Constipation in palliative care: treatment options and considerations for individual patient management.

Constipation is an all too common symptom in palliative care patients and may be associated with a range of severe issues and experiences. Its effects on patients contribute to both physical and psychological scarring during a very distressing stage of life not only for the patient but also for their caregivers. It is during this time that, too often, the complexity of managing the condition moves the locus of control away from the patient toward the health professionals. This article considers a number of different treatment options and facets of individual management that may enable patients to move the locus of control back to a position of joint management by patients, caregivers, and health professionals.

Constipation management in palliative care: treatments and the potential of independent nurse prescribing.

Constipation is a common symptom in palliative care patients that can generate considerable suffering owing to both the inherent physical discomfort and the attendant psychological issues such as embarrassment. This article considers the management of constipation for palliative care patients, including the importance of the patient's own definition of their problem, the need for thorough and frequent assessment, established treatment options, and the challenges that nurses may face. It provides a simple algorithm to assist in the management process, and also looks at the current strength of the evidence base for two more recent therapies. Finally, it examines the potential of the independent nurse prescriber (INP) for constipation management in the UK, using a brief case study to illustrate a commonly experienced constipation management scenario for the INP in the community setting.

On the Record: An Innovative Simulation Teaching Resource to Teach Undergraduate Nurses How to Write Legally Defensible Patient Documents.

BACKGROUND: Good patient documentation writing skills are an essential component of a nurse's portfolio to satisfy the professional and legal requirements of record keeping. Traditionally, however, documentation is viewed as a dry topic as it is not always applied well to practical situations; therefore, this topic readily lends itself to being delivered in an innovative and engaging way. This pilot study used a low fidelity simulated "courtroom" session to teach this essential nursing skill to undergraduate nurses. METHOD: The pilot study took place with three cohorts of undergraduate nurses (n = 200) from all four fields of nursing in the second year of a 3-year Bachelor of Science nursing program. RESULTS: These results were captured in a variety of ways and evaluated using Kirkpatrick and Kirkpatrick's four-level evaluation model. The results indicated that the simulation engaged and focused students in an interactive way. CONCLUSION: The pilot study results indicated that a move away from traditional didactic teaching to a more customized method of learning accommodates the documented trends of learning styles across different generations. This pilot study has led to a university-wide study involving students and staff from three different faculties. [J Nurs Educ. 2021;60(7):414-418.].

Assessment, diagnosis and management of constipation.

Constipation is a common, treatable condition that can be experienced by all age groups. This article outlines the different types of constipation and explains how the condition is diagnosed. A comprehensive and person-centred assessment is fundamental to identifying constipation, and should include taking the patient's clinical history and discussing any lifestyle factors that may be causing or contributing to the condition. This article also details the pharmacological and non-pharmacological interventions that nurses can employ in the management of constipation, including providing advice on lifestyle changes and the use of laxatives.

Correlation Between Laminar Wall Shear Stress and Growth of Unruptured Cerebral Aneurysms: In Vivo Assessment.

BACKGROUND: Cerebral aneurysm growth is significantly associated with aneurysm rupture, but risk factors for aneurysm growth are not well characterized. It is believed that altered intracranial hemodynamics may contribute to the pathophysiology of aneurysm growth, but these mechanisms are not fully understood. OBJECTIVE: Here, we assess the correlation between growth of unruptured cerebral aneurysms over time and average laminar shear stress on the wall of the parent vessel proximal to the aneurysm. METHODS: Patients with unruptured, untreated cerebral aneurysms followed over time at our institution between 2005 and 2017 were retrospectively reviewed. Patients were included if at least 1 quantitative magnetic resonance angiography study was performed at baseline and follow-up. The nonparametric Wilcoxon-Mann-Whitney test was used to compare mean parent vessel-laminar wall shear stress (PV-LWSS) proximal to the aneurysm in growing versus stable aneurysms. Change in PV-LWSS over time was evaluated using the 1-way repeated measures analysis of variance test. RESULTS: Thirty-three patients with 45 total aneurysms were included (63% female, mean age 60 years). Four patients presented with aneurysm growth over time. Unstable aneurysms had significantly higher PV-LWSS compared with stable aneurysms at the time of first diagnosis (29.3 vs. 13.1 dynes/cm2, P = 0.02) and at 1-year follow-up (25.8 vs. 12.3 dynes/cm2, P = 0.05). CONCLUSIONS: The subset of unruptured cerebral aneurysms that demonstrate growth over time has a significantly higher mean PV-LWSS than stable aneurysms, as measured by quantitative magnetic resonance angiography. This information at the time of diagnosis may help predict future aneurysm growth, stratify rupture risk, and identify those aneurysms that should undergo prophylactic treatment.

Ratio of Arteriovenous Malformation Draining Vein to Adjacent Venous Sinus Diameter Is Associated with Increased Risk of Venous Stenosis.

BACKGROUND: The development of venous outflow stenosis in cerebral arteriovenous malformation (AVM) is poorly understood. The location of stenosis within the AVM draining vein in relation to the adjacent venous sinus and the hypothesis that the ratio of draining vein to adjacent sinus diameter might predict the development of venous stenosis were explored. METHODS: Patients with supratentorial AVMs (1997-2018) were reviewed (N = 290). AVM draining vein and adjacent venous sinus diameters, degree of draining vein stenosis, and distance from the maximal stenotic point to the junction of the adjacent draining sinus were recorded. Correlation between percentage of AVM draining vein stenosis and the ratio of AVM draining vein to venous sinus diameters was analyzed. RESULTS: A total of 360 draining veins in 243 AVMs with complete angiographic data were measured. Venous stenosis (in 131 draining veins) was observed within 20 mm of the junction to the adjacent draining sinus in 85% of our sample. The ratio of draining vein to adjacent sinus diameter correlated positively with the percentage of venous stenosis (P < 0.01, r = 0.21). The ratio between 0.51-1.0 and >1.0 showed significant tighter stenosis compared with the ratio ≤0.5 (25.9% and 28.9% vs. 10.0%, respectively; P < 0.01). CONCLUSIONS: AVM venous outflow stenosis is observed close to the adjacent venous sinus junction. The degree of venous stenosis is greater when the ratio of AVM draining vein/adjacent venous sinus diameter is >0.5. This may be related to more turbulent flow at the junction of the draining vein and venous sinus, especially in larger draining veins, which causes venous stenosis to develop over time.

IMP2ART systematic review of education for healthcare professionals implementing supported self-management for asthma.

Despite a robust evidence base for its effectiveness, implementation of supported self-management for asthma is suboptimal. Professional education is an implementation strategy with proven effectiveness, though the specific features linked with effectiveness are often unclear. We performed a systematic review of randomised controlled trials and controlled clinical trials (published from 1990 and updated to May 2017 using forward citation searching) to determine the effectiveness of professional education on asthma self-management support and identify features of effective initiatives. Primary outcomes reflected professional behaviour change (provision of asthma action plans) and patient outcomes (asthma control; unscheduled care). Data were coded using the Effective Practice and Organisation of Care Taxonomy, the Theoretical Domains Framework (TDF), and Bloom's Taxonomy and synthesised narratively. Of 15,637 articles identified, 18 (reporting 15 studies including 21 educational initiatives) met inclusion criteria. Risk of bias was high for five studies, and unclear for 10. Three of 6 initiatives improved action plan provision; 1/2 improved asthma control; and 2/7 reduced unscheduled care. Compared to ineffective initiatives, effective initiatives were more often coded as being guideline-based; involving local opinion leaders; including inter-professional education; and addressing the TDF domains 'social influences'; 'environmental context and resources'; 'behavioural regulation'; 'beliefs about consequences'; and 'social/professional role and identity'. Findings should be interpreted cautiously as many strategies were specified infrequently. However, identified features warrant further investigation as part of implementation strategies aiming to improve the provision of supported self-management for asthma.

Educating professionals to support self-management in people with asthma or diabetes: protocol for a systematic review and scoping exercise.

INTRODUCTION: Supported self-management for asthma helps people adjust their treatment in response to symptom changes. This improves day-to-day control and reduces the risk of asthma attacks and the need for emergency healthcare. However, implementation remains poor in routine clinical practice. This systematic review is part of a programme of work developing an intervention to help primary care practice teams embed self-management support into routine asthma care. The aim of the review is to synthesise the evidence regarding the effectiveness of educational interventions for professionals supporting self-management in people with asthma or diabetes (type 1 and type 2). These two conditions have the most robust evidence base for the effectiveness of implementing supported self-management. METHODS AND ANALYSIS: Electronic searches will be conducted in CENTRAL, MEDLINE, EMBASE, ISI Web of Science, CINAHL, PsycINFO, AMED, Global Health, WHO Global Health Library, ERIC, BNI, RDRB/CME and Google Scholar. Eligible studies are randomised controlled trials or controlled clinical trials published between 1990 and 2016 which evaluated professional education interventions facilitating asthma or diabetes supported self-management. Further relevant work will be identified from trial registries, citation searching and through contact with authors of included studies. This will be supplemented by scoping potentially relevant educational packages described in English language policy literature or health service websites. Screening, data extraction and risk of bias assessment (using the Cochrane Risk of Bias Tool) will be completed by two independent reviewers, with a third reviewer arbitrating where necessary. We plan a theoretically informed narrative synthesis of the aggregated data as heterogeneity is likely to preclude meta-analysis. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review. The results will be described in a paper submitted for peer-reviewed publication and will inform the development of an implementation intervention. STUDY REGISTRATION NUMBER: PROSPERO CRD42016032922.

Geographic variation of reproductive tactics in lubber grasshoppers.

We investigate plastic and interpopulation variation of trade-offs among reproductive tactics. There is a potential three-way trade-off among timing of reproduction, somatic storage, and investment in reproduction. We tested whether this trade-off shows latitudinal interpopulation variation. We studied populations of the lubber grasshopper, Romalea microptera, from Florida (FL; lowest latitude), Louisiana (LA; intermediate latitude), and Georgia (GA; highest latitude), each tested at three diet levels. All three populations differed in their multivariate responses of the three reproductive tactics we studied. This difference across populations was due primarily to age at first reproduction, secondarily to somatic storage, and less so to clutch mass. Age at first reproduction was least in GA, intermediate in LA, and greatest in FL grasshoppers. Somatic storage was greatest in FL and LA, and least in GA grasshoppers. Clutch mass was greatest in LA and GA, and least in FL grasshoppers. Diet levels also differed in this suite of reproductive tactics, primarily due to variation in age at reproduction. In contrast to significant, independent effects of population and diet, we find no evidence that the trade-off itself varies across populations (as indicated by the non-significant interaction of population and diet level). Thus, we show that the innate allocation of resources among reproductive tactics is different across populations, but all three populations responded similarly to a range of diet levels.

Interpopulation variation in developmental titers of vitellogenin, but not storage proteins, in lubber grasshoppers.

We examined simultaneous plastic and latitudinal interpopulation variation in the time course of hemolymph protein titers during egg production in the lubber grasshopper. Our goal was to gain insight into possible evolutionary changes in the physiology underlying reproductive plasticity. We used lubbers from three locations in the United States (Florida [FL], Louisiana [LA], and Georgia [GA]), each offered three daily food rations. Previous genetic analysis indicated that grasshoppers from FL (the low-latitude population) and GA (the high-latitude population) were phylogenetically closer to each other than to LA grasshoppers (the intermediate-latitude population). The ages at maximum titers of vitellogenin (Vg(max)) and three storage proteins that were referred to as major hemolymph proteins (MHP(max)) were used as indices of the progress of oocyte development. Age at Vg(max) was affected significantly both by diet and by population. Perhaps most importantly, age at Vg(max) was less for GA grasshoppers than for FL and LA grasshoppers; this pattern differs from the phylogenetic relationships of the populations. Age at MHP(max) was significantly affected only by diet and not by population. Hence, the regulation of these proteins may differ across populations. Finally, we found no evidence that plasticity of reproductive investment in response to food availability differs across populations (as indicated by nonsignificant interactions of population and feeding environment).

Developing discharge practice through education: module development, delivery and outcomes.

In England (UK) the discharge of patients from hospital is a source of constant scrutiny from primary care trusts in order to reduce the patient length of stay in Hospital. To support nurses in practice a part time, post registration discharge practice education module was developed entitled Facilitating Timely Patient Discharge. It was the first of its kind to be accredited at degree level (level 6) during 2006. University evaluation of the module involved an academic assignment based on a 3000 word case study. Projects in practice were integrated to enable the students to apply theories to clinical practice. This aspect was driven by an organisational impetus to demonstrate learning back in practice to the benefit of Heart of England Foundation Trust (HEFT). Students self assessed their individual ability pre and post the discharge module using questionnaires citing 17 areas of discharge practice analysing knowledge and ability. They demonstrated an increase in knowledge and ability in key areas such as; 'understanding complex discharge' and 'teaching discharge practice to peers'. Although these were not formally included in the outcomes or evaluations they may inform future module development and design of delivery. The questionnaires were designed and developed with support for projects in practice from the Foundation of Nursing Studies in London.