The FATHER Model of Loss and Grief After Child's Life-Limiting Illness.

CONTEXT: Loss of a child to a life-limiting condition (LLC) is 1 of the most traumatic life events for parents. Research focusing on fathers' experiences is in its infancy. OBJECTIVES: Using a meta-ethnographic approach, we systematically reviewed the literature around fathers' predeath and postdeath experiences of loss and grief. DATA SOURCES: We searched Medline, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Science Direct, and used the meta-ethnography reporting guidelines; the Preferred Reporting Items for Systematic Reviews and Meta-Analyses; and sampling strategy, type of study, approaches, range of years, limits, inclusion and exclusions, terms used, and electronic sources recommendations. STUDY SELECTION: We used the Guide to Children's Palliative Care and the directory of LLCs to select qualitative articles published up until the end of March 2023 that described fathers' predeath and postdeath experiences of loss and grief after their child's LLC. We excluded studies that failed to differentiate outcomes between mothers and fathers. DATA EXTRACTION: Extracted data included study details, participants' characteristics, response rate, source of participants, method and time of data collection, children's characteristics, and quality assessment. First-order and second-order data were also extracted. RESULTS: Forty studies informed a FATHER model of loss and grief. This highlights both similarities (ambivalence, trauma responses, fatigue, anxiety, unresolved grief, guilt) and distinct features defining the predeath and postdeath experiences of loss and grief. LIMITATIONS: There was a bias toward greater mother participation in research. Specific categories of fathers remain underrepresented in palliative care literature. CONCLUSIONS: Many fathers experience disenfranchised grief and deterioration in mental health after a child's diagnosis and postdeath. Our model opens possibilities for personalized clinical support in the palliative care system for fathers.

Improving Access to Integrated Behavioral Health in a Nurse-Led Federally Qualified Health Center.

INTRODUCTION: All patients of a nurse-led federally qualified health center and faculty practice interested in medication management were automatically referred to the psychiatric mental health nurse practitioner in the clinic. This approach was not sustainable to provide access to patients who needed both simple and complex medication management. Thus, a search for a new care model that also focused on the full-scope practice of a psychiatric RN was initiated. AIMS: The specific aims of this project were to create a fully integrated, nurse-led model of a psychiatric nurse practitioner and behavioral health care team within primary care to facilitate (1) patients receiving an appropriate level of care and (2) care team members performing at the top of their scope of practice. METHODS: The guiding model for process implementation was Rapid Cycle Quality Improvement. Three task forces were established to develop interventions in the areas of Roles and Responsibilities, Training and Implementation, and the electronic health record. RESULTS: The process measures of referrals to the psychiatric care team and psychiatric assessment intakes performed as expected. Both measures were higher at the onset of the project and lower 1 year later. The outcome indicator, number of case reviews, increased dramatically over time. CONCLUSIONS: For psychiatric nurse practitioners, this quality improvement effort provides evidence that a consultative role can be effective in supporting primary care providers. Through providing education, establishing patient tiers, and establishing an effective workflow, more patients may have access to psychiatric services.

Impact of mode of training and recertification on ALSFRS-R rater performance.

OBJECTIVE: The ALS Functional Rating Scale-Revised (ALSFRS-R) is the most frequent primary outcome measure in ALS trials. The reliable and accurate performance of this instrument is critical. The Barrow Neurological Institute Clinical Research Organization (BNI-CRO) has been performing evaluator training and certification for the ALSFRS-R since 2011. Here we evaluate the impact of evaluator training and participant practice. METHODS: Training records were reviewed for evaluators trained and certified by the BNI-CRO at least twice since 2011. We determined the impact of training intervals on ease of recertification. We also assessed whether the mode of training impacted successful vignette scoring. For self-reported participant assessment, remote training was provided by BNI CRO personnel; we determined whether there was a practice effect on reliable assessment. RESULTS: 117 evaluators completed at least two training sessions either via interactive in-person training, interactive remote training, or by completing a self-training module. Poorer performance on retraining was noted when the interval between pieces of training was 2 years or greater. Mode of training also impacted performance; interactive in-person and remote sessions were associated with better performance than the use of self-training modules. For participant self-assessment, week-week variability in ALSFRS-R scores declined over time as the study progressed. CONCLUSIONS: Standard training of evaluators has an impact on the performance of the ALSFRS-R, with shorter intervals between training positively impacting performance. Interactive training sessions allowing for real-time questions also are associated with better performance. Continued training is important to maintain a high-quality ALSFRS-R assessment.

Microbial pretreatment of biomass: potential for reducing severity of thermochemical biomass pretreatment.

Typical pretreatment requires high-energy (steam and electricity) and corrosion-resistant, high-pressure reactors. A review of the literature suggests that fungal pretreatment could potentially lower the severity requirements of acid, temperature and time. These reductions in severity are also expected to result in less biomass degradation and consequently lower inhibitor concentrations compared to conventional thermochemical pretreatment. Furthermore, potential advantages of fungal pretreatment of agricultural residues, such as corn stover, are suggested by its effectiveness in improving the cellulose digestibility of many types of forage fiber and agricultural wastes. Our preliminary tests show a three- to five-fold improvement in enzymatic cellulose digestibility of corn stover after pretreatment with Cyathus stercoreus; and a ten- to 100-fold reduction in shear force needed to obtain the same shear rate of 3.2 to 7 rev/s, respectively, after pretreatment with Phanerochaete chrysosporium.

Carbon mass balance evaluation of cellulase production on soluble and insoluble substrates.

A methodology is described and applied for performing carbon mass balances across cellulase enzyme production processes using both soluble sugar and insoluble cellulose substrates. The fungus Trichoderma reesei was grown on either glucose, lactose, or cellulose in aerobic batch mode, and the evolution of the main carbonaceous components (cell mass, cellulose, soluble protein, adsorbed protein, sugars, and carbon dioxide) was followed. A variety of analytical techniques were utilized to measure these components, including (i) gravimetric analysis, (ii) near-infrared spectroscopy, (iii) bicinchoninic acid based soluble protein measurement, (iv) gas mass spectrometry and flow rate, (v) CHNS/O elemental analyses, and (vi) high-performance liquid chromatography. The combined set of measurements allowed carbon mass balances across the cellulase production process to be assessed to determine the consistency of the underlying kinetic data. Results demonstrate the capability to determine the levels and distribution of all major carbonaceous components during the cellulase production process on both soluble and insoluble substrates. Average carbon mass balance closures were near 100% during early stages (<72 h) of the cultivations using glucose, lactose, or cellulose as the substrates, but carbon mass closures trended high later in the cultivation. Analysis of carbon allocation results suggests that an error in the gas mass flow rate measurement was the primary cause for carbon mass balance closures to exceed 110% late in the process.

Use of measurement uncertainty analysis to assess accuracy of carbon mass balance closure for a cellulase production process.

Closing carbon mass balances is a critical and necessary step for verifying the performance of any conversion process. We developed a methodology for calculating carbon mass balance closures for a cellulase production process and then applied measurement uncertainty analysis to calculate 95% confidence limits to assess the accuracy of the results. Cellulase production experiments were conducted in 7-L fermentors using Trichoderma reesei grown on pure cellulose (Solka-floc), glucose, or lactose. All input and output carbon-containing streams were measured and carbon dioxide in the exhaust gas was quantified using a mass spectrometer. On Solka-floc, carbon mass balances ranged from 90 to 100% closure for the first 48 h but increased to 101 to 135% closure from 72 h to the end of the cultivation at 168 h. Carbon mass balance closures for soluble sugar substrates ranged from 92 to 127% over the entire course of the cultivations. The 95% confidence intervals (CIs) for carbon mass balance closure were typically +/-11 to 12 percentage points after 48 h of cultivation. Many of the carbon mass balance results did not bracket 100% closure within the 95% CIs. These results suggest that measurement problems with the experimental or analytical methods may exist. This work shows that uncertainty analysis can be a useful diagnostic tool for identifying measurement problems in complex biochemical systems.