Chronic Pain Resilience Across Clinical Populations: A Concept Analysis.

BACKGROUND: Chronic pain resilience is a concept that is frequently used in research but lacks theoretical clarity. Understanding chronic pain resilience is germane to developing interventions to improve it and the overall quality of life among individuals with chronic pain. AIMS: To uncover and clarify the unique characteristics of the concept of chronic pain resilience. DESIGN: A concept analysis using Rodgers' evolutionary method. METHODS: Full-text articles published after 2000 in English were used to inform the concept analysis. Scopus, PubMed, PsychINFO, Embase, and CINAHL Plus with Full Text were utilized for literature searches. Rodgers' evolutionary approach was used to clarify the attributes, antecedents, and consequences. RESULTS: The search yielded 31 articles that were used in the analysis. The key attributes of chronic pain resilience included engagement in meaningful activities despite pain, maintaining positive psychological homeostasis, buffering against negative mental outcomes, seeking support, and self-empowerment. After considering surrogate terms, antecedents, attributes, and consequences, chronic pain resilience may be defined as the development of the capacity to successfully adapt to chronic pain. This adaptation results in a move toward optimal social, physical, mental, and behavioral functioning by balancing negative and positive psychosocial factors, despite the additional challenges brought about by living with chronic pain.

The pace of biological aging helps explain the association between insomnia and chronic low back pain.

Chronic low back pain (cLBP) is associated with insomnia and advanced age. Emerging evidence suggests that the severity of both sleep disorders (like insomnia) and chronic pain are associated with a faster pace of biological aging. We aimed to determine whether the pace of biological age mediates the relationship between insomnia and the impact of cLBP in a sample of community-dwelling adults ages 19 to 85 years. Participants (49 with no pain, 32 with low-impact pain, and 37 with high-impact pain) completed sociodemographic, pain, insomnia, and short physical performance battery assessments. We calculated the pace of biological aging using DunedinPACE from blood leukocyte DNA. On average, individuals with high-impact cLBP had significantly faster biological aging than those with low-impact and no chronic pain (p < .001). Bivariate associations of DunedinPACE scores with insomnia severity and functional performance were significant at p < .01 (rs = 0.324 and -0.502, respectively). After adjusting for race and sex, the association of insomnia severity and the impact of cLBP was partially mediated by the pace of biological aging (ß = 0.070, p < .001). Also, the association of insomnia severity with functional performance was partially mediated by the pace of biological aging (ß = -0.105, p < .001). Thus, insomnia remains strongly predictive of cLBP outcomes, and the pace of biological aging helps explain this association. Future prospective studies with repeated assessments are needed to uncover the directionality of these complex relationships and ultimately develop interventions to manage cLBP.

A Single-Entity Method for Actively Controlled Nucleation and High-Quality Protein Crystal Synthesis.

Lack of controls and understanding in nucleation, which proceeds crystal growth and other phase transitions, has been a bottleneck challenge in chemistry, materials, biology, and other fields. The exemplary needs for better methods for biomacromolecule crystallization include (1) synthesizing crystals for high-resolution structure determinations in fundamental research and (2) tuning the crystal habit and thus the corresponding properties in materials and pharmaceutical applications. Herein, a deterministic method is established capable of sustaining the nucleation and growth of a single crystal using the protein lysozyme as a prototype. The supersaturation is localized at the interface between a sample and a precipitant solution, spatially confined by the tip of a single nanopipette. The exchange of matter between the two solutions determines the supersaturation, which is controlled by electrokinetic ion transport driven by an external potential waveform. Nucleation and subsequent crystal growth disrupt the ionic current limited by the nanotip and are detected. The nucleation and growth of individual single crystals are measured in real time. Electroanalytical and optical signatures are elucidated as feedbacks with which active controls in crystal quality and method consistency are achieved: five out of five crystals diffract at a true atomic resolution of up to 1.2 Å. As controls, those synthesized under less optimized conditions diffract poorly. The crystal habits during the growth process are tuned successfully by adjusting the flux. The universal mechanism of nano-transport kinetics, together with the correlations of the diffraction quality and crystal habit with the crystallization control parameters, lay the foundation for the generalization to other materials systems.

Improving Communication Between ICU Nurses and Anesthesia Providers Using a Standardized Handoff Protocol.

PURPOSE: This quality improvement (QI) project aimed to improve handoff communication between intensive care unit (ICU) nurses and anesthesia providers using a standardized preoperative handoff protocol for nonemergent and noncardiac procedures. DESIGN: A quality improvement project. METHODS: Following project approval, the project team provided staff education regarding a pre-populated handoff tool from the electronic medical record (EMR) adapted for perioperative use. In addition, the project team assessed the providers' perception and satisfaction with handoff communication before and after the intervention. FINDINGS: Of the 128 transfers, 76% completed the handoff tool during the 1-month implementation phase. CRNAs (n = 60), Registered Nurses (RNs; n = 88), and anesthesia residents (n = 30) completed the pre-and post-implementation surveys. Pre-implementation, 40% of providers were dissatisfied with communication, and only 14% reported dissatisfaction post-implementation. Also, 40% of providers believed this handoff protocol increased the amount of accurate information shared during reports without delaying the transition of care. CONCLUSIONS: The standardized handoff tool appears to improve information sharing during the transfer of care and improve provider satisfaction with the handoff process. Long term, it may reduce adverse patient events and improve outcomes. Use of a pre-populated handoff tool from the EMR provides a cost-effective solution to decrease erroneous reporting by removing human error associated with the recall.

A Systematic Review of Race, Sex, and Socioeconomic Status Differences in Postoperative Pain and Pain Management.

PURPOSE: Optimal postoperative pain management remains a significant problem despite the availability of multiple preoperative, intraoperative, and postoperative pain management interventions. Recent studies suggest that racialized minorities, female sex, and individuals of lower socioeconomic status (SES) are more likely to experience more severe pain and inadequate pain management postoperatively. Our systematic review aimed to determine race, sex, and SES differences in postoperative pain and postoperative pain management. DESIGN: This study is a systematic review of literature. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, we systematically searched 5 databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Embase, Scopus, and Cochrane. We included primary source peer-reviewed articles published after 1990 that measured postoperative pain and race/ethnicity, sex/gender, or SES, which were published in English. Two pairs of reviewers independently screened each title, abstract, and article for inclusion. In cases of disagreement, a third reviewer broke the tie. FINDINGS: A total of 464 articles were screened, of which 32 were included in this study. In most studies, Blacks/African American experience more severe postoperative pain than Whites/Caucasians. Whites were more likely to be prescribed opioids for pain management than Blacks, Hispanics, and Asians. Also, individuals of lower SES and females reported more postoperative pain. One study found no race/ethnic group differences in pain scores and opioid use after the implementation of the enhanced recovery after surgery (ERAS) protocol. CONCLUSIONS: Optimal postoperative pain relief continues to be a challenge for individuals who self-identify as racialized minorities, females, and those of lower SES. Standardization of care may help reduce disparities in postoperative pain management.

Evaluating the Utilization of a Perioperative Hyperglycemic Protocol: A Quality Improvement Project.

PURPOSE: The purpose of this project to evaluate adherence to the perioperative hyperglycemic protocol among Certified Registered Nurse Anesthetists (CRNAs) at a large academic hospital. A secondary objective of this project is CRNAs' perceptions of barriers to point-of-care (POC) testing and the protocol. DESIGN: A quality improvement project. METHODS: Using Donabedian's conceptual framework, a Phase 1 retrospective chart analysis of 297 patients with diabetes undergoing noncardiac surgery before and after implementing POC testing for intraoperative glucose control was performed. Only patients with preoperative BG ≥ 180 mg/dL were included in this phase of the project, which involved a comparison of the protocol utilization before and after implementation of POC testing. Phase 2 included an assessment of CRNA's perceptions of the protocol. FINDINGS: The final sample included 91 (37 preimplementation; 54 postimplementation) participants. There were no significant demographic differences between the groups. Overall, 52.7% of patients had intraoperative glucose checks, and only 16.5% received insulin. Preoperative BG levels decreased 11.4-points, and postoperative BG levels increased 20.4 points when comparing pre- and postimplementation groups. However, there were significant differences in postoperative glucose levels, pre- and postimplementation. The survey showed that the majority (65.5%) of CRNAs identified difficulty locating the protocol as the primary barrier to utilization. CONCLUSIONS: Although all patients included in this project qualified for an intraoperative glucose check, findings revealed that only half of the patients had a glucose check and less than one fifth of the patients received insulin treatment, indicating poor adherence to the protocol. Thus, while implementing protocols is essential, utilization and adherence to the protocol are critical to improving patient outcomes. Recommendations for continued improvement include increasing protocol accessibility, staff training, compliance monitoring, and a more simple protocol structure.

The applications of cryoneurolysis for acute and chronic pain management.

BACKGROUND: Cryoneurolysis is a term used to describe the application of extreme cold to targeted nerve tissue. The primary goal of the application of a thermal neurolytic technique is to disrupt the conduction of pain signals from the periphery to the central nervous system and eliminate or diminish the experience of pain. Recent advancements in ultrasound technology coupled with the development and approval of handheld devices specifically designed to deliver cryoneurolysis has expanded the use of this modality in the perioperative setting. APPLICATION: Surgical procedures including total knee arthroplasties, shoulder arthroplasties, thoracotomies, and mastectomies have all demonstrated long-term pain relief benefits when cryoneurolysis has been administered days to weeks prior to the planned procedure. In addition, the newly designed handheld device allows for office-based clinical use and has been utilized for various chronic pain conditions including neuropathic and phantom limb pain. CONCLUSION: The evidence clearly demonstrates that cryoneurolysis has a low risk profile and when administered appropriately, provides prolonged analgesia without promoting motor blockade. This narrative review article describes the unique mechanism of action of cryoneurolysis for prolonged pain relief and provides emerging evidence to support its applications in both acute and chronic pain management.

Need for age-specific prostate-specific antigen reference intervals in a Nigerian population.

Background: In Nigeria, the diagnostic value of prostate-specific antigen (PSA) is a matter of debate. PSA levels are known to vary with population, environmental factors, and advancing age. Studies suggest age-specific reference intervals (ASRIs) of PSA value are more accurate than single cut-off PSA value. For ASRIs to be used effectively, reference intervals (RIs) must be fully evaluated. Aim: We determine ASRIs in a Nigerian population. Materials and Methods: The study was carried out from January 2016 to January 2019 among 660 adult Nigerian men aged 30-86 years old in Enugu State. Participants completed questionnaire demographics and previous screening. Age group was the indicator. Among them, a total 24 (3.6%) were excluded. Data from 636 (96.4%) men were analyzed for ASRIs. Estimation of PSA was done as per the International Federation of Clinical Chemistry Guideline. Spearman correlation was used to identify correlates P values < 0.05 which was considered significant. Results: The mean age group was 49.6 ± 10.2 years. ASRIs using 95th percentile, and PSA values in each 10 years groups were 0-1.94 ng/ml (median 0.22), 0-2.52 ng/ml (median 0.42), 0-3.52 ng/ml (median 1.06), 0-4.8 ng/ml (median 2.1), 0-6.95 ng/ml (median 4.1), and 0-5.6 ng/ml (median 2.4), for age groups 30-39, 40-49, 50-59, 60-69, 70-79, and ≥80 years, respectively. There was positive correlation between PSA and age (r = 0.9915, P < 0.0001). Low income and educational background were more prevalent among the study group. Conclusion: Our study provided the ASRIs in our environment but higher than single cut-off value. The data recommended PSA values should be characterized by age and ethnicity.

Drug design and DNA structural research inspired by the Neidle laboratory: DNA minor groove binding and transcription factor inhibition by thiophene diamidines.

The understanding of sequence-specific DNA minor groove interactions has recently made major steps forward and as a result, the goal of development of compounds that target the minor groove is an active research area. In an effort to develop biologically active minor groove agents, we are preparing and exploring the DNA interactions of diverse diamidine derivatives with a 5'-GAATTC-3' binding site using a powerful array of methods including, biosensor-SPR methods, and X-ray crystallography. The benzimidazole-thiophene module provides an excellent minor groove recognition component. A central thiophene in a benzimidazole-thiophene-phenyl aromatic system provides essentially optimum curvature for matching the shape of the minor groove. Comparison of that structure to one with the benzimidazole replaced with an indole shows that the two structures are very similar, but have some interesting and important differences in electrostatic potential maps, the DNA minor groove binding structure based on x-ray crystallographic analysis, and inhibition of the major groove binding PU.1 transcription factor complex. The binding KD for both compounds is under 10 nM and both form amidine H-bonds to DNA bases. They both have bifurcated H-bonds from the benzimidazole or indole groups to bases at the center of the -AATT- binding site. Analysis of the comparative results provides an excellent understanding of how thiophene compounds recognize the minor groove and can act as transcription factor inhibitors.

Rediscovery of Methadone to Improve Outcomes in Pain Management.

Clinically, methadone is most known for its use in the treatment of opioid maintenance therapy. However, methadone's pharmacological profile makes it an excellent analgesic that can enhance acute and chronic pain management. It is a potent µ-receptor agonist with a longer elimination half-life than most clinically used opioids. In addition, methadone inhibits serotonin and norepinephrine uptake, and it is an N-methyl-D-aspartate antagonist. These distinct analgesic pathways mediate hyperalgesic, allodynic, and neuropathic pain. Its unique analgesic properties provide several essential benefits in perioperative use, neuropathic pain, cancer, and noncancer pain. Despite these proven clinical utilities, methadone has not been used widely to treat acute and chronic pain in opioid naïve patients. This article describes the unique pharmacology of methadone and provides emerging evidence to support its application in acute and chronic pain management. Pain management options and guidelines for surgical patients on methadone are discussed as well.

Implementation of a Certified Registered Nurse Anesthetist Second Victim Peer Support Program.

PURPOSE: Second victimhood, a phenomenon experienced by about half of health care providers, occurs when an individual experiences negative physical, psychological, or emotional effects after an adverse event, such as patient-related near miss, harm, or death. The stress of anesthesia practice increases the incidence of this phenomenon among anesthesia providers. Second victimhood increases turnover, absenteeism, and risk of medical error. This project aimed to decrease second victim distress among certified registered nurse anesthetists (CRNAs) by implementing a peer support program - second victims are more likely to use peer support over commonly offered support services. DESIGN: A quality improvement project. METHODS: Eight volunteer CRNAs were trained to provide peer support 24-hours a day. CRNAs needing peer support could self-identify or be identified by a colleague, peer supporter, or lead CRNA, and could locate the peer supporter on call in the electronic anesthesia dashboard. Pre- and post-implementation second victim distress were assessed using the Second Victim Experience and Support Tool, a validated survey that measures distress symptoms and perceived institutional support. FINDINGS: Although differences in pre- and post-implementation survey scores were statistically insignificant, the program was welcomed by leadership and staff. CONCLUSIONS: The program experienced higher utilization compared to similar launch studies, with eight encounters in the first month. Impact on staff morale is expected to increase; long-term peer support can improve provider well-being and patient outcomes.

Heat Islands and Chronic Disease: Could African Americans Be More Vulnerable to Heat-Related Health Impacts?

Global warming and environmental heat stress are public health concerns. Urban heat islands, metropolitan areas with higher temperatures compared to their surrounding rural areas, compound the effects of increased environmental heat. In addition to acute heat-related illness, increased environmental heat is linked to exacerbation of chronic diseases. The purpose of this narrative review is to provide an overview of heat islands and how the effects of heat stress intersect with chronic diseases in the African American (AA) community. Across the United States, AAs are more likely to reside in heat islands, resulting in greater exposure to environmental heat. Unfortunately, chronic diseases exacerbated by increased environmental heat disproportionately impact the AA community. Due to the intersection of these disparities, heat-related health risks are likely higher for the AAs. The increased health risks posed by urban heat island exposure on AAs have significant implications for nursing practice, research, and policy.

Sleep and neighborhood socioeconomic status: a micro longitudinal study of chronic low-back pain and pain-free individuals.

Individuals with chronic low back pain (cLBP) frequently report sleep disturbances. Living in a neighborhood characterized by low-socioeconomic status (SES) is associated with a variety of negative health outcomes, including poor sleep. Whether low-neighborhood SES exacerbates sleep disturbances of people with cLBP, relative to pain-free individuals, has not previously been observed. This study compared associations between neighborhood-level SES, pain-status (cLBP vs. pain-free), and daily sleep metrics in 117 adults (cLBP = 82, pain-free = 35). Neighborhood-level SES was gathered from Neighborhood Atlas, which provides a composite measurement of overall neighborhood deprivation (e.g. area deprivation index). Individuals completed home sleep monitoring for 7-consecutive days/nights. Neighborhood SES and pain-status were tested as predictors of actigraphic sleep variables (e.g., sleep efficiency). Analyses revealed neighborhood-level SES and neighborhood-level SES*pain-status interaction significantly impacted objective sleep quality. These findings provide initial support for the negative impact of low neighborhood-level SES and chronic pain on sleep quality.

Temporal summation of mechanical pain prospectively predicts movement-evoked pain severity in adults with chronic low back pain.

BACKGROUND: Biopsychosocial factors above and beyond pathoanatomical changes likely contribute to the severity of chronic low back pain. A pro-nociceptive endogenous pain modulatory balance (↓inhibition and ↑facilitation) may be an important contributor to chronic low back pain severity and physical function; however, additional research is needed to address this possibility. The objective of this study was to determine whether quantitative sensory tests of endogenous pain inhibition and facilitation prospectively predict movement-evoked pain and cLBP severity self-reported on a validated questionnaire. METHODS: One hundred thirty-four individuals with chronic low back pain were enrolled in this two-session study. During the first study session, temporal summation of mechanical pain and conditioned pain modulation were assessed at the lumbar spine to determine endogenous pain facilitation and inhibition, respectively. One week later, participants returned for a second study session whereby they reported their pain severity and pain interference using the Brief Pain Inventory-Short Form. Movement-evoked pain and physical function capacity were assessed upon completion of the balance, walking, and transition from sit to stand tests of the Short Physical Performance Battery. RESULTS: Temporal summation of mechanical pain, but not conditioned pain modulation, significantly and prospectively predicted greater movement-evoked pain and poorer physical function on the Short Physical Performance Battery. Neither temporal summation nor conditioned pain modulation were significantly related to self-reported pain severity or pain interference on the Brief Pain Inventory-Short Form. CONCLUSIONS: Findings suggest that a pro-nociceptive pain modulatory balance characterized by enhanced pain facilitation may be an important driver of movement-evoked pain severity and poor physical function in individuals with chronic low back pain.

Identification of DNA methylation associated enrichment pathways in adults with non-specific chronic low back pain.

Chronic low back pain (cLBP) that cannot be attributable to a specific pathoanatomical change is associated with high personal and societal costs. Still, the underlying mechanism that causes and sustains such a phenotype is largely unknown. Emerging evidence suggests that epigenetic changes play a role in chronic pain conditions. Using reduced representation bisulfite sequencing (RRBS), we evaluated DNA methylation profiles of adults with non-specific cLBP (n = 50) and pain-free controls (n = 48). We identified 28,325 hypermethylated and 36,936 hypomethylated CpG sites (p < 0.05). After correcting for multiple testing, we identified 159 DMRs (q < 0.01and methylation difference > 10%), the majority of which were located in CpG island (50%) and promoter regions (48%) on the associated genes. The genes associated with the differentially methylated regions were highly enriched in biological processes that have previously been implicated in immune signaling, endochondral ossification, and G-protein coupled transmissions. Our findings support inflammatory alterations and the role of bone maturation in cLBP. This study suggests that epigenetic regulation has an important role in the pathophysiology of non-specific cLBP and a basis for future studies in biomarker development and targeted interventions.

Perceived Injustice Helps Explain the Association Between Chronic Pain Stigma and Movement-Evoked Pain in Adults with Nonspecific Chronic Low Back Pain.

OBJECTIVE: For most patients with chronic low back pain (cLBP), the cause is "nonspecific," meaning there is no clear association between pain and identifiable pathology of the spine or associated tissues. Laypersons and providers alike are less inclined to help, feel less sympathy, dislike patients more, suspect deception, and attribute lower pain severity to patients whose pain does not have an objective basis in tissue pathology. Because of these stigmatizing responses from others, patients with cLBP may feel that their pain is particularly unjust and unfair. These pain-related injustice perceptions may subsequently contribute to greater cLBP severity. The purpose of this study was to examine whether perceived injustice helps explain the relationship between chronic pain stigma and movement-evoked pain severity among individuals with cLBP. METHODS: Participants included 105 patients with cLBP who completed questionnaires assessing chronic pain stigma and pain-related injustice perception, as well as a short physical performance battery for the assessment of movement-evoked pain and physical function. RESULTS: Findings revealed that perceived injustice significantly mediated the association between chronic pain stigma and cLBP severity (indirect effect = 6.64, 95% confidence interval [CI] = 2.041 to 14.913) and physical function (indirect effect = -0.401, 95% CI = -1.029 to -0.052). Greater chronic pain stigma was associated with greater perceived injustice (P = 0.001), which in turn was associated with greater movement-evoked pain severity (P = 0.003). CONCLUSIONS: These results suggest that perceived injustice may be a means through which chronic pain stigma impacts nonspecific cLBP severity and physical function.

Emerging risk factors associated with prevalence of hepatitis c virus infection among Nigerians: Findings from blood donors in an academic hospital, Enugu South-Eastern Nigeria.

AIM: In Nigeria, reports on the prevalence of Hepatitis C risk factors have not been clearly elucidated, we investigate the risk factors that influence the prevalence and how the difference in awareness level of risk factors screening across age groups contributes to the disease. METHODS: A total of 8790 aged 18-55 years old, who attended the Department of Haematology and Blood Transfusion Services, University of Nigeria Teaching Hospital, Enugu were screened. Among them, 135 were diagnosed with hepatitis C infection from 1 January 2017 to 1 January 2019. Participants completed a questionnaire related to demographics, risk factors, history of previous medical screening. Age groups, income and education were indicators. Multivariate analyses were used to identify correlates. RESULTS: A total of 135 blood donors (95 males and 40 females) with a mean age of 35.9 ± 10.5 and 36.4 ± 10.7 years respectively were positive for hepatitis C infection, giving overall prevalence (1.5%), injecting drug use (39%), unprotected multiple sex (22.2%), sacrification (14.8%), blood transfusion (11.1%). Multivariate analysis revealed that injecting drug use (P < .0001), unprotected multiple sex (P = .004), sacrification (P = .036) were independent risk factors that influence the prevalence among younger age groups. Blood transfusion was not significant (P = .053) but the mostly accessed. Low income and educational background were significantly more prevalent among the studied group. CONCLUSION: Injecting drug use, multiple sex and sacrification are independent predictors of prevalence of Hepatitis C infection. The early onset of the risk factors among the younger adult clearly underlines the need for early screening and interventions.

Taste the Pain: The Role of TRP Channels in Pain and Taste Perception.

Transient receptor potential (TRP) channels are a superfamily of cation transmembrane proteins that are expressed in many tissues and respond to many sensory stimuli. TRP channels play a role in sensory signaling for taste, thermosensation, mechanosensation, and nociception. Activation of TRP channels (e.g., TRPM5) in taste receptors by food/chemicals (e.g., capsaicin) is essential in the acquisition of nutrients, which fuel metabolism, growth, and development. Pain signals from these nociceptors are essential for harm avoidance. Dysfunctional TRP channels have been associated with neuropathic pain, inflammation, and reduced ability to detect taste stimuli. Humans have long recognized the relationship between taste and pain. However, the mechanisms and relationship among these taste-pain sensorial experiences are not fully understood. This article provides a narrative review of literature examining the role of TRP channels on taste and pain perception. Genomic variability in the TRPV1 gene has been associated with alterations in various pain conditions. Moreover, polymorphisms of the TRPV1 gene have been associated with alterations in salty taste sensitivity and salt preference. Studies of genetic variations in TRP genes or modulation of TRP pathways may increase our understanding of the shared biological mediators of pain and taste, leading to therapeutic interventions to treat many diseases.

Using Clinical Simulations to Train Healthcare Professionals to Use Electronic Health Records: A Literature Review.

Unintended consequences are adverse events directly related to information technology and may result from inappropriate use of electronic health records by healthcare professionals. Electronic health record competency training has historically used didactic lectures with hands-on experience in a live classroom, and this method fails to teach learners proficiency because the sociotechnical factors that are present in real-world settings are excluded. Additionally, on-the-job training to gain competency can impair patient safety because it distracts clinicians from patient care activities. Clinical simulation-based electronic health record training allows learners to acquire technical and nontechnical skills in a safe environment that will not compromise patient safety. The purpose of this literature review was to summarize the current state-of-the-science on the use of clinical simulations to train healthcare professionals to use electronic health records. The benefits of using simulation-based training that incorporates an organization's contextual factors include improvement of interdisciplinary team communication, clinical performance, clinician-patient-technology communication skills, and recognition of patient safety issues. Design considerations for electronic health record training using clinical simulations involve establishing course objectives, identifying outcome measures, establishing content requirements of both the clinical simulation and electronic health record, and providing adequate debriefing.

Perianesthesia Implications and Considerations for Drug-Induced QT Interval Prolongation.

Prolongation of the QT interval can predispose patients to fatal arrhythmias such as torsade de pointes. While arrhythmias can occur spontaneously in patients with a genetic predisposition, drugs such as ondansetron and droperidol, which are frequently used in the perioperative period, have been implicated in the prolongation of the QT interval. As the list of medications that cause QT prolongation grows, anesthesia providers and perioperative nurses must be informed regarding the importance of the QT interval. This article reviews the physiology and measurement of the QT interval, the risk factors of QT prolongation, the mechanism of drug-induced QT prolongation, and perioperative considerations for patient care.