Rethinking Care Models for Young Adults With Sickle Cell Disease.

This Viewpoint discusses developing new sickle cell disease adult care models to support specialized health care homes that are patient-focused and antiracist, rather than an approach focused mainly on financial incentives.

Beyond cardiomyocytes: Cellular diversity in the heart's response to exercise.

Cardiomyocytes comprise ∼70% to 85% of the total volume of the adult mammalian heart but only about 25% to 35% of its total number of cells. Advances in single cell and single nuclei RNA sequencing have greatly facilitated investigation into and increased appreciation of the potential functions of non-cardiomyocytes in the heart. While much of this work has focused on the relationship between non-cardiomyocytes, disease, and the heart's response to pathological stress, it will also be important to understand the roles that these cells play in the healthy heart, cardiac homeostasis, and the response to physiological stress such as exercise. The present review summarizes recent research highlighting dynamic changes in non-cardiomyocytes in response to the physiological stress of exercise. Of particular interest are changes in fibrotic pathways, the cardiac vasculature, and immune or inflammatory cells. In many instances, limited data are available about how specific lineages change in response to exercise or whether the changes observed are functionally important, underscoring the need for further research.

Serum Proteomics of Older Patients Undergoing Major Cardiac Surgery: Identification of Biomarkers Associated With Postoperative Delirium.

Background: Postoperative delirium (POD) is an acute altered mental state commonly encountered after cardiac surgery. The pathophysiological mechanisms underlying POD remain unclear. We aimed to identify circulating proteins significantly altered after major cardiac surgery with cardiopulmonary bypass (CPB). We also aimed to enable inferences on associations with POD. Methods: Serum and whole blood samples were collected before CPB (n = 16 patients; n = 8 with POD) and again from the same patients on postoperative day 1. All patients were clinically evaluated for POD on postoperative days 1-3. An aptamer-based proteomics platform (SOMAscan) was used to quantify serum protein abundance in patients with POD compared with non-POD controls. We also performed a lipopolysaccharide (LPS)-based in vitro functional analysis (TruCulture) on whole blood samples from patients with POD and non-POD controls to approximate surgical stress. Cytokine levels were determined using a Luminex immunoassay. Results: Cardiac surgery with CPB resulted in a significant (padj < 0.01) change in 48.8% (637 out of 1,305) of proteins detected by SOMAscan. Gene set enrichment showed that the most impacted biological processes involved myeloid cell activation. Specifically, activation and degranulation of neutrophils were the top five highest-scoring processes. Pathway analyses with the Kyoto Encyclopedia of Genes and Genomes (KEGG) showed that metabolic enzymes, particularly those of glycolysis, were elevated in serum concentration after surgery. Several proteins were significantly increased postoperatively in patients diagnosed with POD relative to the non-POD controls, with interleukin-6 (IL-6) showing the greatest fold-change. LPS stimulation of whole blood samples confirmed these findings. Linear regression analysis showed a highly significant correlation between Confusion Assessment Method (CAM) scores and CPB-mediated changes in cGMP-inhibited 3',5'-cyclic phosphodiesterase A (PDE3A). Conclusions: Cardiac surgery with CPB resulted in inflammasome changes accompanied by unexpected increases in metabolic pathways. In exploratory analyses, we found that POD was associated with changes in the expression level of various proteins, most notably IL-6 and PDE3A. This study and ongoing protein biomarker studies will likely help quantify risk or confirm the diagnosis for POD and increase understanding of its pathophysiological mechanisms.

Design of a large-scale escape room for first-year pharmacy student orientation.

BACKGROUND AND PURPOSE: In this article, we developed and implemented an escape room activity for first-year pharmacy student orientation. The purpose of the activity was to engage students in socialization with their classmates, to familiarize students with the key personnel of the program, to acquaint students with co-curricular programming in the academic calendar, and to peruse key policies in the student handbook. EDUCATIONAL ACTIVITY AND SETTING: An escape room was developed for first professional year student orientationin a large classroom setting. The escape room featured several gameplay elements, including a personnel bingo game, a computerized student calendar scavenger hunt, and group assessments designed to acquaint students with policies within the student handbook. One hundred nineteen students participated simultaneously in the orientation escape room activity in break-out groups to accomplish the objectives of the escape room as measured by embedded assessments. FINDINGS: All students successfully escaped the encounter. Students demonstrated proficiency in orientation learning objectives on group assessments. Students were queried about their attitudes towards the instructional design via a post-survey. The proof-of-concept for this work was evaluated via a log of estimated faculty time and monetary costs for implementation. SUMMARY: A student orientation escape room was successfully designed and implemented. Students were assessed to evaluate the retention of knowledge obtained during orientation. Despite not having previously met their classmates, survey responses indicated that studentswere positively inclined toward the educational activity.This is the first report of a co-curricular escape room developed for pharmacy student orientation.

A randomized controlled comparison of flushing protocols in home care patients with peripherally inserted central catheters.

INTRODUCTION/SIGNIFICANCE/POPULATION: Research has failed to demonstrate an optimal flushing solution or frequency for central catheters. In a 2002 study of 50 000 home care patients, catheter dysfunction with loss of patency was the most common complication and occurred in 29% of the peripherally inserted central catheters (PICCs) tracked. With the advent of the Affordable Care Act and the promise of expanded home care services, this study offers evidence as to a preferred flushing protocol to prevent catheter patency complications for home infusion patients with PICCs. METHODS: This prospective, randomized, 1-way, single-blinded posttest with control group study was performed to compare 3 commonly used flushing protocols in home infusion patients with PICCs. The independent variable was the flushing protocol, and dependent variables included the development of patency-related complications and other significant issues such as sluggishness, occlusion, missed medication doses, catheter replacement, additional nursing visits, and the use of alteplase (Cathflo Activase). DATA ANALYSIS/RESULTS: Each of the study groups had patients who experienced 1 or more patency-related complications. Additional factors that may affect catheter function, including patient age, gender, diagnosis, therapy type, frequency of catheter use, catheter brand/size/number of lumens, concomitant use of anticoagulant medications, and whether PICCs were used for routine lab testing, were analyzed, and no statistical significance was determined. Catheter dwell time (catheter days) was statistically significant (p = .003, confidence interval = 95%; assuming equal variance) and confirmed the assumption that the longer a home care patient's catheter was in place, the more complications occurred. There were no cases of heparin allergy, heparin-induced thrombocytopenia, or line infection. DISCUSSION/CONCLUSION/RECOMMENDATIONS FOR PRACTICE: The data provide some evidence to support the elimination of heparin flushing in home care patients with PICCs, although data in the saline-only group that related to additional registered nurse visits to assess PICC patency and the use of alteplase (Cathflo Activase) were trending toward significance because this group experienced a higher incidence of these complications than both the heparin groups. These findings should not be translated to home care patients with cancer or pregnancy diagnoses because these populations were excluded from this study. More studies of this topic area should be initiated. Please see video abstract, Supplemental Digital Content 1, for more information (http://links.lww.com/JIN/A3).

Parenteral inotropic therapy in the home: an update for home care and hospice.

This article provides an evidence-based overview of heart failure (HF), including its pathogenesis, staging, assessment, prognosis, and treatment with intravenous inotropic medications in the home. Inotropic infusions in the home setting require advanced care planning, symptom management, and knowledge about ambulatory pumps and devices. These medications can be safely used throughout the continuum of care as pediatric/adult bridges from transplant to hospice care. Nurses who recognize advanced HF symptomatology and use prognostic/risk-stratification models will be better prepared to facilitate this advanced care planning, thus supporting optimal treatment outcomes. The ultimate goal of care for heart failure therapy in the home is to integrate pharmacotherapeutic knowledge of treatment advances with comfort measures and to provide them to patients concurrently and in a seamless process.

Outcomes of a continuing education course on intravenous catheter insertion for experienced registered nurses.

Many experienced nurses report a lack of confidence in their intravenous (IV) catheter skills despite training with a phlebotomist and designated orientation time with the IV team. This study assessed the success of an IV catheter insertion continuing education class aimed at improving experienced nurses' skills levels, confidence, and knowledge regarding IV catheter insertion, maintenance, and infection prevention. Through a partnership between a hospital and a college of nursing continuing education program, a 1-day course was provided for 33 experienced nurses. The educators sought to determine whether a continuing education course improved the knowledge and skills of experienced nurses regarding the insertion of peripheral IV catheters and whether the nurses retained the knowledge and skills learned in a formal IV course over time. The findings showed that the continuing education IV course improved the knowledge and skills of experienced nurses. Improvement in knowledge was shown immediately after the course and 8 to 12 weeks later. Skills improvement with regard to infection prevention and policy adherence was evident. Because confidence data were collected with two different scales before and after the course, they were unusable for statistical testing. Further study is needed to determine whether nurses' confidence levels would improve after the implementation of a formal IV course. Replication studies are also needed to validate the results with a larger sample size.

The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence.

AIMS: To investigate whether opiate substitution therapy (OST) and needle and syringe programmes (NSP) can reduce hepatitis C virus (HCV) transmission among injecting drug users (IDUs). DESIGN: Meta-analysis and pooled analysis, with logistic regression allowing adjustment for gender, injecting duration, crack injecting and homelessness. SETTING: Six UK sites (Birmingham, Bristol, Glasgow, Leeds, London and Wales), community recruitment. PARTICIPANTS: A total of 2986 IDUs surveyed during 2001-09. MEASUREMENT: Questionnaire responses were used to define intervention categories for OST (on OST or not) and high NSP coverage (≥100% versus <100% needles per injection). The primary outcome was new HCV infection, measured as antibody seroconversion at follow-up or HCV antibody-negative/RNA-positive result in cross-sectional surveys. FINDINGS: Preliminary meta-analysis showed little evidence of heterogeneity between the studies on the effects of OST (I2=48%, P=0.09) and NSP (I2=0%, P=0.75), allowing data pooling. The analysis of both interventions included 919 subjects with 40 new HCV infections. Both receiving OST and high NSP coverage were associated with a reduction in new HCV infection [adjusted odds ratios (AORs)=0.41, 95% confidence interval (CI): 0.21-0.82 and 0.48, 95% CI: 0.25-0.93, respectively]. Full harm reduction (on OST plus high NSP coverage) reduced the odds of new HCV infection by nearly 80% (AOR=0.21, 95% CI: 0.08-0.52). Full harm reduction was associated with a reduction in self-reported needle sharing by 48% (AOR 0.52, 95% CI: 0.32-0.83) and mean injecting frequency by 20.8 injections per month (95% CI: -27.3 to -14.4). CONCLUSIONS: There is good evidence that uptake of opiate substitution therapy and high coverage of needle and syringe programmes can substantially reduce the risk of hepatitis C virus transmission among injecting drug users. Research is now required on whether the scaling-up of intervention exposure can reduce and limit hepatitis C virus prevalence in this population.

Open access is almost here: navigating through copyright, fair use, and the TEACH Act.

Dealing with the complexities of copyright, fair use, the TEACH Act, and the concept of open access can confuse even the most experienced educator. Online education has added to the dilemma. This article discusses the latest information on copyright issues, current guidelines for interpreting fair use and incorporating the TEACH Act, and recent developments in open access publishing.

Thermal Stabilization of Erwinia chrysanthemi pectin methylesterase a for application in a sugar beet pulp biorefinery.

Directed evolution approaches were used to construct a thermally stabilized variant of Erwinia chrysanthemi pectin methylesterase A. The final evolved enzyme has four amino acid substitutions that together confer a T(m) value that is approximately 11 degrees C greater than that of the wild-type enzyme, while maintaining near-wild-type kinetic properties. The specific activity, with saturating substrate, of the thermally stabilized enzyme is greater than that of the wild-type enzyme when both are operating at their respective optimal temperatures, 60 degrees C and 50 degrees C. The engineered enzyme may be useful for saccharification of biomass, such as sugar beet pulp, with relatively high pectin content. In particular, the engineered enzyme is able to function in biomass up to temperatures of 65 degrees C without significant loss of activity. Specifically, the thermally stabilized enzyme facilitates the saccharification of sugar beet pulp by the commercial pectinase preparation Pectinex Ultra SPL. Added pectin methylesterase increases the initial rate of sugar production by approximately 50%.

On being a novice.

Lessons learned while being oriented as a program coordinator and nurse planner for a newly created position in an American Nurses Credentialing Center-accredited provider unit are shared. Personal reflection and useful strategies are discussed.

Sensation seeking, self-esteem, and unprotected sex in college students.

This descriptive correlational study examined the relationships of sexual sensation seeking, self-esteem, and self-efficacy in condom use, stages of change, and alcohol consumption to HIV risk-taking behaviors among college students. A total of 159 students completed an online survey in 2004. Instruments included the Sexual Sensation Seeking Scale, College Alcohol Problems Scale, Condom Use Scale, and Rosenberg Self-Esteem Scale. High sensation seekers had higher self-esteem, more self-efficacy in condom usage, fewer problems associated with alcohol consumption, and belonged to Greek organizations (F [1,158] = 12.54; p < .0005). Women who were high sensation seekers perceived more advantages (F [1, 116] = 1.67; p = .05) than disadvantages (F [1, 116] = 2.01; p = .01) to using condoms. Men consumed significantly more alcohol and had more social problems related to alcohol use than women (F [1, 158] = 5.04; p < .03). Students in Greek organizations had significantly more positive attitudes (X(2) [1] = 4.55; p < .03) and more respect for themselves (X(2) [1] = 11.22; p < .0008) than other students and were more likely to be tested for HIV (X(2) [1] = 3.85; p < .05). Students with low self-esteem consumed more alcohol, had more sexual partners, and had more HIV risk-taking behaviors than other students. Even though students were reported to be efficacious in condom usage, they used them inconsistently with their sexual partners and were in the earlier stages of change. Interventions are needed in the community to help sexually active individuals take responsibility for their sexual health and to increase the awareness of the need to be tested for HIV.

Case study: development of and stakeholder responses to a nursing home consumer information system.

California Nursing Home Search (www.calnhs.org), launched in October 2002, provides information about nursing home quality to a broad range of stakeholders. This case study discusses the process of developing a consumer-oriented nursing home Web site and presents an analysis of postlaunch responses from a number of sources (i.e., media, outreach, Web site use, correspondence, meetings, interviews) to determine the impact of the site and how it can be improved and used as an example. Consumers found the Web site valuable, but some needed clarification on navigation. Providers had complaints about the use of quality ratings and concerns about public availability of the data. Most discharge planners and care managers do not use Internet resources to find facilities. Feedback, modifications, updates, and outreach are needed on a continuous basis to ensure the site is a helpful tool for all stakeholders.

Sexual sensation seeking, compulsivity, and HIV risk behaviors in college students.

The purpose of this descriptive and correlational study was to understand the role of sexual compulsivity, sensation seeking, and alcohol use as mediators of HIV risk behaviors among college students. College students (n = 256) completed an online survey in 2003. Instruments included the Sexual Compulsivity Scale (SCS), Sexual Sensation Seeking Scale (SSS), and the College Alcohol Problem Scale (CAPS). Men scored higher on the SSS and SCS than women. Women who belong to Greek organizations reported significantly more personal problems, including depression and low self-esteem, after consuming alcohol than women who were not members of Greek organizations. Four predictor variables associated with HIV risk behaviors were age, high score on SSS and CAPS, but a low score on SCS. The personality dispositions of sexual sensation seeking and compulsivity among college students may need to be explored in other college settings, to determine if these traits are related to HIV risk taking behaviors. Interventions to help women better cope with the effects of alcohol and self-esteem issues may be beneficial.

Barriers and influences in seeking health care among lower income minority women.

The purpose of this study was to identify and describe perceived barriers to seeking health care, determine perceptions of confidence in health care practitioners, and explore strategies to enhance, promote, and improve early health care intervention among low income minority women. Focus group methodology was used to collect data and content analysis was used to analyze the data. Results revealed four broad categories for discussion: (a) confidence in the physician, (b) frequency of engaging in screening procedures, (c) barriers and influences in seeking health care, and (d) a wish list for covered health care services. The study underscored the importance of both spirituality and family in the lives of aging minority women. The paper includes implications for public policy and suggests an agenda for public policy advocates in the new millennium.