2023 updates to the spina bifida transition to adult care guidelines.

PURPOSE: This article provides an update to the 2018 Spina Bifida Association's Transition to Adult Care Guidelines. METHODS: A workgroup of topic experts was convened including authors from the initial guideline workgroup. The workgroup reviewed and updated the primary, secondary, and tertiary outcome goals, clinical questions, and guideline recommendations based on a literature review. RESULTS: Twenty-two additional articles were identified from the literature search. Updated references included observational studies describing transition to adult care outcomes, transition care model initiatives, and a validated self-management assessment tool. CONCLUSION: Structured transition initiatives increase the likelihood of establishing with adult care, decrease acute care use for young adults with spina bifida, and have the potential to improve quality of life and optimize chronic condition management. However, there is still a need to implement structure transition practices more broadly for this population using these recommended guidelines.

Weight Status of Children Participating in the National Spina Bifida Patient Registry.

OBJECTIVES: Describe the distribution of weight status categories and determine factors associated with overweight and obesity (OW/OB) in children and adolescents with spina bifida (SB) using the National Spina Bifida Patient Registry. METHODS: Demographic, anthropometric, and clinical data collected from 2009 through 2018 was used to describe the prevalence of OW/OB. The generalized estimating equation model (GEE) identified factors associated with OW/OB among individuals with SB. RESULTS: Participants (n = 7215) were aged 2 to 19 years (mean = 11.1; standard error, 0.06) and 51.4% female. The majority were non-Hispanic white (57.2%) followed by Hispanic or Latino (25.1%) and non-Hispanic Black (7.5%). The myelomeningocele (MMC) subgroup accounted for 76.3%. Most (60.2%) were community ambulators. The overall percentage of OW/OB was 45.2%, with 49.2% of MMC and 32.0% of nonmyelomeningocele OW/OB. Following the Centers for Disease Control Obesity Severity Classification System, 19.7% of MMC were in class 1, 6.6% in class 2, and 3.5% in class 3. Univariate analysis of MMC participants demonstrated demographic (age, sex, race/ethnicity, and clinic region) and clinical variables (functional level of lesion, ambulation, and number of shunt surgeries) were associated with OW/OB. The GEE model showed that OW/OB was independently, and significantly, associated with age, sex, race/ethnicity, lesion levels, and geographic location of the clinics. CONCLUSIONS: The demographic and clinical factors associated with OW/OB in children and adolescents with SB further our understanding of factors contributing to the higher prevalence of OW/OB in this population and may inform OW/OB prevention and treatment strategies.

Self-efficacy and concerns of nursing students regarding clinical experiences.

BACKGROUND: It is important for nurses to provide safe, high-quality care for patients, and clinical experiences allow nursing students to integrate theory into practice. However, many students have anxiety about clinical rotations. OBJECTIVES: The concerns of nursing students about clinical experiences and factors relating to self-efficacy in a rural Bachelor of Science in Nursing (BSN) program were examined. DESIGN: This was a mixed-methods study, and students were surveyed prior to and at the end of their clinical experiences. SETTING: The study location is a public liberal arts university in the rural, southeast United States. PARTICIPANTS: Junior level students (first and second semester) and senior level students (first and second semester) levels of BSN students participated in this project. RESULTS: Qualitative themes were identified, including concerns regarding clinical competence, expectations of learning, aspects of patient/peer/instructor interactions, as well as learning strategies and preferences. The student's level of confidence regarding communication to patients and physicians, assessment of heart and lung sounds, interview skills, documentation, and discussion of nursing procedures increased significantly from pre to post-survey. Confidence levels in physical assessment skills rose significantly after the clinical experience (t' = -6.3718 with 140 df, p < .001). CONCLUSION: Strategies that nurse educators can use prior to, during, and after the clinical experience to address student concerns about clinical experiences include the use of caring, competent clinical instructors, orientation to clinical sites, laboratory and simulation days, self-reflection, peer-support, and debriefing.

Environmental buttocks burns in children and adolescents with spina bifida in the Southwestern United States.

PURPOSE: Spina Bifida (SB) is a congenital defect of the neural tube resulting in motor and sensory defects and frequently includes insensate skin on the buttocks and feet which are innervated by sacral nerves. For those living in hot climates such as the Southwestern United States, environmental surfaces reach temperatures throughout June-September that cause thermal burns. The objective of this novel case series was to evaluate the circumstances associated with environmental buttocks burns in children with SB who attend the District Medical Group Children's Rehabilitative Services Myelomeningocele (MM) Planning clinic in Phoenix, AZ. METHODS: Nine children and adolescents with SB and a history of environmental buttocks burns were identified through participation in the National Spina Bifida Patient Registry at District Medical Group Children's Rehabilitative Services Myelomeningocele Planning Clinic. Parents and patients were interviewed about the burn circumstances, charts were reviewed, and information was gathered from the NSBPR including level of function and ambulation status. RESULTS: Most of the patients were found to be of emerging independent ages (average age 10 years) and were not with their parents at the time of the burn. All had myelomeningocele (MM), almost all were community ambulators, and all had mid lumbar, low lumbar or sacral level function. There were no non-ambulators. In addition, the majority were wearing incontinence products. CONCLUSIONS: Children and adolescents with MM who are community ambulators, of an emerging independent age, and live in hot climates are at risk of environmental buttocks burns. Enhanced education in environmental thermal burn prevention is important. This education should be particularly focused on the child as they spend more time in settings without their parents. In addition, this enhanced education should extend to those who support the child or teen such as teachers, coaches, family and friends.

Unconscious Weight Bias Among Nursing Students: A Descriptive Study.

There has been both an increase in obesity and anti-obesity bias in the United States. The Harvard Weight Implicit Association Test (IAT) is a reliable, valid test that can measure unconscious weight bias. First semester Bachelor of Science in Nursing (BSN) students were surveyed anonymously mid-semester and at the end of the semester after completing the Harvard Weight IAT. Sixty-nine out of 77 students completed pre- and post-surveys. Weight preference towards others was not shown to be related to the respondent's own self-reported body mass index (BMI). The majority of respondents exhibited more weight-related bias on the IAT than they realized. The three qualitative themes that emerged included Awareness of Personal Beliefs and Stereotypes, Reminder to be Impartial, and Skepticism about the IAT. It is important for undergraduate nursing students to be aware of possible unconscious weight bias in order to provide high-quality care to patients.

Student Perceptions Regarding Collaborative Intraprofessional Nursing Education.

BACKGROUND: Teamwork is an important factor in the provision of high-quality health care. There is a lack of research on collaboration between nursing students at different program levels. PURPOSE: The purpose of this project was to determine student perceptions about collaborative learning activities between prelicensure BSN and MSN students. METHODS: Community assessments by BSN students identified health needs and issues for 6 underserved populations. Online MSN students used these assessments to create low-literacy patient education pamphlets. In turn, BSN students provided educational sessions at community sites using the pamphlets. Both groups completed presurveys and postsurveys assessing their perceptions of collaborative learning. RESULTS: There were statistically significant differences between the respondent groups for 3 survey questions about how this project helped prepare them for future practice and professional collaboration. Eight qualitative themes were identified. CONCLUSION: Although desiring more face-to-face interaction between groups, students reported that collaboration was important.

Knowledge, Attitudes, and Experience With Advance Directives Among Prelicensure Nursing Students.

BACKGROUND: End-of-life decision making can be distressing for nursing students, and the purpose of this investigation was to assess undergraduate nursing students' knowledge, attitudes, and experiences with advance directives. METHOD: One hundred sixty-six Bachelor of Science in Nursing students at four different program levels were surveyed about their knowledge, personal and professional experience, and personal and professional attitudes regarding advance directives. RESULTS: There was a statistically significant progression of knowledge from the junior 1 to the senior 2 semesters. In addition, there was a statistically significant difference in personal attitudes about advance directives by progressive semesters, in personal and professional attitudes between White/Caucasian and Black/African American students, and in knowledge of advance directives and professional attitudes between students 18 to 25 years old and those 26 years and older. CONCLUSION: It is important that nursing students are exposed to advance directives in the prelicensure curriculum to prepare them for their role as professional nurses. [J Nurs Educ. 2018;57(1):35-39.].

Student Perceptions and Acceptance of Mobile Technology in an Undergraduate Nursing Program.

Mobile technology allows healthcare students to access current evidence-based resources. The purpose of this study was to evaluate the student experience of implementing point-of-care (POC) smartphone applications in a first-semester undergraduate nursing program. Teaching methods included using case studies in the laboratory to familiarize students with the apps. At community screening sites, evidence-based guidelines were referenced when students discussed screening results with patients. Surveys were administered prior to implementing this innovation and after the students utilized the apps in direct patient interactions. Survey results were analyzed to evaluate student perceptions and acceptance of mobile technology. Students felt that healthcare smartphone apps were a helpful and convenient way to obtain evidence-based clinical information pertinent to direct care settings. Over 90% of students planned to continue using healthcare smartphone apps. In conclusion, healthcare smartphone apps are a way for students to become comfortable accessing evidence-based clinical resources. It is important to encourage students to use these resources early in the curriculum. Community screenings are an independent health promotion activity which assists in the attainment of health equity and fosters nursing leadership.

Discrepancy in Insulin Regulation between Gestational Diabetes Mellitus (GDM) Platelets and Placenta.

Earlier findings have identified the requirement of insulin signaling on maturation and the translocation of serotonin (5-HT) transporter, SERT to the plasma membrane of the trophoblast in placenta. Because of the defect on insulin receptor (IR) in the trophoblast of the gestational diabetes mellitus (GDM)-associated placenta, SERT is found entrapped in the cytoplasm of the GDM-trophoblast. SERT is encoded by the same gene expressed in trophoblast and platelets. Additionally, alteration in plasma 5-HT levels and the 5-HT uptake rates are associated with the aggregation rates of platelets. Therefore, here, we investigated a novel hypothesis that GDM-associated defects in platelet IR should change their 5-HT uptake rates, and this should be a leading factor for thrombosis in GDM maternal blood. The maternal blood and the placentas were obtained at the time of cesarean section from the GDM and non-diabetic subjects (n = 6 for each group), and the platelets and trophoblasts were isolated to determine the IR activity, surface level of SERT, and their 5-HT uptake rates.Interestingly, no significant differences were evident in IR tyrosine phosphorylation or the downstream elements, AKT and S6K in platelets and their aggregation rates in both groups. Furthermore, insulin stimulation up-regulated 5-HT uptake rates of GDM-platelets as it does in the control group. However, the phosphorylation of IR and the downstream elements were significantly lower in GDM-trophoblast and showed no response to the insulin stimulation while they showed 4-fold increase to insulin stimulation in control group. Similarly, the 5-HT uptake rates of GDM-trophoblast and the SERT expression on their surface were severalfold lower compared with control subjects. IR is expressed in all tissues, but it is not known if diabetes affects IR in all tissues equally. Here, for the first time, our findings with clinical samples show that in GDM-associated defect on IR is tissue type-dependent. While IR is impaired in GDM-placenta, it is unaffected in GDM-platelet.

Shared Decision Aids: Increasing Patient Acceptance of Long-Acting Reversible Contraception.

Unintended pregnancies are an important public health issue. Long-acting reversible contraceptive methods (LARCs) are reliable, safe, highly effective methods for most women; however they are underutilized in the United States. Shared decision aids were added to usual care in five public health family planning clinics in the Southeastern United States, staffed by advance practice nurses and registered nurses. All five sites showed an increase in the use of LARCs during the time period that shared decision aids were used (results statistically significant to p < 0.001). It is important for women to make informed choices about contraception, and shared decision aids can be utilized to support this decision making. This resource has been adopted for statewide use in all public health clinics, and implications for practice suggest that the use of shared decision aids is an effective method to support informed patient decision making and acceptance of LARC methods of contraception.

GDM-associated insulin deficiency hinders the dissociation of SERT from ERp44 and down-regulates placental 5-HT uptake.

Serotonin (5-HT) transporter (SERT) regulates the level of 5-HT in placenta. Initially, we found that in gestational diabetes mellitus (GDM), whereas free plasma 5-HT levels were elevated, the 5-HT uptake rates of trophoblast were significantly down-regulated, due to impairment in the translocation of SERT molecules to the cell surface. We sought to determine the factors mediating the down-regulation of SERT in GDM trophoblast. We previously reported that an endoplasmic reticulum chaperone, ERp44, binds to Cys200 and Cys209 residues of SERT to build a disulfide bond. Following this posttranslational modification, before trafficking to the plasma membrane, SERT must be dissociated from ERp44; and this process is facilitated by insulin signaling and reversed by the insulin receptor blocker AGL2263. However, the GDM-associated defect in insulin signaling hampers the dissociation of ERp44 from SERT. Furthermore, whereas ERp44 constitutively occupies Cys200/Cys209 residues, one of the SERT glycosylation sites, Asp208 located between the two Cys residues, cannot undergo proper glycosylation, which plays an important role in the uptake efficiency of SERT. Herein, we show that the decrease in 5-HT uptake rates of GDM trophoblast is the consequence of defective insulin signaling, which entraps SERT with ERp44 and impairs its glycosylation. In this regard, restoring the normal expression of SERT on the trophoblast surface may represent a novel approach to alleviating some GDM-associated complications.

Can improved intra- and inter-team communication reduce missed delirium?

To assess the prevalence and the team interaction in cases of missed delirium in acute care veterans coded as not having a diagnosis of delirium in admission or discharge notes. In this retrospective study, the records of 183 hospitalized veterans admitted to the emergency department (ED), medicine, surgery and psychiatry services and coded as not having a diagnosis of delirium were analyzed. Clinical notes of each case were examined using DSM IV TR criteria for delirium. Of the 52 cases assessed to have delirium, 5 cases had been miscoded as not having delirium. In the remaining 47 cases the diagnosis of delirium had been missed. The rates of undiagnosed delirium were ED 46/160, medicine 39/132, surgery 4/17, psychiatry 4/29 and consult liaison (CL) 0/9. Of the 5 cases of delirium identified by the CL service, 2 consult diagnoses were accepted and 3 were rejected. Nursing notes had words suggesting delirium in 70.2 % of 47 cases compared to 41.3 and 43.6 % of the clinician case notes for these patients admitted to ED and medicine respectively. No delirium or cognitive screening scales were utilized in the work up of the 52 cases involving delirium. The study results suggest that continuing education by the CL service of all hospital personnel involved in patient care may improve the diagnosis of delirium. Also, increased clinician-nursing intra-team communication, in addition to careful scrutiny of the nursing and clinician notes may contribute to the reduced incidence of missed delirium.

Examining the use and outcomes of a new hospital-grade breast pump in exclusively pumping NICU mothers.

PURPOSE: To determine whether exclusively pumping mothers of preterm infants could achieve full milk production while using the Ameda Platinum breast pump the first 14 days postpartum. SUBJECTS: Twenty-six mothers who delivered infants between 26 and 32 weeks' gestation at 2 Intermountain Healthcare hospitals completed the study. Mothers could not take milk-enhancing or milk-reducing substances, feed directly at the breast, have had breast surgery, or use any other breast pump during the study. DESIGN: Nonexperimental, descriptive study. METHODS: Mothers were instructed to use the Ameda Platinum breast pump exclusively 8 times daily, for 14 days. They recorded milk volumes, suction pressures, cycle speeds, and time spent pumping. A "Performance Questionnaire" was completed at the end of the study with questions about the ease of use, preferred speed and suction settings, and overall performance of the pump. MAIN OUTCOME MEASURE: Full milk production was defined as 700 mL/d. Speed and suction settings, as well as average pumping session length, were analyzed in relation to categories of maximum milk volumes expressed. RESULTS: The average maximum daily milk volume for all mothers was 817 mL/d. Sixteen mothers produced milk volumes more than 700 mL/d and 9 of these mothers were able to express more than 1000 mL/d. Those with daily milk production more than 700 mL/d used lower suction pressure settings to stimulate the milk ejection reflex and to empty the breast. These higher-producing mothers also chose ending speeds of 50 to 60 cycles per minute, similar to the nutritive sucking pattern of a healthy newborn. Mothers producing less than 500 mL/d used higher suction pressures, faster ending cycle speeds, and longer pumping times. Suction pressures varied widely among all of the mothers and were influenced by the mothers' nipple or breast sensitivity, which varied from mother to mother and day to day. Mothers reported liking separate controls for speed and suction and used them to achieve maximum comfort and milk volume. CONCLUSIONS: The Ameda Platinum breast pump is an effective hospital-grade pump for exclusively pumping mothers to establish full milk production by 14 days postpartum. Separate control of speed and suction allows mothers a wide range of options to achieve greater comfort and multiple milk ejections, both of which contribute to optimal milk expression.

What is the evidence to support the use of therapeutic gardens for the elderly?

Horticulture therapy employs plants and gardening activities in therapeutic and rehabilitation activities and could be utilized to improve the quality of life of the worldwide aging population, possibly reducing costs for long-term, assisted living and dementia unit residents. Preliminary studies have reported the benefits of horticultural therapy and garden settings in reduction of pain, improvement in attention, lessening of stress, modulation of agitation, lowering of as needed medications, antipsychotics and reduction of falls. This is especially relevant for both the United States and the Republic of Korea since aging is occurring at an unprecedented rate, with Korea experiencing some of the world's greatest increases in elderly populations. In support of the role of nature as a therapeutic modality in geriatrics, most of the existing studies of garden settings have utilized views of nature or indoor plants with sparse studies employing therapeutic gardens and rehabilitation greenhouses. With few controlled clinical trials demonstrating the positive or negative effects of the use of garden settings for the rehabilitation of the aging populations, a more vigorous quantitative analysis of the benefits is long overdue. This literature review presents the data supporting future studies of the effects of natural settings for the long term care and rehabilitation of the elderly having the medical and mental health problems frequently occurring with aging.

Habituation of visual evoked responses in neonates and fetuses: a MEG study.

In this study we aimed to develop a habituation paradigm that allows the investigation of response decrement and response recovery and examine its applicability for measuring the habituation of the visually evoked responses (VERs) in neonatal and fetal magnetoencephalographic recordings. Two paradigms, one with a long and one with a short inter-train interval (ITI), were developed and tested in separate studies. Both paradigms consisted of a train of four light flashes; each train being followed by a 500Hz burst tone. Healthy pregnant women underwent two prenatal measurements and returned with their babies for a neonatal investigation. The amplitudes of the neonatal VERs in the long-ITI condition showed within-train response decrement. An increased response to the auditory dishabituator was found confirming response recovery. In the short-ITI condition, neonatal amplitude decrement could not be demonstrated while response recovery was present. In both ITI conditions, the response rate of the cortical responses was much lower in the fetuses than in the neonates. Fetal VERs in the long-ITI condition indicate amplitude decline from the first to the second flash with no further decrease. The long-ITI paradigm might be useful to investigate habituation of the VERs in neonates and fetuses, although the latter requires precaution.

Salem VAMC-U.S. Army Fort Bragg Warrior Transition Clinic telepsychiatry collaboration: 12-month operation clinical perspective.

OBJECTIVE: To describe the clinical experience in the first Veterans Affairs (VA)-U.S. Army Warrior Transition Clinic (WTC) telepsychiatry operation (September 2008-August 2009). MATERIALS: Joint VA and U.S. Army records. METHODS: Analysis of intake, follow-up, and last visit records. RESULTS: One hundred twenty active-duty U.S. Army soldiers were seen (394 clinic visits). Ninety-eight soldiers had one or more combat tours, principally in Iraq and Afghanistan. Posttraumatic stress disorder was diagnosed in 50.0% of the cases by the WTC telepsychiatrists. The majority of the soldiers had medical comorbidities, especially chronic pain (75.0%), in addition to mental health problems. Several of the soldiers were recovering from trauma (20.8%) and/or surgery (23.3%), 11.7% exhibited traumatic brain injuries, and 17.5% had headaches. Disrupted relationships (74.2%) were notable for non-family members, especially military cohorts such as other persons in the same WTC squad or platoon. CONCLUSION: The observations in this report come from a cross-section of soldiers who were triaged to meet WTC admission criteria. As this is the prototype VA-U.S. Army telepsychiatry collaboration, there are no comparative data at this time. The nature of the medical and psychiatric problems treated in the military WTC represents an index of the more severe combat trauma treated on military bases from ongoing combat operations and may predict future VA-U.S. Army collaborative telepsychiatry clinic experiences.

Spectral power differences in the brain activity of growth-restricted and normal fetuses.

Using non-invasive fetal magnetoencephalography (fMEG), we investigated spontaneous brain activity in 28 fetuses diagnosed with intrauterine growth restriction (IUGR) and compared the results to 47 normal-growth fetuses. The fetal gestational age ranged from 28 to 39 weeks with post-natal recordings obtained on 17 of the IUGR fetuses. Power spectrum was computed and was divided into four frequency bands. A significant difference in the relative spectral power in delta, theta and beta bands (P<0.01) was observed only in the 28-32 week gestation age group with alpha band showing a similar trend (P=0.054). This observation suggests that growth restriction may have a more pronounced effect on the fetal brain in early gestation. Larger population studies could reveal the potential value of fMEG as an additional surveillance tool for growth-restricted fetuses.