Larger stem to bone diameter ratio predicts lower cemented endoprosthesis failure.

BACKGROUND AND OBJECTIVES: With continued advances in treatment options, patients with endoprosthetic reconstruction are living longer and consequently relying upon their devices for a longer duration. Major causes of endoprosthesis failure include aseptic loosening and mechanical failure. In the setting of tumor resection, loss of bone stock and use of radiation therapy increase the risk for these complications. As such, considerations of remaining native bone and stem length and diameter may be increasingly important. We asked the following questions: (1) What was the overall rate of endoprosthesis failure at a minimum of 5-year follow-up? (2) Does resection length increase implant failure rates? (3) Does implant size and its ratio to cortical width of bone alter implant failure rates? METHODS: We retrospectively analyzed patient outcomes at a single institution between the years of 1999-2022 who underwent cemented endoprosthetic reconstruction at the hip or knee and identified 150 patients. Of these 150, 55 had a follow-up of greater than 5 years and were used for analysis. Radiographs of these patients at time of surgery were assessed and measured for resection length, bone diameter, stem diameter, and remaining bone length. Resection percentage, and stem to bone diameter ratios were then calculated and their relationship to endoprosthesis failure were analyzed. RESULTS: Patients in this cohort had a mean age of 55.8, and mean follow-up of 59.96 months. There were 78 distal femoral replacements (52%), 16 proximal femoral replacements (10.7%), and 56 proximal tibial replacements (37.3%). There were five patients who experienced aseptic loosening and six patients who experienced mechanical failure. Patients with implant failure had a smaller mean stem to bone diameter (36% vs. 44%; p = 0.002). A stem to bone diameter of 40% appeared to be a breaking point between success and failure in this series, with 90% of patients with implant failure having a stem: bone ratio less than 40%. Stem to bone ratio less than 40% increased risk for failure versus stems that were at least 40% the diameter of bone (6/19 [31.6%] vs. 0/36 [0%]; odds ratio 0.68; p < 0.001). Resection length did not appear to have an impact on the rates of aseptic loosening and mechanical failure in this series. CONCLUSIONS: Data from this series suggests a benefit to using stems with a larger diameter when implanting cemented endoprostheses at the hip or knee. Stems which were less than 40% the diameter of bone were substantially more likely to undergo implant failure.

"More is not always better": Park's sweet spot theory-driven implementation strategy for viable optimal safe nurse staffing policy in practice.

AIM: This paper aims to propose Park's sweet spot theory-driven implementation strategy, which makes optimal safe staffing policy really work in nursing practice. BACKGROUND: For the last 40 years, mainstream nursing workforce research has emphasized that having more registered nurses leads to better patient outcomes, and yet staffing policies have failed to implement this crucial concept. Meanwhile, global nursing shortages have become rampant, a problem that only dilutes the skill-mix ratios in the nursing workforce. Low fertility and an aging population worldwide are then accelerating these shortages. These dire circumstances may be persisting because of unclear, unsubstantiated cost-efficiency in the nursing workforce. For this reason, there remains a dearth of well-researched evidence for a clear threshold on optimal safe staffing levels that could maximize quality of care relative to cost given limited healthcare financial budgets and which could also be fitted into each care setting. Along with that, an implementation strategy for optimal safe staffing levels is nonexistent. SOURCES OF EVIDENCE: An implementation strategy has been developed through interdisciplinary consilience-based theory synthesis of both prospective theory and regulatory focus theory combined with Park's optimized nursing staffing (sweet spot) estimation theory. DISCUSSION/CONCLUSIONS: A theory-driven novel implementation strategy is proposed, which functions as a nudge strategy that uses the synchronous balance of quality of care, nurse staffing, and cost. It illustrates (1) how to create shared value among patients, nurses, and stakeholders through robust evidence-based, informed shared decision-making rationales on the optimal safe nurse staffing levels and (2) how to induce stakeholders to overcome resistance to innovation and improve their nursing workforce through value chain in management science. IMPLICATIONS FOR NURSING WORKFORCE POLICY: This novel implementation strategy may be a viable solution to mitigate the nursing shortage by leading stakeholders (1) to compete with each other (on the basis of nursing sufficiency) and (2) to competitively demonstrate the patient-centered value (patient-perceived care quality relative to cost) of their institutions.

Novel neuroelectrophysiological age index associated with imaging features of brain aging and sleep disorders.

Sleep architecture and microstructures alter with aging and sleep disorder-led accelerated aging. We proposed a sleep EEG based brain age prediction model using convolutional neural networks. We then associated the estimated brain age index with brain structural aging features, sleep disorders and various sleep parameters. Our model also showed a higher BAI (predicted brain age minus chronological age) is associated with cortical thinning in various functional areas. We found a higher BAI for sleep disorder groups compared to healthy sleepers, as well as significant differences in the spectral pattern of EEG among different sleep disorders (lower power in slow and ϑ waves for sleep apnea vs. higher power in ß and σ for insomnia), suggesting sleep disorder-dependent pathomechanisms of aging. Our results demonstrate that the new EEG-BAI can be a biomarker reflecting brain health in normal and various sleep disorder subjects, and may be used to assess treatment efficacy.

Potential effects of nicotine content in cigarettes on use of other substances.

A national nicotine reduction policy has the potential to reduce cigarette smoking and associated adverse health impacts among vulnerable populations. However, possible unanticipated adverse effects of reducing nicotine content in cigarettes, such as increasing the use of alcohol or other abused substances, must be examined. The purpose of this study was to evaluate the effects of exposure to varying doses of nicotine in cigarettes on use of other substances. This was a secondary analysis (n = 753) of three simultaneous, multisite, double-blind, randomized-controlled trials examining 12 weeks of exposure to study cigarettes varying in nicotine content (0.4, 2.4, 15.8 mg nicotine/g tobacco) among daily smokers from three vulnerable populations: individuals with affective disorders (n = 251), individuals with opioid use disorder (n = 256), and socioeconomically-disadvantaged women of reproductive age (n = 246). Effect of study cigarette assignment on urine toxicology screens (performed weekly) and responses to drug and alcohol use questionnaires (completed at study weeks 6 and 12) were examined using negative binomial regression, logistic regression, or repeated measures analysis of variance, controlling for sex, age, and menthol status. The most common substances identified using urine toxicology included tetrahydrocannabinol (THC; 44.8%), cocaine (9.2%), benzodiazepine (8.6%), and amphetamines (8.0%), with 57.2% of participants testing positive at least once for substance use (27.3% if excluding THC). No significant main effects of nicotine dose were found on any of the examined outcomes. These results suggest that reducing nicotine content does not systematically increase use of other substances, even among individuals at increased risk of substance use. ClinicalTrials.gov Identifiers: NCT02232737, NCT2250664, NCT2250534.

Provision of pre-hospital medical care for terrorist attacks.

The delivery of medical care to the severely injured during major incidents and mass casualty events has been a recurring challenge for decades across the world. From events in resource-poor developing countries, through richly funded military conflicts, to the most equipped of developed nations, the provision of rapid medical care to the severely injured during major incidents and mass casualty events has been a priority for healthcare providers. This is often under the most difficult of circumstances.1,2 Whilst mass casualty events are a persistent global challenge, it is clear in developed countries that patients and their families demand and expect a high standard of care from their rescuers, that this care should be delivered rapidly, and this should be of the highest quality possible.3 Whilst there is respect afforded to those who 'run towards danger' during a high-threat situation, first responders are subjected to a high degree of scrutiny for their actions, even when the circumstances they are presented with are considered to be extraordinary.4 Likewise, even for those who are catastrophically injured beyond salvage, society expects the response to be dignified, calculated, and thorough.3.

Nursing policy and practice in Mongolia: Issues and the way forward.

Global inequality exists in the availability of a nursing workforce, supported evidentially by the ratio, in low-income countries, of only 9.1 nurses per 10 000 people versus 107.7 nurses per 10 000 people in high-income countries. Mongolia is no exception with 42.14 nurses per 10 000 people and a nursing shortage severe enough to endanger patient safety and well-being. This paper details both a policy analysis and contextually well-designed recommendations to strengthen Mongolia's nursing science and practice systems. Obstacles that significantly affect the successful development of nursing and midwifery professions in Mongolia include (1) a lack of strategic planning and regulation; (2) low status of nurses and midwives; (3) absence of professional representation for nurses and midwives; and (4) a dearth of strategic programs for postgraduate training of nurses and midwives. The suggested recommendations include the appointment of a chief nursing office within the government and a cohort of nurse leaders to work to establish a nursing and midwifery board as an independent, professional regulatory body in Mongolia to develop and implement standards to ensure best practice, higher standards of nurse education, and regulate the profession.

Variation in SARS-CoV-2 molecular test sensitivity by specimen types in a large sample of emergency department patients.

BACKGROUND: Provider-collected nasopharyngeal specimens for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) molecular testing are the standard of care in many clinical settings, but patient-collected saliva and anterior nares specimens are less invasive and more flexible alternatives. Prior studies comparing specimen types for SARS-CoV-2 molecular testing have been limited by small sample sizes and low pretest probability. We conducted a large observational study among symptomatic adults at 7 emergency departments of Kaiser Permanente Southern California to examine sensitivity of SARS-CoV-2 molecular tests by specimen type and patient characteristics. METHODS: Provider-collected nasopharyngeal/oropharyngeal (NP/OP) specimens and patient-collected saliva and anterior nares specimens were collected at the same visit and analyzed with the Roche cobas® SARS-CoV-2 assay. Patients were considered truly positive for SARS-CoV-2 if any of the three specimens was positive and negative if all three specimens were negative. Factors associated with discordant and missed positive results were examined with multivariable logistic regression. RESULTS: Of 2112 patients, 350 (16.6%) were positive for SARS-CoV-2. Sensitivity of NP/OP was 93.7% (95% confidence interval [CI] 90.6%-96.0%), sensitivity of saliva was 87.7% (83.8%-91.0%), and sensitivity of anterior nares was 85.4% (81.3%-89.0%). Patients ages 18-39 years versus ≥40 years were more likely to have discordant results [adjusted odds ratio (aOR) 1.97 (1.12-3.45)], as were patients with <4 symptoms versus ≥4 [aOR 2.43 (1.39-4.25)]. Cycle threshold values were higher for saliva and anterior nares than NP/OP specimens, as well as for specimens in discordant versus concordant sets and patients with fewer symptoms. CONCLUSION: This study provides robust evidence that patient-collected saliva and anterior nares are sensitive for SARS-CoV-2 molecular testing in emergency department settings, particularly among adults ages ≥40 years and those with multiple symptoms. Higher sensitivity of provider-collected NP/OP specimens must be weighed against the benefits of patient-collected specimens in tailored strategies for SARS-CoV-2 testing.

Technical Note: Volumetric computed tomography for radiotherapy simulation and treatment planning.

PURPOSE: For lung and liver tumors requiring radiotherapy, motion artifacts are common in 4D-CT images due to the small axial field-of-view (aFOV) of conventional CT scanners. This may negatively impact contouring and dose calculation accuracy and could lead to a geographic miss during treatment. Recent advancements in volumetric CT (vCT) enable an aFOV up to 160 mm in a single rotation, which may reduce motion artifacts. However, the impact of large aFOV on CT number required for dose calculation needs to be evaluated before clinical implementation. The objective of this study was to determine the utility of a 256-slice vCT scanner for 4D-CT simulation by evaluating image quality and generating relative electron density (RED) curves. METHODS: Images were acquired on a 256-slice GE Revolution CT scanner with 40 mm, 80 mm, 120 mm, 140 mm, and 160 mm aFOV. Image quality was assessed by evaluating CT number linearity, uniformity, noise, and low-contrast resolution. The relationship between each quality metric and aFOV was assessed. RESULTS: CT number linearity, uniformity, noise, and low-contrast resolution were within the expected range for each image set, except CT number in Teflon and Delrin, which were underestimated. Spearman correlation coefficient (ρ) showed that the CT number for Teflon (ρ = 1.0, p = 0.02), Delrin (ρ = 1.0, p = 0.02), and air (ρ = 1.0, p = 0.02) was significantly related to aFOV, while all other measurements were not. The measured deviations from expected values were not clinically significant. CONCLUSION: These results suggest that vCT can be used for CT simulation for radiation treatment planning.

International Nurses Day 2021 literary contribution: At a fork in the research journey: a poem in resistance to publishing in highly ranked journals.

In celebration of International Nurses Day 2021 and in critique of scholars who are driven to publish as many articles as possible in highly ranked journals, a short poem is offered here. This poem has resonance for the scholarly world in terms of questioning why we keep trying to be seen as successful scholars in the eyes of others employing a publish or perish mentality rather than pursuing the true purpose of our scholarly existence. The author asks nurses, 'Why are you doing science'?

An audit of liquid-based cytology samples reported as high-risk human papillomavirus and borderline nuclear change in endocervical cells.

INTRODUCTION: Primary human papillomavirus (HPV) screening, testing for the virus responsible for 99% of cervical cancers, was introduced in 2018-2020 in the UK. This was preceded by HPV triage of low-grade cytology from 2012. Much of the evidence incorporated into current National Health Service (NHS) colposcopy guidance assessed outcomes prior to this change in screening. The aim of this paper is to assess adherence to NHS cervical screening programme standards, determine the incidence of cases reported as high-risk HPV plus borderline nuclear change in endocervical cells, to calculate colposcopic accuracy and assess histological outcomes in this cohort. METHOD: A retrospective audit of women referred to a colposcopy clinic in one NHS trust from 2016 to 2018. Data relating to histological outcomes, cytological follow-up and demographics were collected. RESULTS: Of 2001 referrals, 22 data sets identifying HPV-positive borderline endocervical change were eligible for analysis (1.2% incidence). Median age was 29.5. Two-thirds (68.2%, n = 15) had high-grade dysplasia at diagnostic biopsy. Those women with reassuring histology had normal cytological follow-up. Colposcopic accuracy was moderate (positive predictive value 43.8%, negative predictive value 100%). CONCLUSIONS: Borderline nuclear change in endocervical cells is an uncommon condition but should be treated as a high-grade referral. All women should be offered a diagnostic biopsy at the initial colposcopy; if no histopathological abnormality is identified, alternative sources of pathology should be considered. Excisional treatment should be recommended to unreliable attenders, those with a complete family and inadequate colposcopy (TZ3) and considered in younger women with a TZ3.

Association between sleep quality and nurse productivity among Korean clinical nurses.

AIMS: To determine the association between sleep quality and nurse productivity. BACKGROUND: Although poor sleep quality may decrease nurses' productivity, the association between the two has not yet been evaluated in the literature. METHODS: A cross-sectional survey was completed in May 2014 by 188 nurses working in acute hospitals in South Korea using the Pittsburgh Sleep Quality Index. Descriptive statistics, t tests, ANOVA, Pearson's correlation, and stepwise multiple regression were conducted for data analysis. RESULTS: The prevalence of poor sleep quality was high (79.8%). Among the components of sleep quality, sleep disturbances (ß = -0.19) and subjective sleep quality (ß = -0.16) were determined to be statistically significant predictive factors of nurse productivity, in addition to shift work (ß = -0.20) and age (ß = 0.32). CONCLUSION: Poor sleep quality may lead to lower nurse productivity. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders and executives should consider measures to improve nurses' sleep quality and enhance nurse productivity. Steps that need to be considered include longer intervals between shift-work cycles, clockwise scheduling order, a longer break time after night shift work, allowing nurses to nap before / during a night shift, and providing a worksite healthy sleep programme.

Optimizing staffing, quality, and cost in home healthcare nursing: theory synthesis.

AIMS: To propose a new theory pinpointing the optimal nurse staffing threshold delivering the maximum quality of care relative to attendant costs in home health care. BACKGROUND: Little knowledge exists on the theoretical foundation addressing the inter-relationship among quality of care, nurse staffing, and cost. DESIGN: Theory synthesis. DATA SOURCES: Cochrane Library, PubMed, CINAHL, EBSCOhost Web and Web of Science (25 February - 26 April 2013; 20 January - 22 March 2015). IMPLICATIONS FOR NURSING: Most of the existing theories/models lacked the detail necessary to explain the relationship among quality of care, nurse staffing and cost. Two notable exceptions are: 'Production Function for Staffing and Quality in Nursing Homes,' which describes an S-shaped trajectory between quality of care and nurse staffing and 'Thirty-day Survival Isoquant and Estimated Costs According to the Nurse Staff Mix,' which depicts a positive quadric relationship between nurse staffing and cost according to quality of care. A synthesis of these theories led to an innovative multi-dimensional econometric theory helping to determine the maximum quality of care for patients while simultaneously delivering nurse staffing in the most cost-effective way. The theory-driven threshold, navigated by Mathematical Programming based on the Duality Theorem in Mathematical Economics, will help nurse executives defend sufficient nurse staffing with scientific justification to ensure optimal patient care; help stakeholders set an evidence-based reasonable economical goal; and facilitate patient-centred decision-making in choosing the institution which delivers the best quality of care. CONCLUSIONS: A new theory to determine the optimum nurse staffing maximizing quality of care relative to cost was proposed.

Korean Patient-Perceived Satisfaction Scale of Community-Based Case Management Services (Korean-PSCCM): Development and Psychometric Evaluation.

This study aimed to develop and psychometrically test an instrument for measuring patient-perceived satisfaction with community-based case management services in Korea. The study was conducted in 4 phases: Phase I, development of the instrument; Phase II, pilot testing of the instrument; Phase III, a large-scale study to test reliability and validity; and Phase IV, conversion of the new instrument from Korean to English. The new instrument was determined to have six factors-advocacy of case manager, outcome of care, communication skills, practice of a healthy lifestyle, referral, and recognition of risk factors-and also shown to be reliable.

Head-to-head comparison of udenafil vs amlodipine in the treatment of secondary Raynaud's phenomenon: a double-blind, randomized, cross-over study.

OBJECTIVE: RP is a reversible vasoconstriction of digital arteries that causes pain and skin discoloration. This study compared the efficacy of the new phosphodiesterase type 5 inhibitor udenafil with that of the calcium channel blocker amlodipine in the treatment of secondary RP. METHODS: A total of 29 patients with secondary RP associated with connective tissue diseases were enrolled in this double-blind, randomized, cross-over study. The patients were randomized to receive udenafil 100 mg/day or amlodipine 10 mg/day for 4 weeks. After a washout period they were crossed over to the other drug for another 4 weeks. The primary outcome was RP frequency before and after treatment. The secondary outcomes were RP condition scores, RP duration, number of digital ulcers, HAQ, physician global assessment and digital artery flow before and after treatment. RESULTS: Amlodipine and udenafil both decreased the rate of RP attack significantly. The drugs did not differ in terms of RP frequency or any of the secondary outcomes except for digital blood flow; udenafil improved it significantly better than amlodipine (P = 0.021). Udenafil was well tolerated without serious adverse effects. CONCLUSION: Udenafil and amlodipine have comparable efficacy in improving RP attacks. In addition, udenafil improves the blood flow in digital arteries compared with amlodipine. TRIAL REGISTRATION: www.clinicaltrials.gov, protocol number NCT01280266.

A cysteine-specific solubilizing tag strategy enables efficient chemical protein synthesis of difficult targets.

We developed a new cysteine-specific solubilizing tag strategy via a cysteine-conjugated succinimide. This solubilizing tag remains stable under common native chemical ligation conditions and can be efficiently removed with palladium-based catalysts. Utilizing this approach, we synthesized two proteins containing notably difficult peptide segments: interleukin-2 (IL-2) and insulin. This IL-2 chemical synthesis represents the simplest and most efficient approach to date, which is enabled by the cysteine-specific solubilizing tag to synthesize and ligate long peptide segments. Additionally, we synthesized a T8P insulin variant, previously identified in an infant with neonatal diabetes. We show that T8P insulin exhibits reduced bioactivity (a 30-fold decrease compared to standard insulin), potentially contributing to the onset of diabetes in these patients. In summary, our work provides an efficient tool to synthesize challenging proteins and opens new avenues for exploring research directions in understanding their biological functions.

The development and validation of a conceptual definition of avoidable transitions from long-term care to the emergency department: A mixed methods study.

Background/Objectives: Transitions to and from Emergency Departments (EDs) can be detrimental to long-term care (LTC) residents and burden the healthcare system. While reducing avoidable transfers is imperative, various terms are used interchangeably including inappropriate, preventable, or unnecessary transitions. Our study objectives were to develop a conceptual definition of avoidable LTC-ED transitions and to verify the level of stakeholder agreement with this definition. Methods: The EXamining Aged Care Transitions study adopted an exploratory sequential mixed-method design. The study was conducted in 2015-2016 in 16 LTC facilities, 1 ED, and 1 Emergency Medical Service (EMS) in a major urban center in western Canada. Phase 1 included 80 participants, (healthcare aides, licensed practical nurses, registered nurses, LTC managers, family members of residents, and EMS staff). We conducted semistructured interviews (n = 25) and focus groups (n = 19). In Phase 2, 327 ED staff, EMS staff, LTC staff, and medical directors responded to a survey based on the qualitative findings. Results: Avoidable transitions were attributed to limited resources in LTC, insufficient preventive care, and resident or family wishes. The definition generated was: A transition of an LTC resident to the ED is considered avoidable if: (a) Diagnostic testing, medical assessment, and treatment can be accessed in a timely manner by other means; (b) the reasons for a transfer are unclear and the transition would increase the disorientation, pain, or discomfort of a resident, outweighing a clear benefit of a transfer; and (c) the transition is against the wishes expressed by the resident over time, including through informal and undocumented conversations. There was a high level of agreement with the definition across the four participant groups. Conclusions and Implications: To effectively reduce LTC resident avoidable transitions, stakeholders must share a common definition. Our conceptual definition may significantly contribute to improved care for LTC residents.

Toward mechatronic MRI-guided focal laser ablation of the prostate: Robust registration for improved needle delivery.

BACKGROUND: Multiparametric MRI (mpMRI) is an effective tool for detecting and staging prostate cancer (PCa), guiding interventional therapy, and monitoring PCa treatment outcomes. MRI-guided focal laser ablation (FLA) therapy is an alternative, minimally invasive treatment method to conventional therapies, which has been demonstrated to control low-grade, localized PCa while preserving patient quality of life. The therapeutic success of FLA depends on the accurate placement of needles for adequate delivery of ablative energy to the target lesion. We previously developed an MR-compatible mechatronic system for prostate FLA needle guidance and validated its performance in open-air and clinical 3T in-bore experiments using virtual targets. PURPOSE: To develop a robust MRI-to-mechatronic system registration method and evaluate its in-bore MR-guided needle delivery accuracy in tissue-mimicking prostate phantoms. METHODS: The improved registration multifiducial assembly houses thirty-six aqueous gadolinium-filled spheres distributed over a 7.3 × 7.3 × 5.2 cm volume. MRI-guided needle guidance accuracy was quantified in agar-based tissue-mimicking prostate phantoms on trajectories (N = 44) to virtual targets covering the mechatronic system's range of motion. 3T gradient-echo recalled (GRE) MRI images were acquired after needle insertions to each target, and the air-filled needle tracks were segmented. Needle guidance error was measured as the shortest Euclidean distance between the target point and the segmented needle trajectory, and angular error was measured as the angle between the targeted trajectory and the segmented needle trajectory. These measurements were made using both the previously designed four-sphere registration fiducial assembly on trajectories (N = 7) and compared with the improved multifiducial assembly using a Mann-Whitney U test. RESULTS: The median needle guidance error of the system using the improved registration fiducial assembly at a depth of 10 cm was 1.02 mm with an interquartile range (IQR) of 0.42-2.94 mm. The upper limit of the one-sided 95% prediction interval of needle guidance error was 4.13 mm. The median (IQR) angular error was 0.0097 rad (0.0057-0.015 rad) with a one-sided 95% prediction interval upper limit of 0.022 rad. The median (IQR) positioning error using the previous four-sphere registration fiducial assembly was 1.87 mm (1.77-2.14 mm). This was found to be significantly different (p = 0.0012) from the median (IQR) positioning error of 0.28 mm (0.14-0.95 mm) using the new registration fiducial assembly on the same trajectories. No significant difference was detected between the medians of the angular errors (p = 0.26). CONCLUSION: This is the first study presenting an improved registration method and validation in tissue-mimicking phantoms of our remotely actuated MR-compatible mechatronic system for delivery of prostate FLA needles. Accounting for the effects of needle deflection, the system was demonstrated to be capable of needle delivery with an error of 4.13 mm or less in 95% of cases under ideal conditions, which is a statistically significant improvement over the previous method. The system will next be validated in a clinical setting.