practitioner presence on multidisciplinary rounds may be an effective method to change the practice toward the ordering of tests based on clinical indication.
Improving aesthetic outcomes after head and neck reconstruction
Authors: Al Afif Ayham , Uys H. Kendal , Taylor S. Mark
Published: May 2018

Purpose of review

Tremendous advancements have been made in head and neck reconstruction following oncologic resection. Despite this, many patients are left with disfiguring postoperative changes. The focus of this review highlights various techniques aimed at improving aesthetic outcomes following head and neck cancer therapy, with a focus on liposuction and fat augmentation.

Recent findings

Over the past decade, the use of liposuction in treating lymphedema after head and neck cancer therapy has showed promising results. Owing to great improvements in harvesting and purification techniques, fat augmentation has been effectively utilized in correcting a wide array of defects. Although free tissue transfer is frequently used in head and neck reconstruction, there is a scarcity of literature on the indications for flap revision procedures.

Head and neck reconstructive surgery can lead to significant cosmetic and functional morbidity. Several tools are available to help improve aesthetic outcomes in this patient population. A thorough understanding of the various techniques and their indications is essential for achieving optimal results.

Video abstract available: See the Video Supplementary Digital Content 1, http://links.lww.com/COOH/A34
Physical Therapy and Exercise for Hospice Patients
Authors: Kowalski Sonya L.
Published: May 2018

Falls are a particular health issue for hospice patients with cancer. Studies have found that 50% of patients diagnosed with advanced cancer fall during the subsequent 6-month time frame. The impact of falls on hospice and cancer patients is costly both in terms of reduced functional quality of life, increased anxiety and resulting pain and suffering. Physical therapy (PT) and exercise have been shown to be effective in reducing falls among older adult populations in the community. The purpose of this article is to review studies that examined PT and exercise for hospice and terminally ill cancer patients. Although none of the five studies evaluated the effect of PT and exercise specifically on falls, outcomes included factors such as balance, strength, pain, sleep and fatigue, all of which can contribute to falls. All the studies reviewed found benefits such as improved health status, functional mobility, or muscle strength.
The 2016 Infusion Therapy Standards of Practice
Authors: Gorski Lisa A.
Published: May 2018

Approximately every 5 years, the Infusion Nurses Society publishes evidence-based practice standards. This article provides an overview of the process used in standards development, describes the format of the standards, and provides a short summary of selected standards as applied to home care. The Standards are an important document that should be available to every home care organization that provides home infusion therapy.
Where the Rubber Hits the Road
Authors: Pastor Diane K. , Jones Andrea , Arms Tamatha
Published: May 2018

Driving cessation for people with dementia is a significant personal safety and public health issue. Home healthcare professionals frequently encounter situations where patients/clients should not continue to drive, and family members are unaware of how to approach the issue. This article will inform readers of the current state of the healthcare driving assessment process, measures and instruments used to assess, and effective strategies and resources when working with families facing the dilemma of how and when to proceed with a driving cessation plan.
Translating Evidence-Based Protocols Into the Home Healthcare Setting
Authors: Beissner Katherine L. , Bach Eileen , Murtaugh Christopher M. , Trifilio MaryGrace , Henderson Charles R. , Barrón Yolanda , Trachtenberg Melissa A. , Reid M. Carrington
Published: May 2018

Activity-limiting pain is common among older home care patients and pain management is complicated by the high prevalence of physical frailty and multimorbidity in the home care population. A comparative effectiveness study was undertaken at a large urban home care agency to examine an evidence-based pain self-management program delivered by physical therapists (PTs). This article focuses on PT training, methods implemented to reinforce content after training and to encourage uptake of the program with appropriate patients, and therapists' fidelity to the program. Seventeen physical therapy teams were included in the cluster randomized controlled trial, with 8 teams (155 PTs) assigned to a control and 9 teams (165 PTs) assigned to a treatment arm. Treatment therapists received interactive training over two sessions, with a follow-up session 6 months later. Additional support was provided via emails, e-learning materials including videos, and a therapist manual. Program fidelity was assessed by examining PT pain documentation in the agency's electronic health record. PT feedback on the program was obtained via semistructured surveys. There were no between-group differences in the number of PTs documenting program elements with the exception of instruction in the use of imagery, which was documented by a higher percentage of intervention therapists (p = 0.002). PTs felt comfortable teaching the program elements, but cited time as the biggest barrier to implementing the protocol. Possible explanations for study results suggesting limited adherence to the program protocol by intervention-group PTs include the top-down implementation strategy, competing organizational priorities, program complexity, competing patient priorities, and inadequate patient buy-in. Implications for the implementation of complex new programs in the home healthcare setting are discussed.
Caring for Chinese-American Home Care Patients
Authors: He Qilian
Published: May 2018

Chinese-Americans are the largest group of Asian Americans. Home care providers in the United States will encounter patients with various levels of traditional Chinese lifestyles, cultural expressions, and health practices. A description of how to prepare for and conduct a home care visit with a patient from China is described. This article integrates recent research about Chinese-American elders and basics of Chinese culture to assist healthcare clinicians in providing supportive, culturally sensitive home care for Chinese patients and developing rapport and trust with them.
Assessment of Activity of Daily Living Among Older Adult Patients in Home Healthcare and Skilled Nursing Facilities
Authors: Osakwe Zainab Toteh , Larson Elaine , Agrawal Mansi , Shang Jinjing
Published: May 2018

Older adult's ability to self-manage illness is dependent on their ability to perform activities of daily living (ADL). Forty-five percent of those older than 65 years will have ongoing clinical needs after hospital discharge and require postacute care (PAC) services in settings such as home healthcare (HHC) and skilled nursing facilities (SNF). The Improving Medicare Post-Acute Care Transformation Act of 2014 requires PAC providers to begin collecting and reporting ADL data to build a coordinated approach to payment and standardize patient assessments and quality measurement. The aim of this integrative review was to compare the methods of assessing ADLs in HHC to SNF. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to ensure results were reported systematically. A scientific literature search without date restriction within the PubMed and Cumulative Index of Nursing and Allied Health Literature databases was conducted. Two independent investigators assessed study quality using the quality appraisal instrument developed by Kmet et al. Study quality was high. Of the 18,749 articles identified by the search, 8 met inclusion criteria and four tools were identified that are used to assess ADLs in SNF and HHC. Although SNF and HHC collect similar ADL information, the range of content covered, item definitions, scoring, and psychometrics are not comparable across settings.
Community-Based Care of the Fibromyalgia Patient
Authors: Davis Kimberly , Sargent Lana , Menzies Victoria
Published: May 2018

Along with a variety of distressing symptoms, a diagnosis of fibromyalgia (FM) brings with it substantial physical, psychosocial, and financial costs. Research shows that self-management is an effective means to manage FM and can lead to fewer healthcare visits. Yet due to the complexity of this disorder, healthcare providers need to be able to tailor treatment to individual patients by understanding effective treatment interventions. Home healthcare nurses (HHNs) are in a unique position to assess and implement effective treatment recommendations in the home setting and as such could consider incorporating self-management strategies into the home visit with the FM patient. Therefore, the purpose of this article is to use a case study to describe the assessment of FM patient's functional ability and quality of life and how the HHN may integrate self-management teaching into the established home care visit. A review of the literature and discussion of self-management interventions for the FM patient is presented. A summary of the case study and proposed clinical implications is offered.
Factors Associated With Stability of Health Nursing Services for Children With Medical Complexity
Authors: Nageswaran Savithri , Golden Shannon L.
Published: May 2018

The objectives of our study are to: (1) identify the factors associated with lack of stable home healthcare nursing services for children with medical complexity, and (2) describe the implications of unstable home healthcare nursing for children, caregivers, nurses, and home healthcare agencies. We collected qualitative data in 20 semistructured in-depth interviews (15 English, 5 Spanish) with 26 primary caregivers of children with medical complexity, and 4 focus groups of 18 home healthcare nurses inquiring about their experiences about home healthcare nursing services for children with medical complexity. During an iterative analysis process, we identified recurrent themes related to stability of home healthcare nursing. Lack of stability in home healthcare nursing was common. These include: (1) not finding nurses to cover shifts, (2) nurse turnover, (3) nurses calling out frequently, and (4) nurses being fired by caregivers. Reasons for lack of stability of home healthcare nursing services were multifactorial and included: nurse-level, child-level, caregiver-level, residence-level, agency-level, and system-level factors. Lack of stable home healthcare nursing affected the well-being of children with medical complexity, and contributed to substantial caregiver burden. There were negative implications of unstable home healthcare services for nurses and home healthcare agencies as well. Lack of stable home healthcare nursing services is a major problem in the home care of children with medical complexity. Although some of the factors for unstable home healthcare nursing services are not modifiable, there are others that are potentially modifiable. Ensuring stable home healthcare nursing services will likely improve care of children and reduce caregiver burden.
Management of Heart Failure in a Rural Community
Authors: Miller Rachel F.
Published: May 2018

In rural Western New York, hospitalizations of patients over 65 years of age with heart failure (HF) exceed state and national levels, demonstrating a need for improved management of older adult HF patients in rural communities. The aim of this project was to implement an evidence-based practice (EBP) guideline for HF management at a certified home health agency (CHHA). The objective was to increase CHHA interdisciplinary staff knowledge and to implement an EBP HF guideline to improve care and reduce hospital readmission rates. This quality improvement project used a quantitative descriptive study design, with a convenience sample of 60 CHHA interdisciplinary staff. A series of four 30-minute educational sessions were provided to the staff regarding the EBP HF guideline. Data were collected using pre- and posteducation testing to assess knowledge. A 3-month evaluation was completed to assess implementation along with readmission data pre- and postimplementation. Of the 60 interdisciplinary staff who received the EBP HF guideline education, 17 participants completed both the pretest and posttest. Results demonstrated a statistically significant increase in knowledge from the pretest (Md = 60.00%) to the posttest (Md = 80.00%) (p = .001). In the 3-month follow-up survey, 66% of the staff reported using the EBP HF guideline on “most” or “all” older adult HF patients. The organization had a 4.32% reduction in all-cause 30-day rehospitalizations from 11.39% to 7.07% following the implementation of the EBP HF guideline.
Development of the International Guidelines for Home Health Nursing
Authors: Narayan Mary , Farris Cindy , Harris Marilyn D. , Hiong Fong Yoke
Published: May 2018

Throughout the world, healthcare is increasingly being provided in home and community-based settings. There is a growing awareness that the most effective, least costly, patient-preferred setting is patients' home. Thus, home healthcare nursing is a growing nursing specialty, requiring a unique set of nursing knowledge and skills. Unlike many other nursing specialties, home healthcare nursing has few professional organizations to develop or support its practice. This article describes how an international network of home healthcare nurses developed international guidelines for home healthcare nurses throughout the world. It outlines how the guidelines for home healthcare nursing practice were developed, how an international panel of reviewers was recruited, and the process they used for reaching a consensus. It also describes the plan for nurses to contribute to future updates to the guidelines.
Identifying the Factors Associated With Canadian Registered Nurses' Engagement in Advance Care Planning
Authors: Rietze Lori , Heale Roberta , Roles Stacey , Hill Laura
Published: May 2018

Advance care planning (ACP) is a series of discussions in which patient values and wishes for end-of-life care are made known. The purpose of this study was to determine the extent to which registered nurses (RNs) engaged in ACP with their patients and understand the factors associated with this practice decision in Canada. One hundred twenty-five RNs participated in this cross-sectional descriptive survey. Registered nurse participants agreed that end-of-life decision making is an important part of their work; however, the majority of respondents did not participate in ACP, especially those RNs who were employed in community settings. Study respondents cited barriers to implementing ACP into their practice such as limited organizational policy, limited expectations of others to engage in ACP, inadequate educational opportunities to learn about or practice ACP, and a lack of patient and family readiness for the conversation. Study conclusions support recommendations for continuing education topics and the importance of organizational support in ACP.
Being on the Frontline
Authors: Grech Antonia , Depares Joanna , Scerri Josianne
Published: May 2018

The aim of this study was to explore the experiences of nurses providing end-of-life care to patients with hematologic malignancies, in a hematology oncology setting, in an acute general hospital. A qualitative hermeneutic phenomenological design was used, and 2 sets of semistructured interviews were conducted with 5 female nurses. The transcribed texts were analyzed using Interpretative Phenomenological Analysis. Two main themes emerged: “battling against medical futility” and “struggling with the emotional burden of care.” Nurses perceived that the transfer of these patients at end of life to intensive critical care settings, coupled with the particularly aggressive treatments and corresponding symptom burden, prevented them from experiencing a dignified death. Consequently, nurses struggled with a gamut of emotions that included feelings of helplessness, distress, and compassion fatigue. Providing nursing care at end of life was perceived to be particularly challenging with the younger patients or with those who reminded them of family members. The findings highlight the unique challenges experienced by these nurses and the need to support them in their work with patients having hematologic malignancies at end of life within a well-resourced setting.
A Process Evaluation of an Outpatient Palliative Care Program
Authors: Liguori David
Published: May 2018

Palliative care has evolved from providing care for patients near end of life into a specialized discipline focused on addressing the physical, emotional, social, and spiritual needs of patients throughout the trajectory of an illness. For patients with metastatic cancer, timely referrals to palliative care are essential in order to have a meaningful impact on their quality of life. Recommendations for screening patients for palliative care have been offered by professional organizations; however, screening all patients with metastatic cancer poses many challenges. This quality improvement project conducted a process evaluation of an outpatient palliative care program and evaluated the feasibility of utilizing a screening tool in an effort to readily identify patients with metastatic cancer who have palliative care needs in an outpatient cancer center. Although nurses' compliance with the screening tool was less than expected, screening for palliative care needs in this setting resulted in more referrals to palliative care compared with physician referrals. Improvements in quality of life were found in patients who received a palliative care consultation, and patients were very satisfied with the care provided by palliative care. The potential for financial improvements was observed as a result of this project.
Differences Between Subtalar Instability and Lateral Ankle Instability Focusing on Subtalar Ligaments Based on Three Dimensional Isotropic Magnetic Resonance Imaging
Authors: Yoon Deuk Young , Moon Sung Gyu , Jung Hong-Geun , Kim Na Ra
Published: May 2018

Objective

The purpose of this study was to assess the differences between subtalar instability (STI) and lateral ankle instability (LAI) focusing on subtalar ligaments using 3-dimensional (3D) isotropic magnetic resonance imaging (MRI).

Methods

Preoperative MRIs of 10 patients with STI who failed nonoperative treatment and consequently underwent arthroscopic subtalar reconstruction were compared with preoperative MRIs of 23 patients with LAI who underwent ligament repair or reconstruction. Dimensions of anterior capsular ligament (ACL), interosseous talocalcaneal ligament (ITCL), calcaneofibular ligament (CFL), and anterior talofibular ligament (ATFL) were measured. Tears of ACL, ITCL, CFL, ATFL, cervical ligament, and inferior extensor retinaculum were analyzed.

Results

Patients with subtalar instability had significantly lower ACL thickness and width than patients with LAI (thickness: 1.48 vs 2.12 mm,P= 0.045; width: 7.30 vs 8.64 mm,P= 0.029). An ACL thickness of 1.8 mm or less had sensitivity and specificity both at 75.0%, and an ACL width of 8 mm or less had sensitivity of 75.0% and specificity of 85.0% for discriminating STI from LAI. Absence or complete tear of ACL was more frequent in patients with STI than in patients with LAI (60.0% vs 13.0%,P= 0.010). The ATFL thickness was significantly greater in patients with LAI (P= 0.001). Complete tear of ATFL was more common in patients with LAI (P= 0.008). Complete tear of CFL was common in both the STI and LAI groups without significant difference (20.0% vs 21.7%). There was no significant difference in thickness and width of ITCL and in CFL thickness. Complete tear of ITCL, cervical ligament, and inferior extensor retinaculum were rare without significant difference.

Conclusion

In patients with STI, the ACL is thin and narrow and more commonly absent or torn compared with patients with LAI. Complete tear of ATFL was more common in patients with LAI. Complete tear of CFL was commonly encountered in both the STI and LAI groups.
Microsatellite Instability and Programmed Cell Death-Ligand 1 Expression in Stage II/III Gastric Cancer
Authors: Choi Yoon Young , Kim Hyunki , Shin Su-Jin , Kim Ha Yan , Lee Jinae , Yang Han-Kwang , Kim Woo Ho , Kim Young-Woo , Kook Myeong-Cherl , Park Young Kyu , Kim Hyung-Ho , Lee Hye Seung , Lee Kyung Hee , Gu Mi Jin , Choi Seung Ho , Hong SoonWon , Kim Jong Won , Hyung Woo Jin , Noh Sung Hoon , Cheong Jae-Ho
Published: May 2018

Objective:

We investigated microsatellite instability (MSI) status and programed cell death ligand 1 (PD-L1) expression as predictors of prognosis and responsiveness to chemotherapy for stage II/III gastric cancer.

Background:

The clinical implications of MSI status and PD-L1 expression in gastric cancer have not been well-elucidated.

Methods:

Tumor specimens and clinical information were collected from patients enrolled in the CLASSIC trial—a randomized controlled study of capecitabine plus oxaliplatin-based adjuvant chemotherapy. Five quasi-monomorphic mononucleotide markers were used to assess tumor MSI status. PD-L1 expressions of tumor and stromal immune cells were evaluated using immunohistochemistry.

Results:

Of 592 patients, 40 (6.8%) had MSI-high (MSI-H) tumors. Among 582 patients available for immunohistochemistry evaluation, PD-L1 was positive in tumor cells (tPD-L1) of 16 patients (2.7%) and stromal immune cells (sPD-L1) of 165 patients (28.4%). Multivariable analysis of disease-free survival (DFS) showed that MSI-H and sPD-L1-positivity were independent prognostic factors [hazard ratio 0.301 (0.123–0.736), 0.714 (0.514–0.991); P = 0.008, 0.044), as were receiving chemotherapy, age, tumor grade, and TNM stage. Although adjuvant chemotherapy improved DFS in the microsatellite-stable (MSS) group (5-year DFS: 66.8% vs 54.1%; P = 0.002); no benefit was observed in the MSI-H group (5-year DFS: 83.9% vs 85.7%; P = 0.931). In the MSS group, sPD-L1-negative patients, but not sPD-L1-positive patients, had significant survival benefit from adjuvant chemotherapy compared with surgery only (5-year DFS: 66.1% vs 50.7%; P = 0.001).

Conclusion:

MSI status and PD-L1 expression are clinically actionable biomarkers for stratifying patients and predicting benefit from adjuvant chemotherapy after D2 gastrectomy for stage II/III gastric cancer.
Rate fluctuations not steps dominate LIP activity during decision-making
Authors: Zhao Xuelong , Kording Konrad P.
Published: May 2018

The idea that lateral intraparietal cortex (LIP) integrates information for and against a decision, is one of the most popular models in neuroscience. However, a recent statistical analysis has suggested that LIP does not integrate information but that individual neurons’ activities jump. The result was based on a model comparison, which is often hard to interpret. There are two worries that can render comparisons problematic. (1) Important aspects of variance are contained in neither model. (2) The analysis is complicated, making it hard to verify. We thus followed up with a simple approach for model comparison: crossvalidation. We find evidence that baseline fluctuations describe much of the variance, which are properly modeled by neither the original paper’s drift-diffusion model, nor simple ramp or step models. Moreover, we find that our straightforward analysis strategy prefers ramping models, both with and without trial-by-trial baseline fluctuations. Our analysis, implementable in a few lines of code, suggests the importance of simple analyses.
Characterizing genetic intra-tumor heterogeneity across 2,658 human cancer genomes
Authors: Dentro Stefan C. , Leshchiner Ignaty , Haase Kerstin , Tarabichi Maxime , Wintersinger Jeff , Deshwar Amit G. , Yu Kaixian , Rubanova Yulia , Macintyre Geoff , Demeulemeester Jonas , Vázquez-García Ignacio , Kleinheinz Kortine , Livitz Dimitri G. , Malikic Salem , Donmez Nilgun , Sengupta Subhajit , Anur Pavana , Jolly Clemency , Cmero Marek , Rosebrock Daniel , Schumacher Steven , Fan Yu , Fittall Matthew , Drews Ruben M. , Yao Xiaotong , Lee Juhee , Schlesner Matthias , Zhu Hongtu , Adams David J. , Getz Gad , Boutros Paul C. , Imielinski Marcin , Beroukhim Rameen , Sahinalp S. Cenk , Ji Yuan , Peifer Martin , Martincorena Inigo , Markowetz Florian , Mustonen Ville , Yuan Ke , Gerstung Moritz , Spellman Paul T. , Wang Wenyi , Morris Quaid D. , Wedge David C. , Van Loo Peter ,   on behalf of the PCAWG Evolution and Heterogeneity Working Groupthe PCAWG consortium.,   the PCAWG consortium
Published: May 2018

Intra-tumor heterogeneity (ITH) is a mechanism of therapeutic resistance and therefore an important clinical challenge. However, the extent, origin and drivers of ITH across cancer types are poorly understood. To address this question, we extensively characterize ITH across whole-genome sequences of 2,658 cancer samples, spanning 38 cancer types. Nearly all informative samples (95.1%) contain evidence of distinct subclonal expansions, with frequent branching relationships between subclones. We observe positive selection of subclonal driver mutations across most cancer types, and identify cancer type specific subclonal patterns of driver gene mutations, fusions, structural variants and copy-number alterations, as well as dynamic changes in mutational processes between subclonal expansions. Our results underline the importance of ITH and its drivers in tumor evolution, and provide an unprecedented pan-cancer resource of comprehensively annotated subclonal events from whole-genome sequencing data.
Combinatorial quorum sensing in Pseudomonas aeruginosa allows for novel cheating strategies
Authors: Gurney James , Azimi Sheyda , Brown Sam P. , Diggle Stephen P.
Published: May 2018

In the opportunistic pathogen Pseudomonas aeruginosa, quorum sensing (QS) is a social trait that is exploitable by non-cooperating cheats. Previously it has been shown that by linking QS to the production of both public and private goods, cheats can be prevented from invading populations of cooperators and this has been termed ‘a metabolic incentive to cooperate’. We hypothesized P. aeruginosa could evolve novel cheating strategies to circumvent private goods metabolism by rewiring its combinatorial response to two QS signals (3O-C12-HSL and C4-HSL). We performed a selection experiment that cycled P. aeruginosa between public and private goods growth media and evolved an isolate which rewired its control of cooperative protease expression from a synergistic (AND-gate) response to dual signal input, to a 3O-C12-HSL only response. We show that this isolate circumvents metabolic incentives to cooperate and acts as a combinatorial signaling cheat, with a higher fitness in competition with its ancestor. Our results show three important principles; first, combinatorial QS allows for diverse social strategies to emerge; second, that restrictions levied by private goods are not sufficient to explain the maintenance of cooperation in natural populations and third that modifying combinatorial QS responses could result in important physiological outcomes in bacterial populations.