Sustaining telehealth among cardiac and pulmonary rehabilitation services: a qualitative framework study.

AIMS: As we move into a new phase of the COVID-19 pandemic, cardiac and pulmonary services are considering how to sustain telehealth modalities long-term. It is important to learn from services that had greater telehealth adoption and determine factors that support sustained use. We aimed to describe how telehealth has been used to deliver cardiac and pulmonary rehabilitation services across Queensland, Australia. METHODS AND RESULTS: Semi-structured interviews (n = 8) and focus groups (n = 7) were conducted with 27 cardiac and pulmonary clinicians and managers from health services across Queensland between June and August 2021. Interview questions were guided by Greenhalgh's Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework. Hybrid inductive/deductive framework analysis elicited six main themes: (i) Variable levels of readiness; (ii) Greater telehealth uptake in pulmonary vs. cardiac rehabilitation; (iii) Safety and risk management; (iv) Client willingness-targeted support required; (v) Equity and access; and (vi) New models of care. We found that sustained integration of telehealth in cardiac and pulmonary rehabilitation will require contributions from all stakeholders: consumers (e.g. co-design), clinicians (e.g. shared learning), health services (e.g. increasing platform functionality), and the profession (e.g. sharing resources). CONCLUSION: There are opportunities for telehealth programmes servicing large geographic areas and opportunities to increase programme participation rates more broadly. Centralized models of care serving large geographic areas could maximize sustainability with current resource limitations; however, realizing the full potential of telehealth will require additional funding for supporting infrastructure and workforce. Individuals and organizations both have roles to play in sustaining telehealth in cardiac and pulmonary services.

Benchmarking service provision, scope of practice, and skill mix for physiotherapists in adult cystic fibrosis care delivery.

BACKGROUND: Increasing age, numbers, and complexity of care are potentially impacting physiotherapy service delivery for adults with cystic fibrosis (CF). PURPOSE: This study aimed to describe physiotherapy service provision, scope of practice, and skill mix in a large tertiary adult CF center, and determine if services were meeting clinical practice recommendations. METHODS: A prospective cross-sectional study examined inpatient and outpatient physiotherapy care across a three-month period in a tertiary adult CF center. Physiotherapy services were described by number and skill level of physiotherapists, total hours of activity, and number, type, and duration of each physiotherapy activity. RESULTS: Twenty-two physiotherapists provided care. Respiratory (n = 1058, 38%), and exercise treatments (n = 338, 12%) were the most frequent. Exercise testing (n = 20, 1%), and detailed treatment reviews (n = 79, 3%) occurred infrequently. Time for research was limited. Junior physiotherapists undertook more exercise treatments per day (p < .01), with senior physiotherapists attending outpatient clinics (p < .01). CONCLUSION: A large number of physiotherapists were involved in the delivery of services. Recommended respiratory and exercise treatments were frequently provided; however, other recommended activities occurred infrequently. The impact of increasing age, numbers of patients, and complexity of care may be contributing to demand exceeding supply for physiotherapy services. Future studies are required to determine innovative approaches to address the gaps in clinical practice recommendations.

Assessing Learning in College Economics: A Sixth National Quinquennial Survey.

This article presents the first report of basic assessment method findings from the 2020 national quinquennial survey on teaching and assessment methods in college economics. Focused on the methods used in the same four types of economics courses surveyed since 1995, the authors find that the primary assessment method in introductory courses remains multiple-choice examinations, with their average weight in determining students' grades increasing since 2010. Intermediate theory, statistics and econometrics, and other upper-division field economics courses rely primarily on short-answer exam questions for determining students' grades. Overall, the authors report notable changes in assessing learning in college economics, with a more balanced approach to using different assessment methods in upper-division economics courses as compared to other economics courses.

Physiotherapy service provision in a specialist adult cystic fibrosis service: A pre-post design study with the inclusion of an allied health assistant.

What is the impact of including an allied health assistant (AHA) role on physiotherapy service delivery in an acute respiratory service? A pragmatic pre-post design study examined physiotherapy services across two 3-month periods: current service delivery [P1] and current service delivery plus AHA [P2]. Clinical and non-clinical activity quantified as number, type and duration (per day) of all staff activity categorised for skill level (AHA, junior, senior). Physiotherapy service delivery increased in P2 compared to P1 (n = 4730 vs n = 3048). Physiotherapists undertook fewer respiratory (p < 0.001) and exercise treatments (p < 0.001) but increased reviews for inpatients (p < 0.001) and at multidisciplinary clinics in P2 (56% vs 76%, p < 0.01). The AHA accounted for 20% of all service provision. AHA activity comprised mainly non-direct clinical care including oversight of respiratory equipment use (e.g. supply, set-up, cleaning, loan audits) and other patient-related administrative tasks associated with delegation handovers, supervision and clinical documentation (72%), delegated supervision of established respiratory (5%) and exercise treatments (10%) and delegated exercise tests (3%). The AHA completed most of the exercise tests (n = 25). AHA non-direct clinical tasks included departmental management activities (11%). No adverse events were reported. AHA inclusion in an acute respiratory care service changed physiotherapy service provision. The AHA completed delegated routine clinical and non-clinical tasks. Physiotherapists increased clinic activity and annual reviews. Including an AHA role offers sustainable options for enhancing physiotherapy service provision in acute respiratory care.

Evidence-Based Care of Children With Tracheostomies: Hospitalization to Home Care.

ABSTRACT: Routine tracheostomy care in children maintains airway patency, minimizes infection, and ensures skin integrity around the tracheostomy stoma to prevent complications. Using evidence-based recommendations for care of the mature tracheostomy limits variation in practice and leads to better patient outcomes in all care settings. Incorporating evidence-based care into practice is especially important because children with tracheostomies are at high risk for morbidity and mortality. The purpose of this review is to summarize the most current, evidence-based literature for pediatric tracheostomy care, including stoma care and tracheostomy suctioning. Rehabilitation nurses can then include these best practices when caring for children with tracheostomies and when educating caregivers who provide tracheostomy care to children at home.

Nurses' Perceptions of Rooming-in for Caregivers of Infants with CCHD.

Congenital heart disease (CHD) is the most common congenital defect. Infants with critical congenital heart disease (CCHD) require complex medical care, and their caregivers need extensive training before being discharged home to safely care for their child. The rooming-in process provides caregivers with an opportunity to learn, practice, and manage the skills required for discharge to home during hospitalization. Although the literature reflects positive implications for the use of the rooming-in process in other populations (e.g., neonatal abstinence syndrome), literature about the rooming-in process in a pediatric cardiac care setting is limited. There remains a gap in the literature pertaining to the viewpoints of nurses, specifically as it relates to implementing a rooming-in process. Therefore, a qualitative study design was chosen to explore the nurses' perceptions of the rooming-in process using focus groups. The purpose of this study was to gain insight from nurses as to strategies to enhance the rooming-in process for caregivers of infants with CCHD. Additionally, we explored potential education and interventions to improve outcomes for infants with CCHD preparing to be discharged home.

Improving the Safety of an Emergency Department-Based Direct Admission Process at a Children's Hospital.

OBJECTIVES: Direct admission refers to admitting a patient to a unit avoiding usual entry points such as the emergency department. Inappropriate placement of direct admissions can result in rapid response activations, codes and unanticipated pediatric intensive care unit (PICU) transfers, which correlate with higher mortality and longer lengths of stay. The objective of the project was to improve the safety of the direct admission process as evidenced by decreasing the transfer of direct admission patients to the PICU within 6 hours. METHODS: Utilizing the model for improvement, a multidisciplinary team was assembled to improve our screening process and reduce unanticipated direct admission-to-PICU transfers within 6 hours of arrival. Our emergency department-based direct admission process includes screening vital signs (temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry) and a Pediatric Early Warning Score. Five Plan-Do-Study-Act cycles focused on role definition, improved documentation, referring facility and family awareness, improved visual management within the ED, and education of partner EMS and transport providers. The primary outcome was PICU transfer within 6 hours of direct admission arrival. Compliance with full screening was a process measure and number of direct admissions a balancing measure. Statistical process control charts and run charts were used to follow the measures. RESULTS: The total number of direct admissions from January 2014 to the end of data collection, June 2018, was 3070 patients. Screening protocol compliance improved from 56% to over 80% for the entire hospital. Unanticipated direct admission-to-PICU transfers decreased from a baseline of 1 every 98 patients to a special cause of 1 in 1126 patients. CONCLUSIONS: By utilizing QI methodology our team was able to implement and sustain a direct admission process that was more consistent, easier to document and improved the safety of our patients. Our study demonstrates that screening direct admissions reliably and consistently can decrease the rate of unanticipated transfer to a higher level of care.

Establishing fidelity for the creating opportunities for personal empowerment: Symptom and technology management resources (COPE-STAR) intervention.

AIM: To establish intervention fidelity for the Creating Opportunities for Personal Empowerment: Symptom and Technology Management Resources web-based intervention to assist caregivers of children aged 1-5 years in managing their child's symptoms and medical technology of tracheostomies and feeding tubes at home. DESIGN: Descriptive study of the strategies used to establish intervention fidelity, specifically using expert and caregiver reviewers. METHODS: To establish fidelity of the intervention, experts and caregivers were asked to evaluate the usefulness, ease of use, and acceptability of the intervention and provide any suggestions for the modules. Caregivers provided caregiver and child characteristics and were administered a health literacy measure, the Newest Vital Sign. Intervention fidelity was established from April 2019-July 2019. RESULTS/FINDINGS: Expert and caregiver reviewers (N = 13) all agreed or strongly agreed that the intervention was useful, easy to use, and acceptable. In addition, caregiver reviewers provided care to children who required multiple technologies and a variety of care needs at home and confirmed adequate health literacy (N = 5). CONCLUSION: The use of expert and caregiver reviewers was very beneficial in establishing intervention fidelity. Caregivers are experts in the care of their child and provide valuable feedback based on their daily experiences at home. Experts provided evidence-based feedback. IMPACT: This nursing intervention addresses caregivers of children who require medical technology by targeting caregiver management for common symptoms, related technologies, and resources for the child and caregiver in the home setting. Intervention fidelity was established and expert and caregiver reviewers confirmed the usefulness, ease of use, and acceptability of the intervention. This study is essential to nursing, other healthcare providers, and healthcare systems in planning and implementing programmes and services for children and their caregivers and for nurse researchers establishing intervention fidelity. TRIAL REGISTRATION: This study is not designated as a clinical trial per NIH/NINR study and grant proposal guidelines.

A Previously Healthy Adolescent With Acute Encephalopathy and Decorticate Posturing.

A 14-year-old previously healthy female was transferred from a local emergency department after being found unresponsive at home. Parental questioning revealed she had fever and pharyngitis 2 weeks before presentation. Past mental health history was negative, including concern for past or present suicidal ideation/attempts, suspected substance use, or toxic ingestion. In the emergency department, she was orotracheally intubated due to a Glasgow Coma Scale of 3. She was hemodynamically stable and euglycemic. Electrocardiogram showed sinus tachycardia. She underwent a noncontrast head computed tomography that was normal and subsequently underwent a lumbar puncture. She had a seizure and was given a loading dose of diazepam and fosphenytoin that led to cessation of extremity movements. She was subsequently transferred to the PICU for additional evaluation. Initial examination without sedation or analgesia demonstrated dilated and minimally responsive pupils, intermittent decorticate posturing, and bilateral lower extremity rigidity and clonus, consistent with a Glasgow Coma Scale of 5. Serum studies were unremarkable with the exception of mild leukocytosis. Chest radiograph only showed atelectasis. She was empirically started on antibiotics to cover for meningitis pending final cerebral spinal fluid test results. The pediatric neurology team was consulted for EEG monitoring, and the patient was eventually sent for computed tomography angiogram and magnetic resonance angiogram/venogram. We will review diagnostic evaluation and management of an adolescent patient with acute encephalopathy with decorticate posturing of unclear etiology.

Prevalence and impact of pelvic floor dysfunction in an adult cystic fibrosis population: a questionnaire survey.

INTRODUCTION AND HYPOTHESIS: Pelvic floor (PF) dysfunction in patients with cystic fibrosis (CF) is poorly understood due to lack of research. The aim of this study was to examine the prevalence, risk factors and bothersomeness of PF dysfunction and its implications for the clinical management of CF. METHODS: Of 64 adults with CF approached at a tertiary hospital, 60 were surveyed. A clinically meaningful score on the Australian Pelvic Floor Questionnaire (APFQ) is ≥1 in each of the bladder, bowel, sexual function and prolapse sections or a global PF score of ≥3. A frequency Likert scale was used to analyse the impact of PF dysfunction on the ability to perform physiotherapy lung management when well and unwell. RESULTS: The prevalence of clinically meaningful bladder dysfunction was 39 % in women and 12 % in men, the prevalence of bowel dysfunction was 54 % in women and 44 % in men, and the prevalence of sexual dysfunction was 43 % in women and 65 % in men. APFQ scores were clinically meaningful only for bowel dysfunction in women (median 1.47, IQR 0.59 - 2.28). PF dysfunction constrains lung management in up to 22 % of patients when well and in 37 % of patients when unwell. CONCLUSIONS: PF dysfunction affects the adult CF population, with PF symptoms limiting the ability of up to one in three patients to participate in physiotherapy management.

Neural mechanisms associated with food motivation in obese and healthy weight adults.

One out of three adults in the United States is clinically obese. Excess food intake is associated with food motivation, which has been found to be higher in obese compared to healthy weight (HW) individuals. Little is known, however, regarding the neural mechanisms associated with food motivation in obese compared to HW adults. The current study used functional magnetic resonance imaging (fMRI) to examine changes in the hemodynamic response in obese and HW adults while they viewed food and nonfood images in premeal and postmeal states. During the premeal condition, obese participants showed increased activation, compared to HW participants, in anterior cingulate cortex (ACC) and medial prefrontal cortex (MPFC). Moreover, in the obese group, self-report measures of disinhibition were negatively correlated with premeal ACC activations and self-report measures of hunger were positively correlated with premeal MPFC activations. During the postmeal condition, obese participants also showed greater activation than HW participants in the MPFC. These results indicate that brain function associated with food motivation differs in obese and HW adults and may have implications for understanding brain mechanisms contributing to overeating and obesity, and variability in response to diet interventions.

An fMRI study examining effects of acute D-cycloserine during symptom provocation in spider phobia.

BACKGROUND: Exposure-based therapy for anxiety disorders is believed to operate on the basis of fear extinction. Studies have shown acute administration of D-cycloserine (DCS) enhances fear extinction in animals and facilitates exposure therapy in humans, but the neural mechanisms are not completely understood. To date, no study has examined neural effects of acute DCS in anxiety-disordered populations. METHODS: Two hours prior to functional magnetic resonance imaging scanning, 23 spider-phobic and 23 non-phobic participants were randomized to receive DCS 100 mg or placebo. During scanning, participants viewed spider, butterfly, and Gaussian-blurred baseline images in a block-design paradigm. Diagnostic and treatment groups were compared regarding differential activations to spider versus butterfly stimuli. RESULTS: In the phobic group, DCS enhanced prefrontal (PFC), dorsal anterior cingulate (ACC), and insula activations. For controls, DCS enhanced ventral ACC and caudate activations. There was a positive correlation between lateral PFC and amygdala activation for the placebo-phobic group. Reported distress during symptom provocation was correlated with amygdala activation in the placebo-phobic group and orbitofrontal cortex activation in the DCS-phobic group. CONCLUSIONS: Results suggest that during initial phobic symptom provocation DCS enhances activation in regions involved in cognitive control and interoceptive integration, including the PFC, ACC, and insular cortices for phobic participants.

Application of ecological models to risks related to being overweight among nurses.

This paper provides a discussion of environmental strategies to improve health behaviors of nurses. Behavioral choices, partly due to social and environmental factors, influence risk of chronic disease. Strategies that modify environments are critical components of public health interventions, particularly those concerned with improving diet and physical activity. Nurses' health behaviors may be especially important, due to their influence as models when caring for patients. Modifications in work environments may enable nurses to acquire and maintain healthy behaviors.

Cloning of human agmatinase. An alternate path for polyamine synthesis induced in liver by hepatitis B virus.

Agmatinase, which hydrolyzes agmatine to putrescine and urea, not only represents a potentially important mechanism for regulating the biological effects of agmatine in mammalian cells but also represents an alternative to ornithine decarboxylase for polyamine biosynthesis. We have isolated a full-length cDNA encoding human agmatinase whose function was confirmed by complementation in yeast. The single-copy human agmatinase gene located on chromosome 1 encodes a 352-residue protein with a putative mitochondrial targeting sequence at the NH(3)-terminus. Human agmatinase has about 30% identity to bacterial agmatinases and <20% identity to mammalian arginases. Residues required for binding of Mn(2+) at the active site in bacterial agmatinase and other members of the arginase superfamily are fully conserved in human agmatinase. Agmatinase mRNA is most abundant in human liver and kidney but also is expressed in several other tissues, including skeletal muscle and brain. Its expression in human liver is induced during hepatitis B virus infection, suggesting that agmatinase may play a role in the pathophysiology of this disease.