Use of an adaptive sensory environment in patients with autism spectrum disorder (ASD) in the perioperative environment: a parallel, randomized controlled trial.

Background: Patients with autism spectrum disorders (ASD) experience higher rates of perioperative anxiety and are likely to receive premedication. Little is known about nonpharmaceutical interventions which may decrease anxiety. This study aims to evaluate the use of an adaptive sensory environment (ASE) to reduce ASD patient anxiety during the perioperative process. Methods: Our feasibility study (ClinicalTrials.govNCT04994613) enrolled 60 patients in two parallel groups randomized to a control (no ASE) or intervention group (ASE). We included all surgical patients aged three to twelve years, with a formal diagnosis of ASD, Asperger's Syndrome, or pervasive developmental disorder not otherwise specified. Preoperative behaviors were recorded by an unblinded nurse utilizing the validated Modified Yale Preoperative Anxiety Scale (mYPAS). The difference in score on the mYPAS was the primary outcome, and an intention-to-treat analysis was employed. A generalized estimating equations model was used to compare mYPAS scores controlling for significant independent variables. Findings: 58 patients were analyzed after 1:1 randomization of 30 patients to each group. Groups were balanced except the median number of intraoperative pain medications was significantly lower in the ASE group (1 vs. 3, p = 0.012). Mean (SD) age for all patients was 7.2 (2.9) years, range 2.6-12.7. 72.4% (42/58) were White and all were Non-Hispanic or Latino. 74% were Male (21/30 ASE and 22/28 Control) and 26% were Female (9/30 ASE and 6/28 Control). No differences were found in mYPAS scores between groups at three time periods (43.5 vs. 42, p = 0.88, 47.8 vs. 48.4, p = 0.76, and 36.4 vs. 43.8, p = 0.15, ASE vs. control group, respectively). The ASE group had a significant within-group decrease in mYPAS scores from nursing intake to transition (p = 0.030). Interpretation: An ASE did not significantly reduce perioperative anxiety. However, the promising results deserve further investigation. Funding: Dayton Children's Hospital Foundation Robert C. Cohn Memorial Research Grant.

Improving breastfeeding duration through creation of a breastfeeding-friendly pediatric practice.

BACKGROUND: Breastfeeding is the gold standard for infant feeding. In the United States, 83.2% of women initiate breastfeeding on their infant's birth. When the infant reaches 6 months of age, however, only 57.6% of mothers are still breastfeeding, and a mere 24.9% are breastfeeding exclusively. LOCAL PROBLEM: Breastfeeding rates in rural areas are below the national averages. The greatest disparities exist in minorities and individuals with lower educational and socioeconomic status. METHODS: A preintervention/postintervention design was used for this quality improvement project. The Model for Improvement's Plan, Do, Study, Act cycle guided the project processes. Breastfeeding rates were obtained at each well-child visit from newborn through 4 months of age. On completion, mean preimplementation and postimplementation breastfeeding rates were compared to determine effectiveness. INTERVENTIONS: A breastfeeding support initiative was implemented at a multisite rural Illinois pediatric practice. An evidence-based breastfeeding policy was developed, staff education sessions were conducted, private lactation rooms were created, and breastfeeding photographs/posters were displayed throughout the offices. Lactation support services were publicized via signs and social media postings. RESULTS: Overall breastfeeding rates were higher at each time point after implementation. Statistically significant increases occurred at the newborn and 1-month visits, with a modest improvement at 2 and 4 months. CONCLUSIONS: This project demonstrated an improvement in breastfeeding duration rates. It is anticipated that this practice-wide standard of care change will promote breastfeeding throughout the first 12 months of life.

The impact of an advance care planning intervention for patients hospitalized with acute decompensated heart failure.

BACKGROUND: Many patients with heart failure (HF) have not addressed end-of-life planning. OBJECTIVE: Evaluate the impact of an advance care planning (ACP) intervention on patients hospitalized with acute decompensated HF. METHODS: A convenience sample of patients hospitalized with HF completed the Advance Directive Attitude Survey (ADAS) before The Conversation Project intervention. Post-intervention scores were collected after 30 days. RESULTS: All participants (n = 30) had positive pre-intervention ADAS scores. Post-intervention scores revealed no significant change (p = 0.53). Twenty eight percent completed an advance directive (AD), 64% discussed the AD with a significant other, 40% established a surrogate decision maker, and 12% discussed the AD with a provider. CONCLUSIONS: Advance directive completion rates were low despite participants having positive attitudes regarding their value. Discussion of goals between the patient and significant other is an important factor in end-of-life planning. Further studies are needed on strategies to improve provider discussions and AD completion.

Sexually Transmitted Infections and Human Immunodeficiency Virus.

The human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) are considered epidemics in the United States. Research on the association between STIs and HIV infectiousness and susceptibility has shown that STIs promote HIV acquisition and transmission via mucosal inflammation and ulceration caused by viral or bacterial pathogens. Some of the most common STIs associated with HIV are chlamydia, gonorrhea, syphilis, and herpes simplex virus type 2. STIs are a major cause of morbidity and mortality, particularly if diagnosis or treatment is delayed. Prevention and treatment of both HIV and STIs is essential to ending these associated epidemics.

Management of Chronic Migraine and Occipital Neuralgia in Post 9/11 Combat Veterans.

INTRODUCTION: The rate of chronic migraine (CM) has been shown to be 20% or greater in the post 9/11 combat veteran population with a history of traumatic brain injury, while the rate is much lower at 3-5% in the general population. Studies have shown that medications such as oral topiramate or intramuscular injections of onabotulinum toxin A (Botox) have been used for CM prevention, and occipital blocks have been shown to be helpful in treating occipital neuralgia and short-term relief of CM. However, there are no known studies that have specifically evaluated the use of Botox and occipital blocks for reducing headache frequency in the US veteran population. The purpose of this study was to evaluate the effectiveness of using occipital blocks and Botox as dual therapy for reducing headache frequency in post 9/11 combat veterans with CM, occipital neuralgia, and a history of TBI or neck trauma. MATERIALS AND METHODS: Following Institutional Review Board approval, a retrospective chart review was completed on post 9/11 combat veterans treated in a headache clinic located at the Central Texas Veteran Health Care System. The electronic medical record was used to retrieve the charts of post 9/11 combat veterans who (1) had a confirmed deployment-related history of TBI or neck trauma; (2) were diagnosed with CM and occipital neuralgia; and (3) were treated in the headache clinic between January 1, 2014 and December 31, 2015 with the administration of occipital blocks and Botox within the first six months. Of 282 charts that were reviewed, a total of 30 (N = 30) veterans fit the criteria. The mean number of self-reported headache days per month (28 days) for the month prior to starting treatment was compared to the number of headache days per month (28 days) 6 months after initiation of therapy. RESULTS: Results revealed that the mean number of headache days in the month prior to treatment was 24.1 (22.0, 25.7). The mean number of headache days in the month post-treatment (6 months after the initiation of dual therapy with occipital blocks and Botox) was 12.9 (9.7, 16.4). The mean difference in the number of headache days from pre- to post-treatment (pre-treatment minus post-treatment) was 11.2 (8.2, 14.2). CONCLUSION: This study evaluated the effectiveness of using occipital blocks and Botox as dual therapy for reducing headache frequency for post 9/11 combat veterans with CM, occipital neuralgia, and a history of TBI or neck trauma. Results revealed a statistically significant reduction in the number of headache days per month after the dual therapy. There were multiple limitations to the study to include a small sample size, lack of a control group, self-reported headaches for only 1 month pre-and post-treatment, and no control for other interventions or events which may have influenced the outcome. There is a strong need for randomized, double blinded, placebo- controlled studies involving dual therapy in this population. This study, though small, may be helpful in stimulating additional studies and treatments in this veteran population.

Mesenteric Ischemia.

Mesenteric ischemia is an uncommon disease most often seen in the elderly. This disease results from blood flow in the mesenteric circulation that inadequately meets metabolic needs of the visceral organs and, if untreated, eventually leads to necrosis of the bowel wall. Mesenteric ischemia is divided into 2 types: acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Delayed diagnosis of CMI can lead to AMI. AMI is associated with extremely high mortalities. Early diagnosis via computed tomography angiography and prompt revascularization via endovascular therapy are recommended for symptomatic patients who have not developed bowel ischemia and necrosis.

Palliative social work in the emergency department.

Recognizing that seriously ill patients and their families utilize emergency departments (EDs) for distressing symptoms, changing goals of care, or at the end of life, palliative care and emergency medicine departments are partnering to enhance the care provided to patients with life-limiting illnesses and their families. A social work model for identifying patients with unmet palliative care needs in the ED is included to illustrate the process as well as specific psychosocial interventions that palliative social workers can provide in this environment. As increasing numbers of palliative and emergency medicine departments partner to both improve ED care for patients with life-threatening illness and initiate palliative care consults earlier in hospitalizations, palliative and ED social workers have an opportunity to join their physician and nurse colleagues who are making inroads in this important and growing area.

A rapid two-stage screening protocol for palliative care in the emergency department: a quality improvement initiative.

BACKGROUND: A rapid two-stage screening protocol was developed to improve referral for palliative care needs among frail elderly in the emergency department (ED). MEASURES: A new triage tool was administered, with assessment tools for activities of daily living, performance, functional staging, symptom burden, and caregiver distress. INTERVENTION: Stage One identified elderly patients meeting criteria for life-limiting conditions. Stage Two referred patients with crescendo losses in activities of daily living, high symptom burden, and caregiver distress to palliative care or hospice. OUTCOMES: Over eight months, 1587 patients were screened, representing 22% of ED visits made by patients older than 65 years during this time period. Of these, 140 met functional decline criteria, and 51 of these needed palliative care consultation. Five patients were referred to hospice, 20 received palliative care, and 26 received no further service. CONCLUSIONS/LESSONS LEARNED: The project shows unmet needs among elderly ED patients, and the feasibility of rapid screening and referral using a quality improvement approach. At its peak, the project accounted for half the referrals to the palliative care consultation service.

Concept mapping a baccalaureate nursing program: a method for success.

The understanding of curricular design and development is paramount for faculty. For novice faculty, learning teaching methods commonly takes precedence over understanding curriculum development. Professional accrediting bodies of nursing programs require curriculum course content to be pertinent and flow logically. Baccalaureate nursing programs can choose to be accredited by the Commission on Collegiate Nursing Education. The purpose of this article is to describe an educational innovation that one College of Nursing implemented to orient new faculty to the curriculum and prepare for an accreditation renewal. Assigned faculty developed and implemented a concept mapping process aimed to evaluate and revise course content based on national standards and guidelines. Undergraduate faculty understanding and ownership of the curriculum was evident throughout the process. The concept mapping process proved to be an innovative approach to enhance the curriculum and equip faculty with an understanding of the relationship between concepts and course content.

Escape to Alcatraz: evolutionary history of slender salamanders (Batrachoseps) on the islands of San Francisco Bay.

BACKGROUND: Island populations are excellent model systems for studies of phenotypic, ecological and molecular evolution. In this study, molecular markers of mitochondrial and nuclear derivation were used to investigate the evolution, structure and origin of populations of the California slender salamander (Batrachoseps attenuatus) inhabiting the six major islands of San Francisco Bay, formed following the rising of sea level around 9,000 years ago. RESULTS: There was a high degree of congruence in the results of analyses of nucleotide and allozyme data, both of which strongly support the hypothesis that, for the majority of the islands, salamanders are descended from hilltop populations that became isolated with the formation of the Bay ca. 9,000 years ago. There are two exceptions (Alcatraz and Yerba Buena) where the evidence suggests that salamander populations are wholly or in part, the result of anthropogenic introductions.Comparison of the molecular data and the interpretations drawn therefrom with an earlier morphological study of many of the same salamander populations show some of the same evolutionary trends. CONCLUSION: In spite of marked differences between the evolutionary rates of the two kinds of molecular markers, both indicate distinctive and similar patterns of population structure for B. attenuatus in the San Francisco Bay Area and its islands. With the two noted exceptions, it is clear that most island populations were established prior to the 9,000 years since the formation of the Bay. Results of coalescence-based analyses suggest that for most island populations the mtDNA lineages from which they were derived date from the Pleistocene.It can be said that, based on observed values of genetic diversity, the last 9,000 years of evolution on these islands have been characterized by relative stability, with the occasional extinction of some haplotypes or alleles that were formerly shared between island and mainland populations but overall maintaining high levels of variation (with the exception of Alcatraz). In contrast, there is some evidence for rapid morphological changes between populations in some islands and their closest mainland counterparts. This pattern of rapid morphological divergence (e. g., resulting from founder effects) is similar to that observed in other studies about recent colonization of island habitats.

Collaborative co-op as a means to expand BSN enrollment & diversity.

The collaborative co-op is an innovative option that emphasizes cultural competence and evidenced-based nursing care. This project provides four summers of more challenging and responsible experiences to enhance students' expertise in supervision and delegation with other members of the health care team. Through experiential learning, students develop an in-depth understanding of differentiated practice roles and the distinct and complimentary responsibilities of the nursing assistant, the practical nurse, and the professional nurse through this highly structured and mentored co-op clinical experience. The co-op students complete all requirements for the BSN degree along with the students enrolled in the traditional BSN program, but they also have the additional summer clinical experiences. Counseling, mentoring, and early identification of academic problems are important features of this structured program.

Home and hospital; hospice and palliative care: how the environment impacts the social work role.

Social workers play key roles on interdisciplinary hospice teams and in hospitals on oncology or palliative care teams. Though palliative care settings include both home hospice and hospital-based consultation services, the different environments and scope of practice impact the role of the social worker. The purpose of this article is to examine the similarities and differences in coordination of care, teamwork, and collaboration in these two fields in order to highlight opportunities for enhancing clinical skills and developing our confidence and presence in asserting social work expertise with our transdisciplinary colleagues.

How and when did Old World ratsnakes disperse into the New World?

To examine Holarctic snake dispersal, we inferred a phylogenetic tree from four mtDNA genes and one scnDNA gene for most species of the Old World (OW) and New World (NW) colubrid group known as ratsnakes. Ancestral area distributions are estimated for various clades using divergence-vicariance analysis and maximum likelihood on trees produced using Bayesian inference. Dates of divergence for the same clades are estimated using penalized likelihood with statistically crosschecked calibration references obtained from the Miocene fossil record. With ancestral areas and associated dates estimated, various hypotheses concerning the age and environment associated with the origin of ratsnakes and the dispersal of NW taxa from OW ancestors were tested. Results suggest that the ratsnakes originated in tropical Asia in the late Eocene and subsequently dispersed to the Western and Eastern Palearctic by the early Oligocene. These analyses also suggest that the monophyletic NW ratsnakes (the Lampropeltini) diverged from OW ratsnakes and dispersed through Beringia in the late Oligocene/early Miocene when this land bridge was mostly composed of deciduous and coniferous forests.

Snake phylogeny: evidence from nuclear and mitochondrial genes.

We constructed phylogenies of snakes from the c-mos and cytochrome b genes using conventional phylogenetic methods as well as the relatively new method of Bayesian inference. For all methods, there was excellent congruence between the c-mos and cytochrome b genes, implying a high level of support for the shared clades. Our results agree with previous studies in two important respects: first, that the scolecophidians and alethinophidians are monophyletic sister clades; and second, that the Colubroidea is a monophyletic group with the Acrochordidae as its sister clade. However, our results differ from previous studies in the finding that Loxocemus and Xenopeltis cluster with pythons. An additional noteworthy result from our data is that the genera Exiliboa and Ungaliophis, often placed with Tropidophis (and Trachyboa, not included in the present study) in the Tropidophiidae, are in reality boids.