bluuebunny/crossref_metadata_2025 huggingface dataset:
Power and Resistance
Authors: Slemon Allie , Bungay Vicky , Jenkins Emily , Brown Helen
Published: November 2018

Mental health challenges are a leading health issue, and while nurses should be well positioned to provide care to this client population, nurses are not adequately prepared for this role during their education. This qualitative narrative inquiry explored nursing students' (N = 15) experiences within their mental health practicums. Analyzed through Foucault's concept of micropower, participants' narratives illustrate that students observed nurses holding power over patients, and enacted resistance to this power in a complex interplay of empowerment and disempowerment. Study findings speak to the need for systemic shifts in mental health practice and ongoing educator support of students in mental health practicums.
Usefulness of Watson's Caring Science for Online Educational Practices in Disciplines Outside of Nursing
Authors: Sitzman Kathleen , Muller Dorothy H.
Published: November 2018

Human caring has long been considered the primary domain of nurses and the primary function of nursing practice. Results related to the study of a Caring Science, Mindful Practice Massive Open Online Course (MOOC), suggest that Watson's Caring Science tenets are meaningful and useful for professionals who work in disciplines outside of nursing. Further study was needed to explore the degree to which Caring Science might be useful and applicable to the practices of non-nurse professionals. The study that is the focus of this article explored perceived usefulness of Watson's Caring Science for professionals from a wide array of disciplines who teach and work in online settings. Results confirm applicability and usefulness across disciplines and in diverse settings. Results also suggest that nurse-mediated Caring Science education and training may help establish common ground upon which further interprofessional and transdisciplinary understanding and collaboration may be built.
A Theoretical Framework for Emancipatory Nursing With a Focus on Environment and Persons' Own and Shared Lifeworld
Authors: Dahlborg Lyckhage Elisabeth , Brink Eva , Lindahl Berit
Published: November 2018

By giving a brief overview of the metaconcepts in nursing, with a focus on environment, we sketch a theoretical framework for an emancipatory perspective in nursing care practice. To meet the requirements of equality in care and treatment, we have in our theoretical framework added a critical lifeworld perspective to the antioppressive practice, to meet requirements of equity in health care encounter. The proposed model of emancipatory nursing goes from overall ideological structures to ontological aspects of the everyday world. Based on the model, nurses could identify what kind of theoretical critical knowledge and thinking they require to conduct equal care and encounter the person behind the patient role.
Cultivating Praxis Through Chinn and Kramer's Emancipatory Knowing
Authors: Peart Jessica , MacKinnon Karen
Published: November 2018

Nursing actions in support of equitable health and social relations have always been central to the work of our discipline. The mandate for social justice advocacy is identified in many of our professional and ethical frameworks, with systems-level advocacy situated as a core competency for advanced practice nurses. And yet, the sociopolitical processes that generate health inequities are not always readily understood by nurses. Emancipatory knowing provides an accessible lens to reveal how social injustice occurs while delineating a practical structure through which reflective action can be undertaken toward social change, otherwise known as nursing praxis.
Creating Emancipatory Dialogues About Identity and Health by Modernizing Interviews
Authors: Boutain Doris M. , Evans-Agnew Robin , Liu Fuqin , Rosemberg Marie-Anne S.
Published: November 2018

Emancipatory insights about health as constituted by demographic identity codifiers remain hidden using current interview methods and analytic techniques. The purpose of this article is to demonstrate how the Identity, Research, and Health Dialogic Open-Ended (I-ReH-DO) Interview was used across 3 separate research topics to enhance emancipatory knowledge development. Three featured research topics focus on health issues relevant to populations worldwide, including asthma management, hypertension management, and preconception care. The use of the I-ReH-DO Interview across multiple studies supports the power of participants to define identity and its health significance, contextualizes research analysis, and advances emancipatory understandings.
Postanesthesia alternation of lower limb contractures in children with spastic cerebral palsy
Authors: Lai Yu-Cheng , Lin Huey-Shyan , Pan Hui-Fen , Chang Wei-Ning , Hsu Chien-Jen , Renn Jenn-Huei , Kuo Tsu-Jen
Published: November 2018

The aim of this study was to clarify the effects of general anesthesia (GA) on joint range of motion (ROM) in children with spastic cerebral palsy (SCP). Eighty-four SCP cases (mean age 8.4 years) admitted for first corrective surgery were retrospectively reviewed. Lower limb ROM were measured 1 day before operation and immediately after GA. Contracture of hip, knee, and ankle joints decreased significantly after GA, with + 11.1° (39.5%) for the hip abduction angle, −3.7° (18.0%) for the Thomas test, −15.0° (19.1%) for the popliteal angle, + 6.6° (39.8%) and 7.0° (109%) for ankle dorsiflexion with knee flexion and extension, respectively (allP < 0.001). These changes were correlated positively to pre-GA contracture and body weight, negatively to age, but independent of preoperative functional level, geographic classification of SCP, or modified Ashworth scale. On the basis of these findings, routine post-GA reassessments of joint ROM before corrective surgeries were recommended for pediatric SCP cases.
Optimization of Casting in Early-onset Scoliosis
Authors: Fedorak Graham T. , Stasikelis Peter J. , Carpenter Ashley M. , Nielson Alexandra N. , D’Astous Jacques L.
Published: November 2018

Background:

Early-onset scoliosis is a spine deformity that presents before the age of 3 years. When compared with age-matched controls, children with the condition are known to be at risk for significant morbidity and mortality. Although many works support the use of casting for this condition, the key technical factors to optimize the outcomes of casting are not clear. This work was designed to evaluate the role of frequency of radiographic imaging and over the shoulder straps in the outcomes of casting.

Methods:

Two surgeons at 2 centers followed nearly identical protocols for applying casts for early-onset scoliosis. At center A, the surgeon hoped to improve outcomes by obtaining radiographs after each cast and by reinforcing the cast with shoulder straps. At center B, the surgeon did not use shoulder straps and limited radiographs to once every 6 months. Children were included if they were 3 years or below of age and had a curve of ≥50 degrees at the time of the first cast and had a minimum of 3 years of follow-up. Center was used as a variable in a multivariable regression that also included: age at first cast, initial curve magnitude, and presence of a syrinx or genetic syndrome with the outcome of curve resolution.

Results:

There were 40 children at center A, 9 of whom experienced resolution of their scoliosis. There were 36 children at center B, and 11 demonstrated scoliosis resolution. At center A, 2 of 10 children with a syrinx or genetic syndrome demonstrated curve resolution while 7 of 30 without these comorbidities did. At center B 3 of 10 children with a syrinx or genetic syndrome had curve resolution while 8 of 26 children without these comorbidities did.

Conclusions:

The children in group A demonstrated results very similar to the children of group B. Thus, the extra burden of shoulder straps and frequent radiographs are unnecessary.

Level of Evidence:

Level III.
Effect of Prosthesis Width and Depth on Heterotopic Ossification After Cervical Disc Arthroplasty
Authors: Zeng Junfeng , Liu Hao , Chen Hua , Rong Xin , Meng Yang , Yang Yi , Deng Yuxiao , Ding Chen
Published: November 2018

Study Design.

Retrospective analysis.

Objective.

To investigate the effect of width and depth of the inserted cervical disc prosthesis on heterotopic ossification (HO) after cervical disc arthroplasty, and to explore the relationship between clinical outcome and HO.

Summary of Background Data.

The mechanism of HO formation still remains unknown. Footprint mismatch of cervical disc prosthesis was common in cervical arthroplasty. Compared with endplate, some inserted prostheses were smaller in width and length.

Methods.

Retrospectively analyze the patients who underwent cervical disc arthroplasty with Prestige-LP Disc in our institute. Patients were divided into HO group or non-HO group according to the McAfee classification. The ratios of the width (Rw) and depth (Rd) of prosthesis to endplate were calculated. Radiographic and clinical assessments included: C2–7 angle, segmental angle, range of motion (ROM) of the index level, visual analogue scale, neck disability index, and Japanese orthopaedic association scores.

Results.

The mean follow-up time was 47.7 months. At the last follow-up, the overall incidence of HO was 34.3% (35/102). There were 35 patients in the HO-group, and 67 patients in the non-HO group. The overall Rw and Rd were 0.887 ± 0.057 and 0.927 ± 0.048, respectively. Both the Rw and Rd of HO-group were smaller than those of non-HO group (0.869 vs. 0.897, P = 0.033; 0.888 vs. 0.948, P < 0.001). There were no significant differences in visual analogue scale, neck disability index, or Japanese orthopaedic association scores, C2-7 angle, or segmental angle between the two groups. But the HO group had less ROM of the index level than the non-HO group (5.3° vs. 9.0°).

Conclusion.

Some of prosthesis had insufficient coverage to the endplate in width and depth. Insufficient coverage of endplate in width and depth may induce the formation of HO. HO could reduce the ROM of the index level, but did not influence the clinical outcome.

Level of Evidence: 3
Longer Preoperative Duration of Symptoms Negatively Affects Health-related Quality of Life After Surgery for Cervical Radiculopathy
Authors: Tarazona Daniel , Boody Barrett , Hilibrand Alan S. , Stull Justin , Bell Kerri , Fang Taolin , Goyal Dhruv , Galetta Matthew , Kaye David , Kepler Christopher K. , Kurd Mark F. , Woods Barrett I. , Radcliff Kris E. , Rihn Jeffery A. , Anderson David Greg , Vaccaro Alexander R. , Schroeder Gregory D.
Published: November 2018

Study Design.

Retrospective cohort.

Objective.

Determine the effect of duration of symptoms (DOS) on health-related quality of life (HRQOL) outcomes for patients with cervical radiculopathy.

Summary of Background Data.

The effect of DOS has not been extensively evaluated for cervical radiculopathy.

Methods.

A retrospective analysis of patients who underwent an anterior cervical decompression and fusion for radiculopathy was performed. Patients were grouped based on DOS of less than 6 months, 6 months to 2 years, and more than 2 years and HRQOL outcomes were evaluated.

Results.

A total of 216 patients were included with a mean follow-up of 16.0 months. There were 86, 61, and 69 patients with symptoms for less than 6 months, 6 months to 2 years, and more than 2 years, respectively. No difference in the absolute postoperative score of the patient reported outcomes was identified between the cohorts. However, in the multivariate analysis, radiculopathy for more than 2 years predicted lower postoperative Short Form-12 Physical Component Score (P = 0.037) and Short Form-12 Mental Component Score (P = 0.029), and higher postoperative Neck Disability Index (P = 0.003), neck pain (P = 0.001), and arm pain (P = 0.004) than radiculopathy for less than 6 months. Furthermore, the recovery ratios for patients with symptoms for less than 6 months demonstrated a greater improvement in NDI, neck pain, and arm pain than for 6 months to 2 years (P = 0.041; 0.005; 0.044) and more than 2 years (P = 0.016; 0.014; 0.002), respectively.

Conclusion.

Patients benefit from spine surgery for cervical radiculopathy at all time points, and the absolute postoperative score for the patient reported outcomes did not vary based on the duration of symptoms; however, the regression analysis clearly identified symptoms for more than 2 years as a predictor of worse outcomes, and the recovery ratio was statistically significantly improved in patients who underwent surgery within 6 months of the onset of symptoms.

Level of Evidence: 3
Treatment for Frailty Does Not Improve Complication Rates in Corrective Surgery for Adult Spinal Deformity
Authors: Yagi Mitsuru , Michikawa Takehiro , Hosogane Naobumi , Fujita Nobuyuki , Okada Eijiro , Suzuki Satoshi , Tsuji Osahiko , Nagoshi Narihito , Asazuma Takashi , Tsuji Takashi , Nakamura Masaya , Matsumoto Morio , Watanabe Kota
Published: November 2018

Study Design.

A retrospective multicenter database review of 240 consecutive patients at least 21 years of age (mean 58 ± 17, range 22–79) who underwent surgery for adult spinal deformity (ASD) and were followed at least 2 years.

Objective.

To investigate how treatment for frailty affects complications in surgery for ASD.

Summary of Background Data.

Several recent studies have focused on associations between frailty and surgical complications. However, it is not clear whether treating frailty affects complication rates in surgery for ASD.

Methods.

Patients were categorized as robust (R group), prefrail, or frail based on the modified frailty index (mFI); prefrail and frail patients were divided by good control of frailty (G group), defined as treatment following the appropriate guidelines for each mFI factor, or poorly controlled frailty (PC group). We compared clinical outcomes and perioperative and 2-year complications between the three groups.

Results.

Of the 240 patients, 142 (59%) were robust, 81 (34%) were prefrail, and 17 (7%) were frail. Among the frail and prefrail patients, 71 (72%) were classified as G and 27 (28%) as PC. The perioperative complication rate was similar in the G and PC groups (32% vs. 37%) but was significantly lower in the R group (15%, P < 0.01). The age- and sex-adjusted odds ratio for 2-year complications was not different in the P group when the G group was referenced (odds ratio 1.3 [0.5–3.2], P = 0.63). In the G and PC groups, which had similar 2-year outcomes, the Scoliosis Research Society-22 function and total scores were significantly lower than in the R group (function: R 3.9 ± 0.7, G 3.5 ± 0.7, P 3.3 ± 0.6; total: R 3.9 ± 0.6, 3.7 ± 0.7, 3.4 ± 0.6; P < 0.01).

Conclusion.

Regardless of its treatment status, frailty increases the risk of complications and inferior clinical outcomes in ASD surgery. Surgeons should routinely evaluate frailty and inform patients of frailty-related risks when considering surgery for ASD.

Level of Evidence: 4
A Pilot Study Evaluating the Effect of Cooler Dialysate Temperature on Hemodynamic Stability During Prolonged Intermittent Renal Replacement Therapy in Acute Kidney Injury*
Authors: Edrees Fahad Y. , Katari Sreelatha , Baty Jack D. , Vijayan Anitha
Published: November 2018

Objectives:

Acute kidney injury requiring renal replacement therapy is associated with high morbidity and mortality. Complications of renal replacement therapy include hemodynamic instability with ensuing shortened treatments, inadequate ultrafiltration, and delay in renal recovery. Studies have shown that lowering dialysate temperature in patients with end-stage renal disease is associated with a decrease in the frequency of intradialytic hypotension. However, data regarding mitigation of hypotension by lowering dialysate temperature in patients with acute kidney injury are scarce. We conducted a prospective, randomized, cross-over pilot study to evaluate the effect of lower dialysate temperature on hemodynamic status of critically ill patients with acute kidney injury during prolonged intermittent renal replacement therapy.

Design:

Single-center prospective, randomized, cross-over study.

Setting:

ICUs and a step down unit in a tertiary referral center.

Patients:

Acute kidney injury patients undergoing prolonged intermittent renal replacement therapy.

Interventions:

Participants were randomized to start prolonged intermittent renal replacement therapy with dialysate temperature of 35°C or dialysate temperature of 37°C.

Measurements and Main Results:

The primary endpoint was the number of hypotensive events, as defined by any of the following: decrease in systolic blood pressure greater than or equal to 20 mm Hg, decrease in mean arterial pressure greater than or equal to 10 mm Hg, decrease in ultrafiltration, or increase in vasopressor requirements. The number of events was analyzed by Poisson regression and other outcomes with repeated-measures analysis of variance. Twenty-one patients underwent a total of 78 prolonged intermittent renal replacement therapy sessions, 39 in each arm. The number of hypotensive events was twice as high during treatments with dialysate temperature of 37°C, compared with treatments with the cooler dialysate (1.49 ± 1.12 vs 0.72 ± 0.69; incidence rate ratio, 2.06; p ≤ 0.0001). Treatment sessions with cooler dialysate were more likely to reach prescribed ultrafiltration targets.

Conclusions:

Patients with acute kidney injury undergoing prolonged intermittent renal replacement therapy with cooler dialysate experienced significantly less hypotension during treatment. Prevention of hemodynamic instability during renal replacement therapy helped to achieve ultrafiltration goals and may help to prevent volume overload in critically ill patients.
Platelet Reactivity in Patients on Aspirin and Clopidogrel Therapy Measured by a New Bedside Whole-Blood Assay
Authors: Polzin Amin , Helten Carolin , Dannenberg Lisa , Mourikis Philipp , Naguib David , Achilles Alina , Knoop Betül , Zako Saif , Rehder Susanne , Görlinger Klaus , Levkau Bodo , Zeus Tobias , Kelm Malte , Hohlfeld Thomas , Hoffmann Till
Published: November 2018

Various tests are available for measuring on-treatment platelet reactivity. The pharmacologically most specific assays are time-consuming and elaborate. A highly specific and convenient assay would be desirable for clinical routine. In this pilot study, we aimed to examine the ability of a novel bedside whole-blood assay—ROTEM platelet—to evaluate platelet inhibition compared with established assays. Platelet reactivity was investigated in 93 patients. Forty-Seven patients were on permanent aspirin therapy and 46 on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. We used ROTEM platelet impedance aggregometry (ROTEM-PTL), light transmission aggregometry (LTA), Multiplate electrode aggregometry (MEA) and vasodilator-stimulated phosphoprotein flow cytometry. Receiver operating characteristic (ROC) analyses showed ROTEM-PTL differentiates well between patients on medication and healthy individuals: aspirin: ROCAUC 0.99 (95% confidence interval, 0.97–1.01); P < 0.0001; DAPT treatment: ROCAUC 0.80 (95% confidence interval, 0.69–0.91); P < 0.001. Pearson regression analyses showed moderate correlations between assays. Aspirin: MEA versus ROTEM-PTL r2 = 0.435, P ≤ 0.001; LTA versus ROTEM-PTL r2 = 0.048, P = 0.180. DAPT: MEA versus ROTEM-PTL r2 = 0.398, P = 0.001; LTA versus ROTEM-PTL r2 = 0.409, P = 0.001; vasodilator-stimulated phosphoprotein versus ROTEM-PTL r2 = 0.164, P = 0.055. ROTEM platelet distinguished well between treated and healthy individuals but correlated moderately with other assays. Clinical trials are needed to investigate the ability of this new assay to identify patients at risk of adverse events.
Assessment of Covert Consciousness in the Intensive Care Unit: Clinical and Ethical Considerations
Authors: Edlow Brian L. , Fins Joseph J.
Published: November 2018

Objective:

To propose a practical ethical framework for how task-based functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) may be used in the intensive care unit (ICU) to identify covert consciousness in patients with acute severe traumatic brain injury (TBI).

Methods:

We present 2 clinical scenarios in which investigational task-based fMRI and EEG were performed in critically ill patients with acute severe TBI who appeared unconscious on the bedside behavioral assessment. From these cases, we consider the clinical and ethical challenges that emerge and suggest how to reconcile them. We also provide recommendations regarding communication with families about ICU patients with covert consciousness.

Results:

Covert consciousness was detected acutely in a patient who died in the ICU due to withdrawal of life-sustaining therapy, whereas covert consciousness was not detected in a patient who subsequently recovered consciousness, communication, and functional independence. These cases raise ethical challenges about how assessment of covert consciousness in the ICU might inform treatment decisions, prognostication, and perceptions about the benefits and burdens of ongoing care.

Conclusions:

Given that covert consciousness can be detected acutely in the ICU, we recommend that clinicians reconsider evaluative norms for ICU patients. As our clinical appreciation of covert consciousness evolves and its ethical import unfolds, we urge prognostic humility and transparency when clinicians communicate with families in the ICU about goals of care.
Tear Meniscus and Corneal Sub-basal Nerve Plexus Assessment in Primary Sjögren Syndrome and Sicca Syndrome Patients
Authors: Cardigos Joana , Barcelos Filipe , Carvalho Helena , Hipólito Diogo , Crisóstomo Sara , Vaz-Patto José , Alves Nuno
Published: November 2018

Purpose:

To evaluate lower tear meniscus and corneal sub-basal nerve plexus in primary Sjögren's syndrome (pSS) and Sicca syndrome patients.

Methods:

Cross-sectional study of 116 patients with Sicca syndrome associated with pSS and not associated with Sjögren's syndrome (non-SS Sicca) and 20 normal control subjects. Tear meniscus height and area were measured using anterior segment optical coherence tomography; corneal sub-basal nerve plexus density, length, and tortuosity were evaluated using in vivo confocal microscopy. Data analysis was performed using IBM-SPSS Statistics 24.0.

Results:

Corneal sub-basal nerve plexus density and length were significantly lower, and tortuosity was significantly higher in pSS and non-SS Sicca groups than in normal control subjects (P < 0.001; P = 0.018, respectively). Corneal sub-basal nerve plexus presented a strong association with Schirmer test I and tear breakup time. Cutoff values of sub-basal nerve plexus density (36.5 nerve/mm2) and length (12.5 mm/mm2) presented 80.2% to 81.9% sensitivity and 85% specificity for detecting Sicca syndrome patients. No significant differences were found between the 3 groups regarding tear meniscus height and area.

Conclusions:

Corneal sub-basal nerve plexus in vivo confocal microscopy may be a useful tool in the assessment of dry eye disease in Sicca syndrome, complementing the information provided by the conventional modalities used in dry eye disease evaluation.
Perfusion Monitoring Shows Minimal Blood Flow From the Flap Pedicle to the Tarsoconjunctival Flap
Authors: Tenland Kajsa , Memarzadeh Khashayar , Berggren Johanna , Nguyen Cu Dinh , Dahlstrand Ulf , Hult Jenny , Engelsberg Karl , Lindstedt Sandra , Sheikh Rafi , Malmsjö Malin
Published: November 2018

Background:

A previous study in pigs has shown that the pedicle of the tarsoconjunctival flap does not appear to have adequate blood perfusion. The aim of this study was to monitor perfusion in tarsoconjunctival flaps in patients with large lower eyelid defects resulting from tumor surgery.

Methods:

The modified Hughes procedure was performed in 13 patients. Blood perfusion was monitored using laser Doppler velocimetry and laser speckle-contrast imaging.

Results:

Blood flow decreased gradually from the pedicle base to the end of the flap and was 19% at the flap base, 11% in the middle of the flap, and 4% in the distal end of the flap. The flaps survived, and there was no tissue necrosis.

Conclusions:

Tarsoconjunctival tissue survival does not seem to be dependent on a conjunctival flap. Free tarsoconjunctival grafts or composite grafts might be considered as viable alternatives in reconstruction of major eyelid defects.
Impact of a Resident-Centered Interprofessional Quality Improvement Intervention on Acute Care Length of Stay
Authors: Walker Megan , Gay Lindsey , Raynaldo Glynda , Von Marensdorff Hans , Bates Jeffrey T. , Friedland Joan A. , Park Jung Hyun , Kehl Ekaterina , Sowers Bryan , Bhavani Sivasubramanium , Lan Charlie , Bozkurt Biykem , Stewart Diana E. , Horstman Molly J.
Published: November 2018

Competency in interprofessional quality improvement and performance measurement is required by the Accreditation Council for Graduate Medical Education. We implemented an interprofessional quality improvement project to support trainee involvement in systems-level improvement to reduce hospital length of stay and engage trainees in efforts to improve the validity and reliability of clinical documentation contributing to risk-adjusted performance measures. The intervention had three components: daily interprofessional disposition huddles to discuss discharge needs, medical documentation curriculum to improve clinical data accuracy, and scheduled coding huddles to provide real-time feedback on documentation. Outcome measures included an unadjusted and risk-adjusted measure of hospital length of stay. Case severity index (CSI) served as a process measure. Statistical process control charts were used to measure change over time. The mean unadjusted length of stay decreased from 5.84 to 4.98 days. Both the unadjusted and the risk-adjusted length of stay measures exceeded the lower control limit of the statistical control chart. The CSI increased and exceeded the upper control limit of the statistical control chart. Improvements were sustained in the year following implementation. The intervention offers a model for academic institutions to satisfy new Common Program Requirements by engaging trainees in performance measurement and interprofessional improvement efforts.
Preservation of Knee Articular Cartilage
Authors: Redondo Michael L. , Naveen Neal B. , Liu Joseph N. , Tauro Tracy M. , Southworth Taylor M. , Cole Brian J.
Published: November 2018

Hyaline articular cartilage is critical for the normal functioning of the knee joint. Untreated focal cartilage defects have the potential to rapidly progress to diffuse osteoarthritis. Over the last several decades, a variety of interventions aiming at preserving articular cartilage and preventing osteoarthritis have been investigated. Reparative cartilage procedures, such as microfracture, penetrate the subchondral bone plate in effort to fill focal cartilage defects with marrow elements and stimulate fibrocartilaginous repair. In contrast, restorative cartilage procedures aim to replace the defective articular surface with autologous or allogeneic hyaline cartilage. This review focuses on the preservation of articular cartilage, and discusses the current reparative and restorative surgical techniques available for treating focal cartilage defects.
Variation in Laboratory Test Naming Conventions in EHRs Within and Between Hospitals
Authors: Wiitala Wyndy L. , Vincent Brenda M. , Burns Jennifer A. , Prescott Hallie C. , Waljee Akbar K. , Cohen Genna R. , Iwashyna Theodore J.
Published: November 2018

Background:

Electronic health records provide clinically rich data for research and quality improvement work. However, the data are often unstructured text, may be inconsistently recorded and extracted into centralized databases, making them difficult to use for research.

Objectives:

We sought to quantify the variation in how key laboratory measures are recorded in the Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW) across hospitals and over time. We included 6 laboratory tests commonly drawn within the first 24 hours of hospital admission (albumin, bilirubin, creatinine, hemoglobin, sodium, white blood cell count) from fiscal years 2005–2015.

Results:

We assessed laboratory test capture for 5,454,411 acute hospital admissions at 121 sites across the VA. The mapping of standardized laboratory nomenclature (Logical Observation Identifiers Names and Codes, LOINCs) to test results in CDW varied within hospital by laboratory test. The relationship between LOINCs and laboratory test names improved over time; by FY2015, 109 (95.6%) hospitals had >90% of the 6 laboratory tests mapped to an appropriate LOINC. All fields used to classify test results are provided in an Appendix (Supplemental Digital Content 1, http://links.lww.com/MLR/B635).

Conclusions:

The use of electronic health record data for research requires assessing data consistency and quality. Using laboratory test results requires the use of both unstructured text fields and the identification of appropriate LOINCs. When using data from multiple facilities, the results should be carefully examined by facility and over time to maximize the capture of data fields.
Effects of Dignity Therapy on Family Members
Authors: Scarton Lisa J. , Boyken Lara , Lucero Robert J. , Fitchett George , Handzo George , Emanuel Linda , Wilkie Diana J.
Published: November 2018

Dignity therapy (DT) provides, for patients with a serious illness, a guided sharable life review through a protocolized interview and the creation of a legacy document. Evidence is mounting in support of the use of DT for patients with a serious illness; however, it is unclear whether DT has effects on family members. The purpose of this article was to provide a systematic literature review of the effects DT has on family members of patients who receive DT. Using a PubMed search with key terms of “Chochinov,” “family,” and “dignity care,” a total of 18 articles published between January 2000 and July 2016 were identified and included in this review. This systematic review was helpful in identifying the strength of the evidence and gaps in the literature focused on DT and expected or actual effects on the DT recipient or family members. Findings identify the need to conduct further research related to the feasibility, acceptability, and effects of DT for family members. Future research should focus on understanding whether and how family members may benefit from receiving the legacy document and whether the timing of family member involvement plays a role in the outcomes of DT.
Effect of a Palliative Screening Tool on Referrals
Authors: Kichler Casie M. , Cothran Fawn A. , Phillips Marcia A.
Published: November 2018

The aim of this study was to develop and trial a screening tool to increase palliative care referrals for hospitalized patients with chronic obstructive pulmonary disease (COPD) at a community hospital. Baseline data were collected retrospectively to determine the palliative care referral rate of patients with COPD at a high risk for readmission using the LACE index. A palliative care referral tool was developed to screen the patients who were at a high risk for readmission for palliative care referral. A 3-month pilot project prospectively evaluated the palliative care referral rate after educating staff on the use of the screening tool and implementing its use. During the baseline study, 2 palliative care referrals were placed out of 19 patients who were deemed appropriate by the screening tool (10.5%). During the pilot project, 16 palliative care referrals were placed out of 45 patients who were deemed appropriate by the screening tool (35.6%). Emergency room visits and readmissions were not significantly different between those with palliative referrals and those without. Barriers to palliative care referral were explored. The improvement in palliative care referrals, which occurred after the introduction of the consensus-driven screening process for patients with COPD, suggests the possibility of improved patient care using this model.
A Patient's Suicidal Ideations and a Clinical Nurse Leader's Responsibility
Authors: Kusheba Jody , Mulvihill Karen
Published: November 2018

Nurses caring for patients at end of life are faced with many ethical dilemmas. A patient's desire to commit suicide affects not only the person who commits suicide but also the patient's family, friends, and health care professionals. This fictional case study demonstrates an ethical dilemma when Beth, a novice hospice clinical nurse leader, is at a home care visit for Joan, a patient with end-stage ovarian cancer, and Joan expresses her wish to commit suicide. The case raises issues about patient autonomy, patient confidentiality, nursing professional code of ethics, beneficence, and whether the nurse’s actions were enough to prevent the death.
Applying the American Nurses Association Credentialing Center Accreditation Program in the Setting of Registered Nurse Remediation
Authors: Harding Andrew D. , Sipe Margie , Whalen Kathryn C. , Almeida Nicole
Published: November 2018

The objective of this project was to use and evaluate the American Nurses Credentialing Center (ANCC) accreditation program in the context of registered nurse practice remediation using Just Culture. The quality improvement project intervention was aimed at educating nursing professional development educators about the accreditation program for registered nurse remedial education and implementing this program for remediation. It compared pre- and postintervention data for nurse educators using the nine key elements.
Pregnancy and Infant Outcomes Among Women Using the Dapivirine Vaginal Ring in Early Pregnancy
Authors: Makanani Bonus , Balkus Jennifer E. , Jiao Yuqing , Noguchi Lisa M. , Palanee-Phillips Thesla , Mbilizi Yamikani , Moodley Jothi , Kintu Kenneth , Reddy Krishnaveni , Kabwigu Samuel , Jeenariain Nitesha , Harkoo Ishana , Mgodi Nyaradzo , Piper Jeanna , Rees Helen , Scheckter Rachel , Beigi Richard , Baeten Jared M. ,   on behalf of the MTN-020/ASPIRE Study Team
Published: November 2018

Background:

Monthly use of the dapivirine vaginal ring has been shown to be safe and effective for HIV-1 prevention in nonpregnant reproductive-aged women. The impact of dapivirine on pregnancy outcomes and infant is not known. We compared pregnancy incidence and outcomes by study arm among HIV-1–uninfected women who became pregnant while participating in MTN-020/ASPIRE.

Methods:

ASPIRE was a randomized, double-blind, placebo-controlled phase III safety and effectiveness study of the dapivirine ring for HIV-1 prevention. Sexually active women aged 18–45 years from Malawi, South Africa, Uganda, and Zimbabwe were enrolled. Urine pregnancy tests were performed monthly, and, if positive, study product was withheld during pregnancy and breastfeeding. Pregnancy-related outcomes included the following: pregnancy incidence, pregnancy outcomes (live birth, preterm birth, pregnancy loss, and congenital anomalies), and infant growth.

Results:

Of 2629 women enrolled in ASPIRE, 169 became pregnant during follow-up, resulting in 179 incident pregnancies and 181 pregnancy outcomes. No difference in pregnancy incidence by study arm was observed (hazard ratio = 0.93; 95% confidence interval: 0.68 to 1.26). The distribution of pregnancy outcomes was similar by study arm, and no difference was noted in the frequency or pattern of congenital anomalies or infant growth parameters by study arm.

Conclusions:

Dapivirine use in the periconception period does not seem to be associated with adverse effects on pregnancy or infant outcomes. Our findings provide support for additional safety studies of the dapivirine ring throughout pregnancy.
The Modified Keystone Flap for Pressure Ulcers
Authors: Byun Il Hwan , Kim Chan Woo , Park Tae Hwan
Published: November 2018

Introduction

The reconstruction of extensive soft tissue defects from pressure ulcers is a great challenge. Resurfacing such defects with like tissues and minimizing morbidities are important. Here we present our surgical experience using a novel modified keystone flap for pressure ulcer patients.

Methods

We retrospectively reviewed the data of 13 consecutive cases reconstructed with the modified keystone flaps between March and December, 2017. The mean dimensions of the reconstructed defect were 7.7 × 6.5 cm, while the mean dimensions of the flap were 12.1 × 8.3 cm.

Results

Time efficient reconstructions with the modified keystone flap were performed without any following major complications. Minor wound dehiscence occurred in only one case, which soon healed with conservative management.

Conclusions

Considering its simple design, reliable flap survival, minimal donor-site morbidity, optimal flap thickness, and evenly distributed surgical tension, our novel technique of the modified keystone flap is as an excellent surgical option for the reconstruction of pressure ulcers in the gluteal region.
Beyond Phonology
Authors: Kargl Reinhard , Landerl Karin
Published: November 2018

German orthography has highly consistent grapheme–phoneme correspondences, whereas the consistency of phoneme–grapheme correspondences is much lower, but morphological consistency is very high. After giving a short description of German language and orthography, the current article reviews earlier findings on early spelling acquisition, showing that even poor spellers are well able to produce phonologically adequate spellings early on. In contrast, the acquisition of orthographic markers, which are mostly morphology-based, is a long-term enterprise. We present data for the close association of morphological awareness (assessed by a classroom measure requiring students to build new word forms based on presented pseudowords) with orthographic spelling skills. In a large sample (N = 796) of students in Grades 4–7, morphological awareness predicted children's spelling skills above and beyond fluid intelligence and phonological spelling skills. In the last section of this article, we review findings on the efficiency of morphology-based spelling intervention in German.
A global genomic approach uncovers novel components for twitching motility-mediated biofilm expansion in Pseudomonas aeruginosa
Authors: Nolan Laura M. , Whitchurch Cynthia B. , Barquist Lars , Katrib Marilyn , Boinett Christine J. , Mayho Matthew , Goulding David , Charles Ian G. , Filloux Alain , Parkhill Julian , Cain Amy K.
Published: November 2018

Pseudomonas aeruginosa is an extremely successful pathogen able to cause both acute and chronic infections in a range of hosts, utilizing a diverse arsenal of cell-associated and secreted virulence factors. A major cell-associated virulence factor, the Type IV pilus (T4P), is required for epithelial cell adherence and mediates a form of surface translocation termed twitching motility, which is necessary to establish a mature biofilm and actively expand these biofilms. P. aeruginosa twitching motility-mediated biofilm expansion is a coordinated, multicellular behaviour, allowing cells to rapidly colonize surfaces, including implanted medical devices. Although at least 44 proteins are known to be involved in the biogenesis, assembly and regulation of the T4P, with additional regulatory components and pathways implicated, it is unclear how these components and pathways interact to control these processes. In the current study, we used a global genomics-based random-mutagenesis technique, transposon directed insertion-site sequencing (TraDIS), coupled with a physical segregation approach, to identify all genes implicated in twitching motility-mediated biofilm expansion in P. aeruginosa. Our approach allowed identification of both known and novel genes, providing new insight into the complex molecular network that regulates this process in P. aeruginosa. Additionally, our data suggest that the flagellum-associated gene products have a differential effect on twitching motility, based on whether components are intra- or extracellular. Overall the success of our TraDIS approach supports the use of this global genomic technique for investigating virulence genes in bacterial pathogens.
Harmonizing Clinical Sequencing And Interpretation For The Emerge III Network
Authors:   The eMERGE Consortium, Gibbs Richard A. , Rehm Heidi L.
Published: November 2018

Background

The eMERGE III Network was tasked with harmonizing genetic testing protocols linking multiple sites and investigators.

Methods

DNA capture panels targeting 109 genes and 1551 variants were constructed by two clinical sequencing centers for analysis of 25,000 participant DNA samples collected at 11 sites where samples were linked to patients with electronic health records. Each step from sample collection, data generation, interpretation, reporting, delivery and storage, were developed and validated in CAP/CLIA settings and harmonized across sequencing centers.

Results

A compliant and secure network was built and enabled ongoing review and reconciliation of clinical interpretations while maintaining communication and data sharing between investigators. Mechanisms for sustained propagation and growth of the network were established. An interim data freeze representing 15,574 sequenced subjects, informed the assay performance for a range of variant types, the rate of return of results for different phenotypes and the frequency of secondary findings. Practical obstacles for implementation and scaling of clinical and research findings were identified and addressed. The eMERGE protocols and tools established are now available for widespread dissemination.

Conclusions

This study established processes for different sequencing sites to harmonize the technical and interpretive aspects of sequencing tests, a critical achievement towards global standardization of genomic testing. The network established experience in the return of results and the rate of secondary findings across diverse biobank populations. Furthermore, the eMERGE network has accomplished integration of structured genomic results into multiple electronic health record systems, setting the stage for clinical decision support to enable genomic medicine.
Inferring the ancestry of everyone
Authors: Kelleher Jerome , Wong Yan , Albers Patrick K. , Wohns Anthony W. , McVean Gil
Published: November 2018

A central problem in evolutionary biology is to infer the full genealogical history of a set of DNA sequences. This history contains rich information about the forces that have influenced a sexually reproducing species. However, existing methods are limited: the most accurate is unable to cope with more than a few dozen samples. With modern genetic data sets rapidly approaching millions of genomes, there is an urgent need for efficient inference methods to exploit such rich resources. We introduce an algorithm to infer whole-genome history which has comparable accuracy to the state-of-the-art but can process around four orders of magnitude more sequences. Additionally, our method results in an “evolutionary encoding” of the original sequence data, enabling efficient access to genealogies and calculation of genetic statistics over the data. We apply this technique to human data from the 1000 Genomes Project, Simons Genome Diversity Project and UK Biobank, showing that the genealogies we estimate are both rich in biological signal and efficient to process.
Landscape genomics of an obligate mutualism: discordant population structures between a leafcutter-ant and its fungal cultivars
Authors: Smith Chad C. , Weber Jesse N. , Mikheyev Alexander S. , Roces Flavio , Bollazzi Martin , Kellner Katrin , Seal Jon N. , Mueller Ulrich G.
Published: November 2018

To explore landscape genomics at the range limit of an obligate mutualism, we used genotyping-by-sequencing (ddRADseq) to quantify population structure and the effect of hostsymbiont interactions between the northernmost fungus-farming leafcutter antAtta texanaand its two main types of cultivated fungus. At local scales, genome-wide differentiation between ants associated with either of the two fungal types is greater than the differentiation associated with the abiotic factors temperature and precipitation, suggesting that specific ant-fungus genome-genome combinations may have been favored by selection. For the ant hosts, we found a broad cline of genetic structure across the range, and a reduction of genetic diversity along the axis of range expansion towards the range margin. In contrast, genetic structure was patchy in the cultivated fungi, with no consistent reduction of fungal genetic diversity at the range margins. This discordance in population-genetic structure between ant hosts and fungal symbionts is surprising because the ant farmers co-disperse with their vertically-transmitted fungal symbionts, but apparently the fungi disperse occasionally also through between-nest horizontal transfer or other unknown dispersal mechanisms. The discordance in populationgenetic structure indicates that genetic drift and gene flow differ in magnitude between each partner in this leafcutter mutualism. Together, these findings imply that variation in the strength of drift and gene flow experienced by each mutualistic partner affects adaptation to environmental stress at the range margin, and genome-genome interactions between host and symbiont influences adaptive genetic differentiation of the host during range evolution in this obligate mutualism.
Domain organization and conformational change of dynactin p150
Authors: Saito Kei , Murayama Takashi , Hata Tomone , Kobayashi Takuya , Shibata Keitaro , Kazuno Saiko , Fujimura Tsutomu , Sakurai Takashi , Toyoshima Yoko Y.
Published: November 2018

Dynactin is a principal regulator of the minus-end directed microtubule motor dynein. The sidearm of dynactin is essential for binding to microtubules and regulation of dynein activity. Although our understanding of the structure of the dynactin backbone (Arp1 rod) has greatly improved recently, structural details of the sidearm part remain elusive. Here, electron microscopy of individual molecules of the dynactin complex revealed that the sidearm was highly flexible and exhibited diverse morphologies. Utilizing mutants for nanogold labeling and deletion analysis, we determined the domain organization of the largest subunit p150 and identified a filamentous structure protruding from the head domain of the sidearm as the coiled-coil 1 (CC1), the dynein-binding domain, in p150. Furthermore, the protrusion formed by CC1 exhibited either a folded or an extended form, suggesting that CC1 works as an extending “arm”. These findings provide clues to understand how dynactin binds to microtubules and regulates dynein.