Practice patterns, role and impact of advanced practice nurses in stroke care: A mixed-methods systematic review.

AIM(S): To undertake a systematic review of the practice patterns and roles of advanced practice nurses (APNs) in inpatient and outpatient stroke-care services; and to evaluate the impact of APN-led inpatient and outpatient stroke-care services on clinical and patient-reported outcomes. DESIGN: A mixed-methods systematic review. METHODS: A systematic search was conducted across six electronic databases for primary studies. Data were synthesised using a convergent integrated approach. DATA SOURCES (INCLUDE SEARCH DATES) *FOR REVIEWS ONLY: A systematic search was conducted across PubMed, CINAHL, Cochrane Library, Embase, PsycInfo and ProQuest Dissertations & Theses Global, for primary studies published between the inception of the databases and 3 November 2022. RESULTS: Findings based on the 18 included primary studies indicate that the APNs' roles have been implemented across the continuum of stroke care, including pre-intervention care, inpatient care and post-discharge care. Practicing at an advanced level, the APNs engaged in clinical, operational and educational undertakings across services and disciplines. Positive clinical and patient-reported outcomes have been attributed to their practice. CONCLUSION: The review highlights the critical role of APNs in improving stroke care, especially in the pre-intervention phase. Their clinical expertise, patient-centered approach and collaboration can transform stroke care. Integrating APNs into stroke care teams is essential for better management and outcomes in light of the increasing stroke burden. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Healthcare institutions should integrate APNs to enhance pre-intervention stroke care, improve diagnostic accuracy and expedite treatment. APNs can prioritise patient-centric care, including assessments, coordination and education. Medication reconciliation, timely rehabilitation referrals and lifestyle modifications for secondary stroke prevention are crucial. Implementing advanced practice nursing frameworks ensures successful APN integration, leading to improved stroke care and better patient outcomes in response to the growing stroke burden. IMPACT (ADDRESSING): What problem did the study address? Poor clarity of the role of advanced practice nurses among patients, physicians, healthcare professionals, health policymakers and nurses. What were the main findings? Advanced practice nurses practise across the continuum of stroke care, mainly in pre-intervention care which takes place before initiating treatment, inpatient care and post-discharge care. The implementation of the advanced practice nurse role in stroke care has contributed positively to clinical and patient-reported outcomes. Where and on whom will the research have an impact? Insights from the review are envisioned to inform healthcare policymakers and leaders in the implementation and evaluation of the APN role in stroke care. REPORTING METHOD: Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. TRIAL AND PROTOCOL REGISTRATION: https://figshare.com/ndownloader/files/41606781; Registered on Open Science Framework osf.io/dav8j.

High-throughput Oligopaint screen identifies druggable 3D genome regulators.

The human genome functions as a three-dimensional chromatin polymer, driven by a complex collection of chromosome interactions1-3. Although the molecular rules governing these interactions are being quickly elucidated, relatively few proteins regulating this process have been identified. Here, to address this gap, we developed high-throughput DNA or RNA labelling with optimized Oligopaints (HiDRO)-an automated imaging pipeline that enables the quantitative measurement of chromatin interactions in single cells across thousands of samples. By screening the human druggable genome, we identified more than 300 factors that influence genome folding during interphase. Among these, 43 genes were validated as either increasing or decreasing interactions between topologically associating domains. Our findings show that genetic or chemical inhibition of the ubiquitous kinase GSK3A leads to increased long-range chromatin looping interactions in a genome-wide and cohesin-dependent manner. These results demonstrate the importance of GSK3A signalling in nuclear architecture and the use of HiDRO for identifying mechanisms of spatial genome organization.

Dissolved silicon in a lake-floodplain system: Dynamics and its role in primary production.

Dissolved silicon (DSi) is essential for aquatic primary production and its limitation relative to nitrogen (N) and phosphorus (P) facilitates cyanobacterial dominance. However, the effects of DSi on phytoplankton growth and community structure have yet to be fully determined in tropical lakes, particularly in relation to N and P. Therefore, this study investigated the role of DSi in Tonlé Sap Lake, Cambodia, a tropical floodplain system well known for its flood-pulse characteristics and high productivity. To that end, seasonal water sampling and in situ water quality measurements were performed around the floating villages of Chhnok Tru region. The concentration of DSi was significantly higher in the dry season than in the wet season at 16.3-22.1 versus 7.2-14.0 mg/L, respectively; however, both sets of measurements were comparable with lakes in other parts of the world. Meanwhile, the average molar ratio of TN:TP:DSi was 69:1:33 in the dry season and 39:1:24 in the wet season, which compared with the Redfield ratio of 16:1:16, suggested limitation of TP and DSi in both seasons. In addition, phytoplankton biomass in terms of chlorophyll-a was found to be a collective function of DSi, TN:TP, dissolved oxygen, and water temperature in both seasons. Taken together, these results suggest that DSi is affected by the annual hydrological cycle in the Tonlé Sap Lake flood-pulse ecosystem, serving as a secondary limiting nutrient of primary production during both the dry and wet seasons.

KARATE: PKA-induced KRAS4B-RHOA-mTORC2 supercomplex phosphorylates AKT in insulin signaling and glucose homeostasis.

AKT is a serine/threonine kinase that plays an important role in metabolism, cell growth, and cytoskeletal dynamics. AKT is activated by two kinases, PDK1 and mTORC2. Although the regulation of PDK1 is well understood, the mechanism that controls mTORC2 is unknown. Here, by investigating insulin receptor signaling in human cells and biochemical reconstitution, we found that insulin induces the activation of mTORC2 toward AKT by assembling a supercomplex with KRAS4B and RHOA GTPases, termed KARATE (KRAS4B-RHOA-mTORC2 Ensemble). Insulin-induced KARATE assembly is controlled via phosphorylation of GTP-bound KRAS4B at S181 and GDP-bound RHOA at S188 by protein kinase A. By developing a KARATE inhibitor, we demonstrate that KRAS4B-RHOA interaction drives KARATE formation. In adipocytes, KARATE controls insulin-dependent translocation of the glucose transporter GLUT4 to the plasma membrane for glucose uptake. Thus, our work reveals a fundamental mechanism that activates mTORC2 toward AKT in insulin-regulated glucose homeostasis.

ACT-FAST: a quality improvement project to increase the percentage of acute stroke patients receiving intravenous thrombolysis within 60 minutes of arrival at the emergency department.

INTRODUCTION: Stroke is a leading cause of death and disability, with the administration of recombinant transcriptase-plasminogen activator (rtPA) improving outcomes in a time-dependent manner. Only 52.3% of eligible stroke patients at our institution received rtPA within 60 minutes of arrival. We aimed to improve the percentage of acute stroke patients receiving rtPA within 60 minutes of arrival at the emergency department (ED). METHODS: This study presents results from the first year of a clinical practice improvement project that implemented quality improvement interventions. The primary outcome measure was percentage of acute ischaemic stroke patients receiving rtPA within 60 minutes of arrival at the ED. Secondary outcome measures included components of total door-to-needle (DTN) time and factors for delay to thrombolysis. Interventions were establishment of standardised acute stroke activation guidelines, screening question at ED registration, prehospital notification of stroke activation, public education, scripting for thrombolysis consent and easy access to equipment. RESULTS: The percentage of patients thrombolysed within 60 minutes increased to 60.6% (p = 0.27), and DTN time decreased from 59 minutes to 54.5 minutes (p = 0.15). This was attributable to reduced door-to-physician time, door-to-imaging time and decision time, although the results were not significant. There was no significant increase in symptomatic intracranial haemorrhage or mortality secondary to stroke. Length of stay was significantly reduced by 1.5 days (p < 0.048). CONCLUSION: The interventions resulted in an increasing but non-significant trend of acute stroke patients receiving thrombolysis within 60 minutes. Outcomes will be monitored for a longer duration to demonstrate trends and sustainability.

Hetero-oligomerization of Rho and Ras GTPases Connects GPCR Activation to mTORC2-AKT Signaling.

The activation of G-protein-coupled receptors (GPCRs) leads to the activation of mTORC2 in cell migration and metabolism. However, the mechanism that links GPCRs to mTORC2 remains unknown. Here, using Dictyostelium cells, we show that GPCR-mediated chemotactic stimulation induces hetero-oligomerization of phosphorylated GDP-bound Rho GTPase and GTP-bound Ras GTPase in directed cell migration. The Rho-Ras hetero-oligomers directly and specifically stimulate mTORC2 activity toward AKT in cells and after biochemical reconstitution using purified proteins in vitro. The Rho-Ras hetero-oligomers do not activate ERK/MAPK, another kinase that functions downstream of GPCRs and Ras. Human KRas4B functionally replace Dictyostelium Ras in mTORC2 activation. In contrast to GDP-Rho, GTP-Rho antagonizes mTORC2-AKT signaling by inhibiting the oligomerization of GDP-Rho with GTP-Ras. These data reveal that GPCR-stimulated hetero-oligomerization of Rho and Ras provides a critical regulatory step that controls mTORC2-AKT signaling.

Predicting Pneumonia in Acute Ischaemic Stroke: Comparison of Five Prediction Scoring Models.

INTRODUCTION: Although pneumonia is a major complication after acute ischaemic stroke (AIS), pneumonia prediction scores have not been extensively validated. This study aimed to compare the discrimination performance of 5 pneumonia prediction scores in AIS patients. MATERIALS AND METHODS: We retrospectively reviewed all consecutive adult AIS patients whom presented to our emergency department within 4.5 hours of symptom-onset between January 2012 and February 2015. Diagnosis had to be made by a neurologist and infarcts confirmed by neuroimaging. We excluded patients with pneumonia on presentation. Pneumonia predictors were based on the 5 prediction scoring models: Kwon's score, Chumbler's score, Acute Ischaemic Stroke-Associated Pneumonia Score (AIS-APS), A2DS2 score and ISAN score. The definition of stroke-associated pneumonia was based on the criteria by the Pneumonia in Stroke Consensus Group. Analysis using area under receiver operating characteristics curve (AUROC) was performed. RESULTS: Forty (5.5%) out of 731 patients analysed had stroke-associated pneumonia (SAP). A2DS2 score had the highest discrimination capacity (AUROC 0.88; 95% CI, 0.84 to 0.92), followed by AIS-APS (AUROC 0.87; 95% CI, 0.83 to 0.91), Kwon's score (AUROC 0.86; 95% CI, 0.82 to 0.92), Prestroke Independence, Sex, Age and National Institutes of Health Stroke Scale (ISAN) score (AUROC 0.85; 95% CI, 0.80 to 0.90) and Chumbler's score (AUROC 0.79; 95% CI, 0.74 to 0.84). However, there was no statistical difference of discrimination capacity among A2DS2 score, AIS-APS and Kwon's score. CONCLUSION: A2DS2 , AIS-APS and Kwon's scores performed comparably in discriminating SAP in AIS patients.

A randomized controlled study to compare the 2% lignocaine and aqueous lubricating gels for female urethral catheterization.

OBJECTIVE: The 2% lignocaine gel has long been used for male urethral catheterization, but aqueous gel as lubricant has been used for females. However, studies report that females experience pain during urethral catheterization. We compared the effectiveness of 2% lignocaine gel (intervention) and aqueous gel (control) for female urethral catheterization in reducing procedural pain. METHODS: A double-blinded, randomized controlled trial (RCT) was conducted from November 2011 to April 2012 in an acute care hospital in Singapore. In total, 52 adult female inpatients (26 interventions vs. 26 controls) requiring urethral catheterization were included in the study. The intervention included patients receiving 2% lignocaine gel as a lubricant for urethral catheterization. Patients' pre- and postprocedural visual analog scale (VAS) were collected prospectively and nonparametric tests were used for data analysis. RESULTS: There was a significant reduction from the preprocedure pain score (Median = 22.0 mm) to the postprocedural pain score (Median = 6.6 mm) in the 2% lignocaine group (Z = -3.8, P < 0.001), but not in the aqueous gel group (pre vs. post: 16.5 mm vs. 18.2 mm; Z = -0.36, P = 0.716). Subjects using 2% lignocaine gel had significantly more reduction in the postprocedural pain score than the aqueous gel group (U = 209.5, P = 0.019). CONCLUSIONS: The 2% lignocaine gel significantly reduces the procedural pain of female urethral catheterization as compared with aqueous gel. This study provides evidence for the hospital to change the current practice in the hope of reducing procedural pain for female patients during urethral catheterization.

The Edinburgh Postnatal Depression Scale detects but does not distinguish anxiety disorders from depression in mothers of infants.

Specific screening tests to detect postpartum anxiety are as yet unavailable. The aim of this study was to test the ability of the Edinburgh Postnatal Depression Scale (EPDS) to detect anxiety disorders in women admitted to residential early parenting centres. Consecutive cohorts of English speaking women admitted with their infants to two centres in Melbourne, Australia completed the Composite International Diagnostic Interview and the Edinburgh Postnatal Depression Scale (EPDS). Anxiety and depression diagnoses were compared with EPDS scores. Of the 145 women (78% recruitment rate), 138 (95%) provided complete data of whom 35 (25%) had at least one anxiety disorder. EPDS scores over 12 correctly identified 28 women (44%) as having major depression, either alone or co-morbid with an anxiety disorder but 10 (16%) had only an anxiety disorder and were not depressed. All of the 26 (41%) women with EPDS scores over 12 with neither diagnosis met diagnostic criteria for minor depression or an adjustment disorder. EPDS scores were unable to distinguish between these diagnostic groups. The presumption that EPDS scores over 12 indicate only probable depression is an oversimplification. Current national initiatives recommend that EPDS scores over 12 warrant treatment for depression, which may lead to inappropriate labeling and therapy.

Laryngeal mask airway can be inserted with inhaled desflurane induction.

PURPOSE: In this prospective, randomized, controlled trial, we investigated the reliability of laryngeal mask airway (LMA) insertion with inhaled desflurane. METHODS: Eighty patients undergoing elective surgery were randomized into two groups to receive either 2.5 mg x kg(-1) propofol (n = 40) or tidal breath desflurane (n = 40) induction followed by LMA insertion. All patients received fentanyl 1 microg x kg(-1) 2 min before induction. Inhalation of desflurane was started at 3% and increased by 3% every 3-5 breaths up to settings of 12%. RESULTS: Insertion of the LMA was faster in the propofol group (131.8 s versus 228.6 s, P < 0.01). The number of patients in whom the jaw opening was described as good (95% versus 72.5%, P = 0.27, for the desflurane and propofol groups, respectively) and the ease of LMA insertion described as good (87.5% versus 72.5%, P = 0.6) were comparable. The LMA was inserted in a single attempt in the majority of patients in both groups (80% versus 77.5%, P = 0.90). There were more complications at insertion in the propofol group than in the desflurane group (2.5% versus 19.5%, P < 0.01), especially for apnea (7.5% versus 70%, P < 0.01) and excitatory movements (2.5% versus 25%, P < 0.01). There were significant decreases in the mean arterial pressure in the propofol group compared to baseline data over the first 5 min of induction. Mean arterial pressure, heart rate, and S(p)(O2) remained stable during the same period in the desflurane group. CONCLUSION: We demonstrated that inhaled desflurane when used with caution in a controlled manner provided acceptable conditions for LMA insertion.