Primary Exposure to SARS-CoV-2 via Infection or Vaccination Determines Mucosal Antibody-Dependent ACE2 Binding Inhibition.

BACKGROUND: Mucosal antibodies play a critical role in preventing SARS-CoV-2 infections or reinfections by blocking the interaction of the receptor-binding domain (RBD) with the angiotensin-converting enzyme 2 (ACE2) receptor on the cell surface. In this study, we investigated the difference between the mucosal antibody response after primary infection and vaccination. METHODS: We assessed longitudinal changes in the quantity and capacity of nasal antibodies to neutralize the interaction of RBD with the ACE2 receptor using the spike protein and RBD from ancestral SARS-CoV-2 (Wuhan-Hu-1), as well as the RBD from the Delta and Omicron variants. RESULTS: Significantly higher mucosal IgA concentrations were detected postinfection vs postvaccination, while vaccination induced higher IgG concentrations. However, ACE2-inhibiting activity did not differ between the cohorts. Regarding whether IgA or IgG drove ACE2 inhibition, infection-induced binding inhibition was driven by both isotypes, while postvaccination binding inhibition was mainly driven by IgG. CONCLUSIONS: Our study provides new insights into the relationship between antibody isotypes and neutralization by using a sensitive and high-throughput ACE2 binding inhibition assay. Key differences are highlighted between vaccination and infection at the mucosal level, showing that despite differences in the response quantity, postinfection and postvaccination ACE2 binding inhibition capacity did not differ.

Relationship between work-related psychosocial factors and self-leadership in advanced nurse practitioners: A cross-sectional study.

AIM: The aim of this study was to investigate the relationship between advanced nurse practitioners' self-leadership and commitment to the workplace, work engagement and influence at work. BACKGROUND: The concept of self-leadership is particularly suited to ANPs, who are required to take responsibility for their work roles. An optimum balance between the ANPs' psychosocial work environment and self-leadership may positively impact work ability in this group and can be compromised by interactions between and among these variables. DESIGN: A cross-sectional correlational study was conducted from July 2020 to August 2020 on 153 ANPs across a national health service. METHODS: The survey was distributed to respondents online. The revised self-leadership questionnaire was used to measure self-leadership, and three scales from the Copenhagen Psychosocial Questionnaire were used to measure commitment to the workplace, work engagement and influence at work. Multiple linear regression was used to examine the association between self-leadership and the psychosocial variables. RESULTS: ANPs with high levels of self-leadership reported high levels of work engagement and commitment to the workplace. No relationship was found between self-leadership and influence at work. CONCLUSION: Improving self-leadership among ANPs by involving them in strategic leadership activities at an organizational level could be an effective strategy for optimizing the role and facilitating ANPs to contribute at an organizational level beyond the clinical interface. However, organizational support is required to ensure that ANPs practise to the full potential of their training and capability. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. IMPACT: This study provided new evidence of a relationship between ANPs' self-leadership and psychosocial factors. This study found that ANPs with high levels of self-leadership reported high levels of work engagement and commitment to the workplace. Policymakers and organizational leaders can optimize the ANP role and facilitate ANPs to contribute strategically to improve care systems. This study identifies a relationship between ANPs' self-leadership and specific psychosocial variables.

Preferences for support in managing symptoms of an asthma flare-up: a pilot study of a discrete choice experiment.

Objective: Information on the preferences of people with asthma for support in managing a flare-up can inform service design which may facilitate appropriate help-seeking. To date, little is known about support preferences for managing a flare-up. The aim of this study was to develop and pilot a discrete choice experiment (DCE) to elicit the preferences of people with asthma with regards to support in managing a flare-up.Methods: Steps in developing the DCE included identification and selection of attributes and levels of the support services, construction of choice tasks, experimental design, construction of DCE instrument, and pretest (n=16) and pilot (n=38) studies of the DCE instrument. A multinomial logit model was used to examine the strength and direction of the six attributes in the pilot study.Results: Our results indicate that from a patient perspective, having a healthcare professional that listens to their concerns was the most valued attribute of support in asthma flare-up management. The other features of support valued by participants were timely access to consultation, a healthcare professional with knowledge of their patient history, a specialist doctor and face-to-face communication. Having a written action plan was the least valued attribute.Conclusions: Our findings suggest patient preference for a model of support in managing their symptoms which includes timely, face-to-face access to a healthcare professional that knows them and listens to their concerns. The findings of the pilot study need to be verified with a larger sample and using models to account for preference heterogeneity.

The effect of thyroid hormone therapy on muscle function, strength and mass in older adults with subclinical hypothyroidism-an ancillary study within two randomized placebo controlled trials.

BACKGROUND: loss of skeletal muscle function, strength and mass is common in older adults, with important socioeconomic impacts. Subclinical hypothyroidism is common with increasing age and has been associated with reduced muscle strength. Yet, no randomized placebo-controlled trial (RCT) has investigated whether treatment of subclinical hypothyroidism affects muscle function and mass. METHODS: this is an ancillary study within two RCTs conducted among adults aged ≥65 years with persistent subclinical hypothyroidism (thyrotropin (TSH) 4.60-19.99 mIU/l, normal free thyroxine). Participants received daily levothyroxine with TSH-guided dose adjustment or placebo and mock titration. Primary outcome was gait speed at final visit (median 18 months). Secondary outcomes were handgrip strength at 1-year follow-up and yearly change in muscle mass. RESULTS: we included 267 participants from Switzerland and the Netherlands. Mean age was 77.5 years (range 65.1-97.1), 129 (48.3%) were women, and their mean baseline TSH was 6.36 mIU/l (standard deviation [SD] 1.9). At final visit, mean TSH was 3.8 mIU/l (SD 2.3) in the levothyroxine group and 5.1 mIU/l (SD 1.8, P < 0.05) in the placebo group. Compared to placebo, participants in the levothyroxine group had similar gait speed at final visit (adjusted between-group mean difference [MD] 0.01 m/s, 95% confidence interval [CI] -0.06 to 0.09), similar handgrip strength at one year (MD -1.22 kg, 95% CI -2.60 to 0.15) and similar yearly change in muscle mass (MD -0.15 m2, 95% CI -0.49 to 0.18). CONCLUSIONS: in this ancillary analysis of two RCTs, treatment of subclinical hypothyroidism did not affect muscle function, strength and mass in individuals 65 years and older.

L-Thyroxine Therapy for Older Adults With Subclinical Hypothyroidism and Hypothyroid Symptoms: Secondary Analysis of a Randomized Trial.

BACKGROUND: L-thyroxine does not improve hypothyroid symptoms among adults with subclinical hypothyroidism (SCH). However, those with greater symptom burden before treatment may still benefit. OBJECTIVE: To determine whether L-thyroxine improves hypothyroid symptoms and tiredness among older adults with SCH and greater symptom burden. DESIGN: Secondary analysis of the randomized, placebo-controlled trial TRUST (Thyroid Hormone Replacement for Untreated Older Adults with Subclinical Hypothyroidism Trial). (ClinicalTrials.gov: NCT01660126). SETTING: Switzerland, Ireland, the Netherlands, and Scotland. PARTICIPANTS: 638 persons aged 65 years or older with persistent SCH (thyroid-stimulating hormone level of 4.60 to 19.9 mIU/L for >3 months and normal free thyroxine level) and complete outcome data. INTERVENTION: L-thyroxine or matching placebo with mock dose titration. MEASUREMENTS: 1-year change in Hypothyroid Symptoms and Tiredness scores (range, 0 to 100; higher scores indicate more symptoms) on the Thyroid-Related Quality-of-Life Patient-Reported Outcome Questionnaire among participants with high symptom burden (baseline Hypothyroid Symptoms score >30 or Tiredness score >40) versus lower symptom burden. RESULTS: 132 participants had Hypothyroid Symptoms scores greater than 30, and 133 had Tiredness scores greater than 40. Among the group with high symptom burden, the Hypothyroid Symptoms score improved similarly between those receiving L-thyroxine (mean within-group change, -12.3 [95% CI, -16.6 to -8.0]) and those receiving placebo (mean within-group change, -10.4 [CI, -15.3 to -5.4]) at 1 year; the adjusted between-group difference was -2.0 (CI, -5.5 to 1.5; P = 0.27). Improvements in Tiredness scores were also similar between those receiving L-thyroxine (mean within-group change, -8.9 [CI, -14.5 to -3.3]) and those receiving placebo (mean within-group change, -10.9 [CI, -16.0 to -5.8]); the adjusted between-group difference was 0.0 (CI, -4.1 to 4.0; P = 0.99). There was no evidence that baseline Hypothyroid Symptoms score or Tiredness score modified the effects of L-thyroxine versus placebo (P for interaction = 0.20 and 0.82, respectively). LIMITATION: Post hoc analysis, small sample size, and examination of only patients with 1-year outcome data. CONCLUSION: In older adults with SCH and high symptom burden at baseline, L-thyroxine did not improve hypothyroid symptoms or tiredness compared with placebo. PRIMARY FUNDING SOURCE: European Union FP7.

The preferences of people with asthma or chronic obstructive pulmonary disease for self-management support: A qualitative descriptive study.

AIMS AND OBJECTIVES: The aim of this study was to explore and describe the self-management support (SMS) preferences of adults with asthma and/or chronic obstructive pulmonary disease (COPD). BACKGROUND: Self-management support interventions have had beneficial outcomes for people with asthma and people with COPD, though challenges remain in their implementation. Increased understanding of the support preferences of people with asthma/COPD can help inform the development of future interventions to address patients' preferences. DESIGN: A qualitative descriptive design was used. METHODS: Semi-structured focus group and individual interviews were conducted with 20 adult participants who had asthma and/or COPD in Ireland. Qualitative content analysis was used to analyse interviews. The SRQR reporting guideline was used. RESULTS: Three themes were identified. Support accessibility included having access to routine and unscheduled support from healthcare professionals with specialist knowledge. Consultation content described the need for comprehensive and person-centred support. The person-provider relationship described the value of healthcare professionals acknowledging patient concerns, noted as a challenge for people with asthma, and continuity in relationships over time. CONCLUSIONS: Routine support for people with asthma/COPD needs to be comprehensive in addressing the individual patient's challenges. Access to timely advice during exacerbations was a priority for people with asthma/COPD, suggesting that flexible access to services as well as routine review may be optimal for supporting self-management of asthma/COPD. Feeling listened to regarding symptoms experienced may be of intrinsic value to people with asthma/COPD. RELEVANCE TO CLINICAL PRACTICE: The study emphasises the importance of continued training in communications skills for healthcare professionals supporting people with asthma/COPD, particularly acknowledging the patient's concerns in the context of symptom changes/flare-up. A respiratory nurse specialist was valued as being a care coordinator who could support routine management as well as managing exacerbations, having specialist knowledge and knowing the patient over time.

Impact of clinical leadership in advanced practice roles on outcomes in health care: A scoping review.

AIM: To undertake a scoping review of the literature exploring the impact of clinical leadership in advanced practice roles in relation to patient, staff and organisational outcomes. BACKGROUND: An increasing number of publications as well as job specifications have identified clinical leadership as a cornerstone of advanced practice roles. However, it is unclear whether embedding clinical leadership in such roles has led to improvements in patient, staff or organisational outcomes. Therefore, identifying the extent to which clinical leadership in advanced practice roles relates to patient, staff and organisational outcomes is needed. METHOD: A scoping review examining the relationship between clinical leadership in advanced practice roles and health care outcomes. Searching in SCOPUS, PubMed, Psychinfo and CINAHL Plus and Web of Science identified 765 potential articles. Independent selection, data extraction tabulation of findings and analysis were completed. RESULTS: Seven studies were identified that met the inclusion criteria. Only studies reporting on nurses in advanced practice roles were included; no studies were identified that reported on the advanced practice roles of allied health professionals. The results indicate that there is no objective evidence of the impact of advanced practitioners' clinical leadership on patient, staff or organisational outcomes. CONCLUSION: There is a paucity of objective evidence to identify the extent to which clinical leadership is enacted in advanced practice roles. The review indicates a need for closer alignment of AP clinical leadership policy aspirations and formal operational leadership opportunities for APs. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers have a key role in supporting and equipping APs with leadership competencies and opportunities to enable both capability and capacity building of such roles. Nurse managers should involve APs in health care leadership at an organisational level to maximize their contribution to health, quality practice environments and health care reform. Additionally, a distinct involvement in staff development, change, operational strategic decisions and policy development should be part of the AP role, which is facilitated by management.

Perceived importance and performance of clinical leadership in practice: A cross-sectional study of nurses and midwives of all grades.

AIM: To explore the differences in perceived importance and actual performance of clinical leadership for all grades of nurses and midwives engaged in clinical practice. BACKGROUND: Clinical leadership is central to the provision of person-centred care. However, little is known about how nurses and midwives perceive this in practice. METHODS: Data were collected on a sample of nurses and midwives in the Republic of Ireland, using a cross-sectional study design (n = 324). The clinical leadership needs analysis instrument was used to measure perceived importance and performance of clinical leadership in practice. Grades of nurses/midwives included; staff, manager, advanced practitioner and senior manager. RESULTS: Senior managers were more likely to report significantly higher scores than staff grades for perceived importance of Technology & Care Initiatives (p < .01) and Financial & Service Management (p = .02). Performance of Staff & Care Delivery was significantly higher for senior managers than staff grades [F(5,309) = 6.06 p < .01]. CONCLUSION: There was a mismatch between the perceived importance and actual performance of clinical leadership in practice between different grades of staff. IMPLICATIONS FOR NURSING MANAGEMENT: Leadership training for all grades and mentoring of staff grades can promote the building of confidence and empower staff in leading clinical practice.

Development and psychometric testing of the clinical leadership needs analysis (CLeeNA) instrument for nurses and midwives.

AIM: The aim of this study is to report the development and psychometric testing of the clinical leadership needs analysis instrument (CLeeNA). BACKGROUND: Limited emphasis is placed on the clinical leadership needs of nurses and midwives that are fundamental to supporting the delivery of high quality, safe patient care. METHODS: A development and validation study of CLeeNA was undertaken using cross-sectional data. A sample of 324 registered nurses and midwives completed the questionnaire using a 7-point adjectival scale. Principal component analysis was conducted to explore scale grouping of items (n = 103 items). RESULTS: Principal component analysis, item reduction and parallel analysis on the items of the instrument resulted in seven factors consisting of 56 items. These factors were identified as: Staff and Care Delivery; Technology and Care Initiatives; Self and Team Development; Standards of Care; Financial and Service Management; Leadership and Clinical Practice; Patient Safety and Risk Management. CONCLUSION: The identified factors are reflective of an ever-changing health care environment. IMPLICATIONS FOR NURSING MANAGEMENT: Potentially, after further testing, this instrument could be used by nursing management and educators to measure clinical leadership needs, inform the design of clinical leadership training programmes and provide valuable information about health care leadership development.

Effect of tree foliage supplementation of tropical grass diet on in vitro digestibility and fermentation, microbial biomass synthesis and enteric methane production in ruminants.

The objective of this study was to evaluate the influence of tree foliage species supplemented in ruminant diets based on Pennisetum purpureum on the in vitro digestibility and fermentation, microbial biomass synthesis and enteric methane production. Seven experimental diets were evaluated, including a control treatment based on P. purpureum (PT) grass, and six additional treatments supplemented with 30.0% foliage from Neomillspaughia emargiata (NE), Tabernaemontana amygdalifolia (TA), Caesalpinia gaumeri (CG), Piscidia piscipula (PP), Leucaena leucocephala (LL) and Havardia albicans (HA). A randomised complete block design repeated in two periods (block) was used. The highest gas production (P < 0.05) was recorded in treatments TA and PT (237 and 228 mL g-1, respectively). The highest in vitro digestibility of dry matter (IVDMD) and organic matter (IVOMD) (P < 0.05) was recorded in the control treatment PT (57.9% and 66.1%, respectively). Treatments LL, NE, TA and PP promoted greater microbial biomass synthesis (290, 223, 220 and 213 mg g-1, respectively) (P < 0.05). The proportion of propionic acid also increased in these latter treatments and in treatments CG and HA (P < 0.05). Additionally, treatments LL, PP, NE and TA decreased methane production (25.8, 29.5, 30.6 and 31.8 L kg-1 of digested dry matter, respectively). In conclusion, supplementation with L. leucocephala, P. piscipula, N. emargiata and T. amygdalifolia in ruminant diets based on P. purpureum is one feed alternative that can promote greater efficiency and synthesis of microbial biomass, increase the proportions of propionic and butyric acid and decrease the production of enteric methane by 15.6 to 31.6%.

Frameworks for self-management support for chronic disease: a cross-country comparative document analysis.

BACKGROUND: In a number of countries, frameworks have been developed to improve self-management support (SMS) in order to reduce the impact of chronic disease. The frameworks potentially provide direction for system-wide change in the provision of SMS by healthcare systems. Although policy formulation sets a foundation for health service reform, little is currently known about the processes which underpin SMS framework development as well as the respective implementation and evaluation plans. METHODS: The aim of this study was to conduct a cross-country comparative document analysis of frameworks on SMS for chronic diseases in member countries of the Organisation for Economic Cooperation and Development. SMS frameworks were sourced through a systematic grey literature search and compared through document analysis using the Health Policy Triangle framework focusing on policy context, contents, actors involved and processes of development, implementation and evaluation. RESULTS: Eight framework documents published from 2008 to 2017 were included for analysis from: Scotland, Wales, Ireland, Manitoba, Queensland, Western Australia, Tasmania and the Northern Territory. The number of chronic diseases identified for SMS varied across the frameworks. A notable gap was a lack of focus on multimorbidity. Common courses of action across countries included the provision of self-management programmes for individuals with chronic disease and education to health professionals, though different approaches were proposed. The 'actors' involved in policy formulation were inconsistent across countries and it was only clear from two frameworks that individuals with chronic disease were directly involved. Half of the frameworks had SMS implementation plans with timelines. Although all frameworks referred to the need for evaluation of SMS implementation, few provided a detailed plan. CONCLUSIONS: Differences across frameworks may have implications for their success including: the extent to which people with chronic disease are involved in policy making; the courses of action taken to enhance SMS; and planned implementation processes including governance and infrastructure. Further research is needed to examine how differences in frameworks have affected implementation and to identify the critical success factors in SMS policy implementation.

Effects of quebracho tannin extract on intake, digestibility, rumen fermentation, and methane production in crossbred heifers fed low-quality tropical grass.

The aim of this work was to evaluate the effect of quebracho tannins extract (QTE) on feed intake, dry matter (DM) digestibility, and methane (CH4) emissions in cattle fed low-quality Pennisetum purpureum grass. Five heifers (Bos taurus × Bos indicus) with an average live weight (LW) of 295 ± 19 kg were allotted to five treatments (0, 1, 2, 3, and 4% QTE/kg DM) in a 5 × 5 Latin square design. Intake, digestibility, and total methane emissions (L/day) were recorded for periods of 23 h when cattle were housed in open-circuit respiration chambers. Dry matter intake (DMI), organic matter intake (OMI), dry matter digestibility (DMD), and organic matter digestibility (OMD) were different between treatments with 0 and 4% of QTE/kg DM (P < 0.05). Total volatile fatty acid and the molar proportion of acetate in the rumen was not affected (P < 0.05); however, the molar proportion of propionate increased linearly (P < 0.01) for treatments with 3 and 4% QTE. Total CH4 production decreased linearly (P < 0.01) as QTE increased in the diet, particularly with 3 and 4% concentration. When expressed as DMI and OMI by CH4, production (L/kg) was different between treatments with 0 vs 3 and 4% QTE (P < 0.05). It is concluded that the addition of QTE at 2 or 3% of dry matter ration can decrease methane production up to 29 and 41%, respectively, without significantly compromising feed intake and nutrients digestibility.

Energy utilization, nitrogen balance and microbial protein supply in cattle fed Pennisetum purpureum and condensed tannins.

The aim of the experiment was to assess the effect of condensed tannins (CT) on feed intake, dry matter digestibility, nitrogen balance, supply of microbial protein to the small intestine and energy utilization in cattle fed a basal ration of Pennisetum purpureum grass. Five heifers (Bos taurus × Bos indicus) with an average live weight of 295 ± 19 kg were allotted to five treatments consisting of increasing levels of CT (0, 1, 2, 3 and 4% CT/kg DM) in a 5 × 5 Latin square design. Dry matter intake (DMI) was similar (p > 0.05) between treatments containing 0, 1, 2 and 3% of CT/kg DM and it was reduced (p < 0.05) to 4% CT (5.71 kg DM/day) with respect to that observed with 0% CT (6.65 kg DM/day). Nitrogen balance, purine derivatives excretion in urine, microbial protein synthesis and efficiency of synthesis of microbial nitrogen in the rumen were not affected (p ≥ 0.05) by the increase in the levels of condensed tannins in the ration. Energy loss as CH4 was on average 2.7% of the gross energy consumed daily. Metabolizable energy intake was 49.06 MJ/day in cattle fed low-quality tropical grass with a DMI of 6.27 kg/day. It is concluded that concentrations of CT between 2 and 3% of DM of ration reduced energy loss as CH4 by 31.3% and 47.6%, respectively, without affecting intakes of dry and organic matter; however, digestibilities of dry and organic matter are negatively affected.

Effects of feeding ground pods of Enterolobium cyclocarpum Jacq. Griseb on dry matter intake, rumen fermentation, and enteric methane production by Pelibuey sheep fed tropical grass.

An experiment was carried out to determine the effect of supplementing ground pods of Enterolobium cyclocarpum in a basal ration of Pennisetum purpureum grass on feed intake, rumen volatile fatty acids (VFAs), and protozoa and methane (CH4) production by hair sheep. Four male sheep (Pelibuey × Katahdin) with a mean live weight of 27.0 kg (SD ± 0.5) were supplemented with 0.00, 0.15, 0.30, and 0.45 kg of dry matter (DM) of E. cyclocarpum pods daily; equivalent to 0.00, 4.35, 8.70, and 13.05 g of crude saponins, respectively. Dry matter intake (DMI), organic matter intake (OMI), and molar proportions of propionic acid increased linearly (P < 0.05) as pods of E. cyclocarpum in the ration were increased. Higher intakes of DM and OM were found when lambs were fed 0.45 kg DM per day of E. cyclocarpum, and the highest proportion of propionic acid (0.21 and 0.22, respectively) was obtained with 0.15 and 0.30 kg of DM per lamb of E. cyclocarpum, while apparent digestibility of neutral detergent fiber (NDF) and molar proportion of acetic acid were reduced (P < 0.05). Rumen CH4 production decreased (P < 0.05) when 0.30 and 0.45 kg of DM/lamb/day of E. cyclocarpum were fed (21.8 and 25.3 L CH4/lamb/day, respectively). These results suggest that to improve the feeding of sheep fed tropical grass, it is advisable to supplement the basal ration with up to 0.30 kg DM of E. cyclocarpum pods.

Physician's Prescribing Preference as an Instrumental Variable: Exploring Assumptions Using Survey Data.

BACKGROUND: Physician's prescribing preference is increasingly used as an instrumental variable in studies of therapeutic effects. However, differences in prescribing patterns among physicians may reflect differences in preferences or in case-mix. Furthermore, there is debate regarding the possible assumptions for point estimation using physician's preference as an instrument. METHODS: A survey was sent to general practitioners (GPs) in The Netherlands, the United Kingdom, New Zealand, Ireland, Switzerland, and Germany, asking whether they would prescribe levothyroxine to eight fictitious patients with subclinical hypothyroidism. We investigated (1) whether variation in physician's preference was observable and to what extent it was explained by characteristics of GPs and their patient populations and (2) whether the data were compatible with deterministic and stochastic monotonicity assumptions. RESULTS: Levothyroxine prescriptions varied substantially among the 526 responding GPs. Between-GP variance in levothyroxine prescriptions (logit scale) was 9.9 (95% confidence interval: 8.0, 12) in the initial mixed effects logistic model, 8.3 (6.7, 10) after adding a fixed effect for country and 8.2 (6.6, 10) after adding GP characteristics. The occurring prescription patterns falsified the deterministic monotonicity assumption. All cases in all countries were more likely to receive levothyroxine if a different case of the same GP received levothyroxine, which is compatible with the stochastic monotonicity assumption. The data were incompatible with this assumption for a different definition of the instrument. CONCLUSIONS: Our study supports the existence of physician's preference as a determinant in treatment decisions. Deterministic monotonicity will generally not be plausible for physician's preference as an instrument. Depending on the definition of the instrument, stochastic monotonicity may be plausible.

Work characteristics, job satisfaction and intention to leave: a cross-sectional survey of advanced nurse practitioners.

BACKGROUND: Advanced Nurse Practitioners (ANPs) are highly skilled health care professionals with the potential to play a major role in improving the quality and accessibility of health care services. However, there is emerging evidence of disquiet among nurse practitioners who often work in suboptimal work environments. Therefore, it is important to understand the elements that contribute to ANPs' job satisfaction and retention in healthcare services. AIM: To examine the effects of commitment to the workplace, work engagement, and influence at work on job satisfaction and intention to leave of ANPs. METHODS: A total of 153 ANP's on the advanced practice section of the Nursing and Midwifery Board of Ireland register completed a web survey between July and August 2020. Independent variables (commitment to the workplace, work engagement, and influence at work) were measured using the Copenhagen Psychosocial Questionnaire (COPSOQ). Multivariable logistic regression models were used to investigate the association between dependent and independent variables. RESULTS: Participants who reported higher levels of influence at work and higher levels of commitment to the workplace were also satisfied in their job (OR 1.05, 95% CI 1.01-1.09, p = 0.025), (OR 1.10, 95% CI 1.06-1.14, p < 0.001) respectively. Additionally, ANPs with higher levels of commitment to work were significantly less likely to leave their role (OR 0.94, 95% CI .92-.96, p < 0.001). CONCLUSION: Healthcare organisations can improve job satisfaction and decrease intention to leave by creating environments in which ANPs are supported by their colleagues and supervisors, and facilitate their practice to the full extent of their capabilities.

Reducing challenging behaviours among children and adolescents with intellectual disabilities in community settings: a systematic review of interventions.

Background: Challenging behaviours are common among children and adolescents with intellectual disabilities. Such behaviours often result in poor quality of life outcomes such as physical injury, difficulties with relationships and community integration. Aim: This systematic review aimed to synthesise evidence from studies that assessed the effect of interventions used to reduce/manage challenging behaviour among children with intellectual disabilities in community settings. Methods: Studies published between January 2015 and January 2021 were sought from five electronic databases. The quality of studies was assessed, and a narrative synthesis was conducted. Results: A total of 11 studies were included which utilised various non-pharmacological interventions including multi-model interventions, microswitch technology, cognitive behavioural therapy, art, music and illustrated stories. Microswitch cluster technology was the most used intervention. Studies using pharmacological interventions were not retrieved. Results indicated that a person-centred planning approach was key to offering individualised treatment. Conclusions: The superiority of one intervention or a combination of interventions could not be determined from this review given the heterogeneity of studies. Future research is required to explore the use and effects of pharmacological interventions to compare outcomes and improve quality of care of children with intellectual disabilities.

Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study.

OBJECTIVES: Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021. DESIGN: We conducted a secondary data analysis with a quasi-experimental design. SETTING: We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'. PRIMARY AND SECONDARY OUTCOME MEASURES: We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis. PARTICIPANTS: We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021. RESULTS: 40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001). CONCLUSIONS: A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

Patient-Reported Satisfaction with Thyroid Hormone Replacement Therapy for Subclinical Hypothyroidism in Older Adults: A Pooled Analysis of Individual Participant Data from Two Randomized Controlled Trials.

Background: The benefit of levothyroxine treatment of subclinical hypothyroidism (SCH) is subject to debate. This study compared treatment satisfaction between older adults with SCH using levothyroxine or placebo. Methods: We analyzed pooled individual participant data from two randomized, double-blind, placebo-controlled trials investigating the effects of levothyroxine treatment in older adults with SCH. Community-dwelling participants aged ≥65 years, with SCH (persistent thyrotropin levels 4.60-19.99 mIU/L for >3 months and normal free T4 level), were included. Intervention dose titration until thyrotropin levels normalized, with a mock dose adjustment of placebo. Treatment satisfaction was determined during the final study visit using the Treatment Satisfaction Questionnaire for Medication (TSQM), encompassing perceived effectiveness, side effects, convenience, and global satisfaction, along with the participants' desire to continue study medication after the trial. Results: We included 536 participants. At baseline, the median (interquartile range [IQR]) age was 74.9 (69.7-81.4) years, and 292 (55%) were women. The median (IQR) thyrotropin levels were 5.80 (5.10-7.00) mIU/L at baseline in both groups; at final visit, 4.97 (3.90-6.35) mIU/L in the placebo and 3.24 (2.49-4.41) mIU/L in the levothyroxine group. After treatment, the groups did not differ significantly in global satisfaction (mean difference [CI] -1.1 [-4.5 to 2.1], p = 0.48), nor in any other domain of treatment satisfaction. These results held true regardless of baseline thyrotropin levels or symptom burden. No major differences were found in the numbers of participants who wished to continue medication after the trial (levothyroxine 35% vs. placebo 27%), did not wish to continue (levothyroxine 27% vs. placebo 30%), or did not know (levothyroxine 37% vs. placebo 42%) (p = 0.14). In a subpopulation with high symptom burden from hypothyroid symptoms at baseline, those using levothyroxine more often desired to continue the medication after the trial than those using placebo (mean difference [CI]: -21.1% [-35.6% to -6.5%]). Conclusion: These pooled data from two RCTs showed no major differences in treatment satisfaction between older adults receiving levothyroxine or placebo. This finding has important implications for decision-making regarding initiating levothyroxine treatment for SCH. Our findings generally support refraining from routinely prescribing levothyroxine in older adults with SCH.

The association between nurse staffing and quality of care in emergency departments: A systematic review.

BACKGROUND: The relationship between nurse staffing, skill-mix and quality of care has been well-established in medical and surgical settings, however, there is relatively limited evidence of this relationship in emergency departments. Those that have been published identified that lower nurse staffing levels in emergency departments are generally associated with worse outcomes with the conclusion that the evidence in emergency settings was, at best, weak. METHODS: We searched thirteen electronic databases for potentially eligible papers published in English up to December 2023. Studies were included if they reported on patient outcomes associated with nurse staffing within emergency departments. Observational, cross-sectional, prospective, retrospective, interrupted time-series designs, difference-in-difference, randomised control trials or quasi-experimental studies and controlled before and after studies study designs were considered for inclusion. Team members independently screened titles and abstracts. Data was synthesised using a narrative approach. RESULTS: We identified 16 papers for inclusion; the majority of the studies (n = 10/16) were observational. The evidence reviewed identified that poorer staffing levels within emergency departments are associated with increased patient wait times, a higher proportion of patients who leave without being seen and an increased length of stay. Lower levels of nurse staffing are also associated with an increase in time to medications and therapeutic interventions, and increased risk of cardiac arrest within the emergency department. CONCLUSION: Overall, there remains limited high-quality empirical evidence addressing the association between emergency department nurse staffing and patient outcomes. However, it is evident that lower levels of nurse staffing are associated with adverse events that can result in delays to the provision of care and serious outcomes for patients. There is a need for longitudinal studies coupled with research that considers the relationship with skill-mix, other staffing grades and patient outcomes as well as a wider range of geographical settings. TWEETABLE ABSTRACT: Lower levels of nurse staffing in emergency departments are associated with delays in patients receiving treatments and poor quality care including an increase in leaving without being seen, delay in accessing treatments and medications and cardiac arrest.