Changes in the Composition of the Gut Microbiota and the Blood Transcriptome in Preterm Infants at Less than 29 Weeks Gestation Diagnosed with Bronchopulmonary Dysplasia.

Bronchopulmonary dysplasia (BPD) is a common chronic lung condition in preterm infants that results in abnormal lung development and leads to considerable morbidity and mortality, making BPD one of the most common complications of preterm birth. We employed RNA sequencing and 16S rRNA gene sequencing to profile gene expression in blood and the composition of the fecal microbiota in infants born at <29 weeks gestational age and diagnosed with BPD in comparison to those of preterm infants that were not diagnosed with BPD. 16S rRNA gene sequencing, performed longitudinally on 255 fecal samples collected from 50 infants in the first months of life, identified significant differences in the relative levels of abundance of Klebsiella, Salmonella, Escherichia/Shigella, and Bifidobacterium in the BPD infants in a manner that was birth mode dependent. Transcriptome sequencing (RNA-Seq) analysis revealed that more than 400 genes were upregulated in infants with BPD. Genes upregulated in BPD infants were significantly enriched for functions related to red blood cell development and oxygen transport, while several immune-related pathways were downregulated. We also identified a gene expression signature consistent with an enrichment of immunosuppressive CD71+ early erythroid cells in infants with BPD. Intriguingly, genes that were correlated in their expression with the relative abundances of specific taxa in the microbiota were significantly enriched for roles in the immune system, suggesting that changes in the microbiota might influence immune gene expression systemically.IMPORTANCE Bronchopulmonary dysplasia (BPD) is a serious inflammatory condition of the lung and is the most common complication associated with preterm birth. A large body of evidence now suggests that the gut microbiota can influence immunity and inflammation systemically; however, the role of the gut microbiota in BPD has not been evaluated to date. Here, we report that there are significant differences in the gut microbiota of infants born at <29 weeks gestation and subsequently diagnosed with BPD, which are particularly pronounced when infants are stratified by birth mode. We also show that erythroid and immune gene expression levels are significantly altered in BPD infants. Interestingly, we identified an association between the composition of the microbiota and immune gene expression in blood in early life. Together, these findings suggest that the composition of the microbiota may influence the risk of developing BPD and, more generally, may shape systemic immune gene expression.

Effect of Joint Commission International Accreditation on the Nursing Work Environment in a Tertiary Medical Center.

How might a tertiary hospital's nursing staff respond to the huge improvement effort required for external accreditation if they are encouraged to lead the change process themselves? This article reports the results of a concurrent evaluation of the nursing work climate at ward level, before and after accreditation by the Joint Commission International. Physician-nurse relations improved; the involvement of social workers, dieticians, and physiotherapists increased; support services responded more quickly to requests; and management-line staff relations became closer.

Computerization and its contribution to care quality improvement: the nurses' perspective.

BACKGROUND: Despite the widely held belief that the computerization of hospital medical systems contributes to improved patient care management, especially in the context of ordering medications and record keeping, extensive study of the attitudes of medical staff to computerization has found them to be negative. The views of nursing staff have been barely studied and so are unclear. The study reported here investigated the association between nurses' current computer use and skills, the extent of their involvement in quality control and improvement activities on the ward and their perception of the contribution of computerization to improving nursing care. The study was made in the context of a Joint Commission International Accreditation (JCIA) in a large tertiary medical center in Israel. The perception of the role of leadership commitment in the success of a quality initiative was also tested for. METHODS: Two convenience samples were drawn from 33 clinical wards and units of the medical center. They were questioned at two time points, one before the JCIA and a second after JCIA completion. Of all nurses (N=489), 89 were paired to allow analysis of the study data in a before-and-after design. Thus, this study built three data sets: a pre-JCIA set, a post-JCIA set and a paired sample who completed the questionnaire both before and after JCIA. Data were collected by structured self-administered anonymous questionnaire. RESULTS: After the JCIA the participants ranked the role of leadership in quality improvement, the extent of their own quality control activity, and the contribution of computers to quality improvement higher than before the JCIA. Significant Pearson correlations were found showing that the higher the rating given to quality improvement leadership the more nurses reported quality improvement activities undertaken by them and the higher nurses rated the impact of computerization on the quality of care. In a regression analysis quality improvement leadership and computer use/skills accounted for 30% of the variance in the perceived contribution of computerization to quality improvement. CONCLUSIONS: (a) The present study is the first to show a relationship between organizational leadership and computer use by nurses for the purpose of improving clinical care. (b) The nurses' appreciation of the contribution computerization can make to data management and to clinical care quality improvement were both increased by the JCI accreditation process.

Polypharmacy in dermatology: analysis of a nationally representative sample of 46,273 dermatology patient visits in the United States from 1995 to 2009.

There are no large-scale studies ofpolypharmacy (PP) in dermatology. The authors examined trends in PP (simultaneous use of > or = 4 medications in our study) and associated clinical factors among a nationally representative sample of 46,273 (weighted count +/- standard error [SE]: 617,970,596 +/- 25,187,959) dermatology-related (International Classification of Diseases, Ninth Revision, Clinical Modification codes 680-709) patient visits from 1995 to 2009. Data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey were examined. The overall frequency (+/- SE) of PP was 8.9% +/- 0.4%. There was almost a doubling in the frequency of PP in dermatology from 1995 to 2009 (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.67-2.44, after controlling for comorbidities and sex). This increase was noted among patients with > 1 diagnoses, and all age groups including the younger than 25 age category (PP frequency +/- SE, 7.4% +/- 0.4%; OR, 1.45; 95% CI, 1.12-1.88), and not just among patients in the geriatric age range with multiple complex dermatologic problems. Some of the most frequent conditions in the PP group included acne, psoriasis, atopic dermatitis, and infections of the skin and subcutaneous tissue, conditions that are known to be affected by psychodermatologic factors. PP among these patients may in part be an indication of their complex presentation caused by psychosocial vs dermatopathologic factors.

Moral distress and structural empowerment among a national sample of Israeli intensive care nurses.

AIM: The aim of this study was to determine levels of structural empowerment, moral distress, and the association between them among intensive care nurses. BACKGROUND: Structural empowerment is the ability to access sources of power. Moral distress is the painful feelings experienced when a person knows the right thing to do but cannot do so due to external constraints. Several studies suggest a theoretical relationship between these concepts. DESIGN: Cross-sectional, descriptive correlational study. METHODS: Members of the Evidence Based Nursing Practice Committee of the Israeli Society for Cardiology and Critical Care Nurses recruited a convenience sample of intensive care nurses from their respective institutions and units. Nurses were asked to complete three questionnaires (demographic and work characteristics, Moral Distress Scale, and the Conditions of Work Effectiveness Questionnaire-II). Data were collected between May-September 2009. RESULTS: Intensive Care nurses had moderate levels of structural empowerment, low levels of moral distress frequency, and moderately high moral distress intensity. A weak correlation was found between moral distress frequency and structural empowerment. No other structural empowerment component was associated with moral distress. Work characteristics as opposed to demographic characteristics were more associated with the study variables. CONCLUSIONS: This study weakly supports the association between structural empowerment and moral distress. It also provides further evidence to the theory of structural empowerment as characterized in the critical care environment. Further studies are indicated to determine what other factors might be associated with moral distress.

Pretend play of children with acquired brain injury: an exploratory study.

OBJECTIVE: This exploratory study aimed to describe the self-initiated pretend play of three children who had sustained an acquired brain injury (ABI). No previous research was found. METHODS: Three children aged 3.0-6.0 years were recruited through purposive sampling. Pretend play ability was assessed using the Child-Initiated Pretend Play Assessment. RESULTS: Two of the three children scored below the range expected for children their age and one child scored above the range, indicating a wide range of pretend play ability for the children. None of the children could sustain their engagement in pretend play to complete the time of the assessment. CONCLUSION: Complex pretend play ability is a functional assessment of cognitive ability involving sequential planning, problem-solving, language and social understanding. Cognitive fatigue is argued to explain the children's limited ability to engage in play for the time expected for their ages. More research is required.

ICU nurses' oral-care practices and the current best evidence.

PURPOSE: The purpose of this study was to describe the oral-care practices of ICU nurses, to compare those practices with current evidence-based practice, and to determine if the use of evidence-based practice was associated with personal demographic or professional characteristics. DESIGN: A national survey of oral-care practices of ICU nurses was conducted using a convenience sample of 218 practicing ICU nurses in 2004-05. The survey instrument included questions about demographic and professional characteristics and a checklist of oral-care practices. Nurses rated their perceived level of priority concerning oral care on a scale from 0 to 100. A score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with the current best evidence. This score was then statistically analyzed using ANOVA to determine differences of EBP based on demographic and professional characteristics. FINDINGS: The most commonly used equipment was gauze pads (84%), followed by tongue depressors (55%), and toothbrushes (34%). Chlorhexidine was the most common solution used (75%). Less than half (44%) reported brushing their patients' teeth. The majority performed an oral assessment before beginning oral care (71%); however, none could describe what assessment tool was used. Only 57% of nurses reported documenting their oral care. Nurses rated oral care of intubated patients with a priority of 67+/-27.1. Wide variations were noted within and between units in terms of which techniques, equipment, and solutions were used. No significant relationships were found between the use of an evidence-based protocol and demographic and professional characteristics or with the priority given to oral care. CONCLUSIONS: While nurses ranked oral care a high priority, many did not implement the latest evidence into their current practice. The level of research utilization was not related to personal or professional characteristics. Therefore attempts should be made to encourage all ICU nurses to introduce and use evidence-based, oral-care protocols. CLINICAL RELEVANCE: Practicing ICU nurses in this survey were often not adhering to the latest evidence-based practice and therefore need to be educated and encouraged to do so in order to improve patient care.