The association of gender-affirming hormone therapy duration and body mass index on bone mineral density in gender diverse adults.

Introduction: Feminizing and masculinizing gender-affirming hormone therapy (fGAHT, mGAHT) results in bone mineral density (BMD) maintenance or improvement over time in transgender and gender diverse (TGD) adults. Mostly European TGD studies have explored GAHT's impact on BMD, but the association of BMI and BMD in TGD adults deserves further study. Objective: To determine whether GAHT duration or BMI are associated with BMD and Z-scores among TGD young adults. Methods: Cross-sectional study of nonsmoking TGD adults aged 18-40 years without prior gonadectomy or gonadotropin-releasing hormone agonist (GnRHa) therapy taking GAHT for > 1 year. BMD and Z-scores were collected from dual-energy x-ray absorptiometry. Associations between femoral neck, total hip, and lumbar spine BMDs and Z-scores and the predictors, GAHT duration and BMI, were estimated using linear regression. Results: Among 15 fGAHT and 15 mGAHT, mean BMIs were 27.6 +/- standard deviation (SD) 6.4 kg/m2 and 25.3 +/- 5.9 kg/m2, respectively. Both groups had mean BMDs and Z-scores within expected male and female reference ranges at all three sites. Higher BMI among mGAHT was associated with higher femoral neck and total hip BMDs (femoral neck: ß = 0.019 +/- standard error [SE] 0.007 g/cm2, total hip: ß = 0.017 +/- 0.006 g/cm2; both p < 0.05) and Z-scores using male and female references. GAHT duration was not associated with BMDs or Z-scores for either group. Conclusions: Z-scores in young, nonsmoking TGD adults taking GAHT for > 1 year, without prior gonadectomy or GnRHa, and with mean BMIs in the overweight range, were reassuringly within the expected ranges for age based on male and female references. Higher BMI, but not longer GAHT duration, was associated with higher femoral neck and total hip BMDs and Z-scores among mGAHT. Larger, prospective studies are needed to understand how body composition changes, normal or low BMIs, and gonadectomy affect bone density in TGD adults.

Integrating Palliative Care Social Workers into Subacute Settings: Feasibility of the Assessing & Listening to Individual Goals and Needs Intervention Trial.

Objectives: Determine feasibility, acceptability, and preliminary effects of the Palliative Care Social Worker-led ALIGN (Assessing & Listening to Individual Goals and Needs) intervention in older persons admitted to Skilled Nursing Facility (SNF) and their caregivers. Design: A pilot pragmatic randomized stepped wedge design of ALIGN versus usual care in three SNFs. Setting and Participants: One hundred and twenty older adults and caregivers (optional) with advanced medical illnesses. Measures: Primary outcomes were feasibility and acceptability. We collected exploratory patient-/caregiver-centered outcomes at baseline and three months and conducted a medical record review at six months to assess documentation of Advance Directives (AD). We also collected exploratory health care utilization data, including hospitalizations, mortality, and hospice utilization. Results: Of 179 patients approached, 120 enrolled (60 ALIGN patients with 15 caregivers and 60 usual care patients and 21 caregivers). Four intervention patients refused ALIGN visits, 8 patients died or discharged before initial visit, and 48 intervention patients received ALIGN visits, with ∼80% having caregivers participating in visits, regardless of caregiver study enrollment. Quantitative exploratory outcomes were not powered to detect a difference between groups. We found 91% of ALIGN patients had a completed AD in medical record compared to 39.6% of usual care patients (p < 0.001). Qualitative feedback from participants and SNF staff supported high acceptability and satisfaction with ALIGN. Conclusion and Clinical Implications: A pragmatic trial of the ALIGN intervention is feasible and preliminary effects suggest ALIGN is effective in increasing AD documentation. Further research is warranted to understand effects on caregivers and health care utilization. The current model for SNF does not address the palliative care needs of patients. ALIGN has potential to be an effective, scalable, acceptable, and reproducible intervention to improve certain palliative care outcomes within subacute settings.

Evaluating the Effectiveness of End-Tidal Carbon Dioxide Monitoring During Burn Wound Care in the Nonintubated Patient Population.

Daily burn wound care for nonintubated patients involves administration of intravenous analgesic and sedation agents. Vital signs and oxygen saturation monitoring alone can result in late signs of oversedation and ineffective breathing. End-tidal carbon dioxide (EtCo2) monitoring provides immediate feedback of effective breathing during procedural sedation. The purpose of this study was to describe the nurse's sedation and analgesic therapy management of nonintubated patients during burn wound care when EtCo2 was used. This IRB approved study involved observing 22 burn nurses and 4 burn technicians during burn wound care of nonintubated patients. This descriptive, observational study compared adverse breathing/airway events, pain measurements, and sedation effectiveness, before and after introducing EtCo2 monitoring. Patients observed in this study were similar in age, type and size of burn, and use of recreational substances. Nurses and technicians also had similar burn experience. No statistically significant findings were found in this study; however, nurses in practice longer were found to apply oxygen sooner, which prevented decreased oxygen saturation events. When EtCo2 was used, less analgesia and sedation were required to maintain patient comfort. Time required for burn wound care was reduced by 22%, and 30% less overall analgesic and sedation agent dosages were administered after the introduction of EtCo2 monitoring. EtCo2 was found to enhance nurses' assessment of patients' response to intravenous analgesia and sedation effectiveness during burn wound care for nonintubated patients. Nurses with greater experience used oxygen sooner in the procedure, and patients had fewer decreases in SpO2.

Sexual Health: Exploring Patient Needs and Healthcare Provider Comfort and Knowledge.

BACKGROUND: Sexual health is an important quality-of-life issue for many cancer survivors; however, this issue remains inadequately discussed by healthcare providers (HCPs) and patients. OBJECTIVES: The purpose of this study is to explore whether clinical oncology HCPs have adequate knowledge and are comfortable addressing sexual health issues, and to explore and describe patients' attitudes, beliefs, and informational needs regarding sexual health. METHODS: A survey was completed by HCPs and three patient focus groups were conducted to learn more about sexual health. Survey data were analyzed using descriptive statistics, and qualitative responses were analyzed using content analysis. FINDINGS: The majority of survey respondents reported on the importance of discussing sexual concerns with patients, lacked sexual health training, and were uncomfortable discussing sexual health with patients. Focus group participants wanted access to timely information during treatment, online educational resources, and brochures and handouts; involvement of significant others; support from providers, peers, and survivors; and expert consultation.

Crew Resource Management for Obstetric and Neonatal Teams to Improve Communication During Cesarean Births.

OBJECTIVE: To assess the effectiveness of crew resource management training and interventions on the quality and quantity of communication during cesarean births in a tertiary academic hospital's labor and birthing services. DESIGN: A prospective pre-post crew resource management training intervention. SETTING: Tertiary academic hospital in the Western United States. PARTICIPANTS: All members of obstetric and neonatal teams that participated in cesarean births. METHODS: Over a 5-month time period, all obstetric and neonatal staff were required to participate in team training in crew resource management critical language, communication, and team structure. Trained observers collected baseline data (n = 52) for 3 months on the quantity and quality of communications that occurred during cesarean births. Postintervention data (n = 50) were gathered for 3 months after team training. Analysis approach included use of Fisher's exact test, independent-samples t test, and multilevel generalized linear regression models with Poisson distribution. RESULTS: There was a statistically significant increase in quantity and quality of communication from pre- to postintervention assessment for obstetric and neonatal staff. Although the increase in quality was similarly great between both types of teams, increase in quantity was more substantial in obstetric staff. CONCLUSION: Principles of team communication training shown to be effective in increasing communication among team members in a variety of clinical areas were also effective in improving communication in the labor and birth setting during cesarean births.

Determining high touch areas in the operating room with levels of contamination.

BACKGROUND: The Centers for Disease Control and Prevention put forth the recommendation to clean areas considered high touch more frequently than minimal touch surfaces. The operating room was not included in these recommendations. The purpose of this study was to determine the most frequently touched surfaces in the operating room and their level of contamination. METHODS: Phase 1 was a descriptive study to identify high touch areas in the operating room. In phase 2, high touch areas determined in phase 1 were cultured to determine if high touch areas observed were also highly contaminated and if they were more contaminated than a low touch surface. RESULTS: The 5 primary high touch surfaces in order were the anesthesia computer mouse, OR bed, nurse computer mouse, OR door, and anesthesia medical cart. Using the OR light as a control, this study demonstrated that a low touch area was less contaminated than the high touch areas with the exception of the OR bed. CONCLUSIONS: Based on information and data collected in this study, it is recommended that an enhanced cleaning protocol be established based on the most frequently touched surfaces in the operating room.

Mentoring Clinical Nurses to Write for Publication: Strategies for Success.

: Clinical nurses often find writing a challenge, but it's important to disseminate clinical practice initiatives that result in notable patient outcomes. Nurses have a responsibility to share what they do to improve patient care. The increased emphasis on the development and evaluation of evidence-based practice has made it necessary for nurses to share best practices that are associated with improved patient outcomes. We developed a six-month Writing for Publication workshop series designed to teach clinical nurses about the writing process and mentor them through the stages of preparing a manuscript to submit for publication. This successful program helped novice nurse authors become published professionals and had a great impact on our organization.

Skin Irritation during Video-EEG Monitoring.

OBJECTIVES: Video-EEG (VEEG) monitoring, indicated to characterize and diagnose seizures, is recorded over several days with electrodes glued to the patient's scalp. Our investigation was designed to determine the incidence of electrode-related skin irritation during VEEG in the epilepsy monitoring unit (EMU) and implement a series of interventions to reduce the incidence of moderate to severe irritation. METHODS: Between May 2012 and March 2015, EMU patients were assessed for skin lesions before electrode placement and at discharge. Prospectively gathered demographic data included: age, gender, race/ethnicity, length of monitoring (LOM), skin prep medium (SPM) used, self-reported skin sensitivity, history of skin diseases, and skin products used on the day of admission. When present, electrode-related skin irritation was graded as mild, moderate, or severe. Data were collected before any intervention (baseline-group) and thereafter with each intervention: standardization (single SPM, raising awareness, monitoring for electrode-related discomfort); face washing; applying skin barrier; replacing tape with gauze; and using disposable electrodes. RESULTS: Data from 861 patients were analyzed (104-146 per group). At baseline, any skin irritation occurred in 27.3% of patients; it was moderate or severe in 19.1%. LOM ≥4 days and electrode position on facial skin were associated with significantly higher risk. All interventions reduced rates of skin irritation, but only the standardization intervention was statistically significant. CONCLUSIONS: During VEEG admissions, electrode-related skin irritation occurred in about one-third of patients; it was moderate to severe in one-fifth. A standardized care process with regular monitoring for discomfort led to significant improvement in the rate of irritation.

Evaluating palliative care needs in Middle Eastern countries.

BACKGROUND: Cancer incidence in Middle Eastern countries, most categorized as low- and middle-income, is predicted to double in the next 10 years, greater than in any other part of the world. While progress has been made in cancer diagnosis/treatment, much remains to be done to improve palliative care for the majority of patients with cancer who present with advanced disease. OBJECTIVE: To determine knowledge, beliefs, barriers, and resources regarding palliative care services in Middle Eastern countries and use findings to inform future educational and training activities. DESIGN: Descriptive survey. SETTING/SUBJECTS: Fifteen Middle Eastern countries; convenience sample of 776 nurses (44.3%), physicians (38.3%) and psychosocial, academic, and other health care professionals (17.4%) employed in varied settings. MEASUREMENTS: Palliative care needs assessment. RESULTS: Improved pain management services are key facilitators. Top barriers include lack of designated palliative care beds/services, community awareness, staff training, access to hospice services, and personnel/time. The nonexistence of functioning home-based and hospice services leaves families/providers unable to honor patient wishes. Respondents were least satisfied with discussions around advance directives and wish to learn more about palliative care focusing on communication techniques. Populations requiring special consideration comprise: patients with ethnic diversity, language barriers, and low literacy; pediatric and young adults; and the elderly. CONCLUSIONS: The majority of Middle Eastern patients with cancer are treated in outlying regions; the community is pivotal and must be incorporated into future plans for developing palliative care services. Promoting palliative care education and certification for physicians and nurses is crucial; home-based and hospice services must be sustained.

Intradermal lidocaine or bacteriostatic normal saline to decrease pain before intravenous catheter insertion: a meta-analysis.

PURPOSE: Anesthetics used to decrease pain during peripheral intravenous catheter insertion have been studied with equivocal results. This meta-analysis determined if lidocaine or bacteriostatic normal saline (BaNS) is more effective in reducing pain associated with peripheral intravenous catheter cannulation in adults. METHODS: PubMed, EMBASE, CINAHL, ProQuest Dissertation and Theses, and Web of Science databases were queried. Thirteen randomized controlled trials were analyzed. RESULTS: Mean sample was 119.9 (±82.0); combined N was 1,559. Mean effect size was z = 0.46 (confidence interval = 0.24-0.68) indicating lidocaine was more effective than BaNS in providing pain relief (P < .001). CONCLUSION: Cost-benefit issues and lidocaine drug shortages must be considered when making definitive practice recommendations.