FMR1 allelic complexity in premutation carriers provides no evidence for a correlation with age at amenorrhea.

BACKGROUND: Premutations in the Fragile X Messenger Ribonucleoprotein 1 (FMR1) gene, defined as between 55 and 200 CGGs, have been implicated in fragile X-associated primary ovarian insufficiency (FXPOI). Only 20% of female premutation carriers develop early ovulatory dysfunction, the reason for this incomplete penetrance is unknown. This study validated the mathematical model in premutation alleles, after assigning each allele a score representing allelic complexity. Subsequently, allelic scores were used to investigate the impact of allele complexity on age at amenorrhea for 58 premutation cases (116 alleles) previously published. METHODS: The allelic score was determined using a formula previously described by our group. The impact of each allelic score on age at amenorrhea was analyzed using Pearson's test and a contour plot generated to visualize the effect. RESULTS: Correlation of allelic score revealed two distinct complexity behaviors in premutation alleles. No significant correlation was observed between the allelic score of premutation alleles and age at amenorrhea. The same lack of significant correlation was observed regarding normal-sized alleles, despite a nearly significant trend. CONCLUSIONS: Our results suggest that the use of allelic scores combination have the potential to explain female infertility, namely the development of FXPOI, or ovarian dysfunction, despite the lack of correlation with age at amenorrhea. Such a finding is of great clinical significance for early identification of females at risk of ovulatory dysfunction, enhancement of fertility preservation techniques, and increasing the probability for a successful pregnancy in females with premutations. Additional investigation is necessary to validate this hypothesis.

The efficacy of bone reconstructive therapies in the management of peri-implantitis. A systematic review and meta-analysis.

AIM: To evaluate the efficacy of bone reconstructive procedures for the reduction of probing pocket depth (PPD), bleeding on probing (BOP), and suppuration in peri-implantitis-related bone defects at ≥12-month follow-up. MATERIALS AND METHODS: Three databases were searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared bone reconstructive therapies to access flap surgery (AFS) (Focused Question-FQ 1), and RCTs, CCTs, and prospective case series that assessed the efficacy of reconstructive therapies (FQ 2). Meta-analysis was performed for FQ1 when more than three studies were identified, while for FQ2 a network was drawn based on RCTs with common treatment arms. RESULTS: Seven RCTs were identified for FQ1 while five RCTs and six prospective case series for FQ2. There was no significant difference in PPD change between AFS and reconstructive surgery (-0.387; p = .325) at 12 months. Furthermore, no clear differences in terms of PPD and BOP changes resulted from the different reconstructive therapies included in the network. Only a small percentage of treated cases with any modality achieved peri-implantitis resolution, as defined by different composite outcomes. CONCLUSIONS: Reconstructive surgery does not offer significant improvements in peri-implant clinical parameters as compared to AFS at 12 months. It was not possible to establish a hierarchy of efficacy among the different biomaterials employed for reconstructive surgery.

Molecular Biomarkers in Peri-Implant Health and Disease: A Cross-Sectional Pilot Study.

BACKGROUND: The aim of this feasibility study was to investigate the concentration level of CCL-20/MIP-3α, BAFF/BLyS, IL-23, RANKL, and Osteoprotegerin in the Peri-Implant Crevicular Fluid (PICF), from patients diagnosed with peri-implant mucositis and peri-implantitis, and to compare them with PICF from patients with healthy implants. METHODS: Participants with at least one dental implant with healthy peri-implant tissues, peri-implant mucositis, or peri-implantitis were included. PICF was collected using paper strips from healthy and diseased peri-implant sites (n = 19). Biomarker levels were analyzed using a custom Multiplex ELISA Assay Kit. RESULTS: In comparison to peri-implant health, the peri-implant mucositis group showed an increased concentration of CCL-20 MIP-3α, BAFF/BLyS, IL-23, RANKL, and Osteoprotegerin. The peri-implantitis group had the lowest median concentration of Osteoprotegerin (1963 ng/mL); this group had a similar concentration of RANKL (640.84 ng/mL) when compared to the peri-implant health group. BAFF/BLyS (17.06 ng/mL) showed the highest concentration in the peri-implantitis group. CONCLUSIONS: This feasibility study suggests that IL-23 and RANKL may help to elucidate the pathogenesis during the conversion from peri-implant health to peri-implantitis. Further research is required in BAFF/BLyS for the early diagnosis of peri-implantitis.

The Effect of Microcosm Biofilm Decontamination on Surface Topography, Chemistry, and Biocompatibility Dynamics of Implant Titanium Surfaces.

Since the inception of dental implants, a steadily increasing prevalence of peri-implantitis has been documented. Irrespective of the treatment protocol applied for the management of peri-implantitis, this biofilm-associated pathology, continues to be a clinical challenge yielding unpredictable and variable levels of resolution, and in some cases resulting in implant loss. This paper investigated the effect of microcosm biofilm in vitro decontamination on surface topography, wettability, chemistry, and biocompatibility, following decontamination protocols applied to previously infected implant titanium (Ti) surfaces, both micro-rough -Sandblasted, Large-grit, Acid-etched (SLA)-and smooth surfaces -Machined (M). Microcosm biofilms were grown on SLA and M Ti discs. These were treated with TiBrushes (TiB), combination of TiB and photodynamic therapy (PDT), combination of TiB and 0.2%CHX/1%NaClO, plus or minus Ultraviolet-C (UV-C) radiation. Surface topography was evaluated by Scanning Electron Microscopy (SEM) and Laser Surface Profilometry. Surface function was analysed through wettability analysis. Surface chemistry evaluation of the discs was performed under SEM/Energy-dispersive X-ray spectroscopy (EDX) and X-ray photoelectron spectroscopy (XPS). Biocompatibility was tested with the cytocompatibility assay using human osteoblast-like osteosarcoma cell line (MG-63) cells. Elemental analysis of the discs disclosed chemical surface alterations resulting from the different treatment modalities. Titanium, carbon, oxygen, sodium, aluminium, silver, were identified by EDX as the main components of all the discs. Based on the data drawn from this study, we have shown that following the decontamination of Ti surfaces the biomaterial surface chemistry and topography was altered. The type of treatment and Ti surface had a significant effect on cytocompatibility (p = 0.0001). Although, no treatment modality hindered the titanium surface biocompatibility, parameters such as the use of chemical agents and micro-rough surfaces had a higher cytotoxic effect in MG-63 cells. The use of smooth surfaces, and photofunctionalisation of the TiO2 layer had a beneficial effect on cytocompatibility following decontamination.

Adverse Drug Event-Related Admissions to a Pediatric Emergency Unit.

OBJECTIVES: The objectives of this study were to analyze adverse drug events (ADEs) related to admissions to a pediatric emergency unit and to identify the associated risk factors. METHODS: This was a prospective study. Demographic data and details of medications were collected for each patient admitted. Case studies were performed by clinical pharmacists and the clinical team to discuss whether the admission was due to an ADE and to characterize the ADE. Multivariate logistic regression was used for statistical analysis. RESULTS: In total, 1708 pediatric patients were included in this study. Adverse drug events were the cause of hospital admission in 12.3% of the studied population. The majority of patients presenting with an ADE were in the age group of 0 to 5 years (61.6%), had a mean ± SD age of 4.9 ± 3.9 years, were female (51.2%), were Caucasian (72.0%), and had infectious disorders (49.3%). High frequencies of medication errors (68.8%), use of drugs to treat respiratory disorders (27.7%), and ADEs of mild severity (75.3%) were reported. The risk of being admitted to the pediatric emergency unit for any ADE increased in cases of neurological (odds ratio [OR], 4.63; 95% confidence interval [CI], 2.38-8.99), dermatological (OR, 3.16; 95% CI, 1.93-5.18), and respiratory (OR, 3.02; 95% CI, 1.89-4.83) disorders. CONCLUSIONS: A high frequency of ADE-related admissions to the pediatric emergency unit was observed. The risk of being admitted to the pediatric emergency unit for any ADE increased in cases of neurological, dermatological, and respiratory disorders. Clinical pharmacists play an important role in the identification of ADEs and the education of child caregivers and health care providers concerning pediatric medication.

Differences in the periodontal microbiome of successfully treated and persistent aggressive periodontitis.

AIMS: The primary aim of this investigation was to analyse the periodontal microbiome in patients with aggressive periodontitis (AgP) following treatment. METHODS: Sixty-six AgP patients were recalled on average 7 years after completion of active periodontal treatment and had subgingival plaque samples collected and processed for 16S rRNA gene sequencing analyses. RESULTS: Of 66 participants, 52 showed persistent periodontal disease, while 13 participants were considered as "successfully treated AgP" (no probing pocket depths >4 mm) and 1 was fully edentulous. Genera associated with persistent generalized disease included Actinomyces, Alloprevotella, Capnocytophaga, Filifactor, Fretibacterium, Fusobacterium, Leptotrichia, Mogibacterium, Saccharibacteria [G-1], Selenomonas and Treponema. "Successfully treated" patients harboured higher proportions of Haemophilus, Rothia, and Lautropia and of Corynebacterium, Streptococcus and Peptidiphaga genera. Overall, patients with persistent generalized AgP (GAgP) revealed higher alpha diversity compared to persistent localized AgP (LAgP) and stable patients (p < .001). Beta diversity analyses revealed significant differences only between stable and persistent GAgP groups (p = .004). CONCLUSION: Patients with persistent AgP showed a more dysbiotic subgingival biofilm than those who have been successfully treated. It remains to be established whether such differences were predisposing to disease activity or were a result of a dysbiotic change associated with disease recurrence in the presence of sub-standard supportive periodontal therapy or other patient-related factors.

Cisplatin-induced human peripheral blood mononuclear cells' oxidative stress and nephrotoxicity in head and neck cancer patients: the influence of hydrogen peroxide.

Cisplatin is a widely used antineoplastic agent in the treatment of head and neck cancer. However, it is highly nephrotoxic. Oxidative stress is the main mechanism responsible for cisplatin-induced nephrotoxicity. The aim of this study was to characterize cisplatin-induced nephrotoxicity, oxidative stress in peripheral blood mononuclear cells, and the relationship between them. Twenty-four patients were included in the study. Patients had their blood collected prior to cisplatin administration, and 5 and 20 days after initiating therapy, to assess renal function and to determine oxidative stress with MitoSOX™Red, H2DCF-DA, and Amplex® Red tests. Renal function was assessed by measuring serum creatinine, creatinine clearance, and blood urea nitrogen (BUN). Serum creatinine and creatinine clearance were used to grade nephrotoxicity using Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Compared to baseline values, the mean BUN and serum creatinine increased 135 and 100%, respectively, 5 days after cisplatin infusion. Mean creatinine clearance showed a 43% decrease compared to baseline value. Non-statistically significant changes in superoxide anion (O 2•- ), hydrogen peroxide (H2O2), and general reactive oxygen species production occurred. A higher production of H2O2 was correlated with variation in serum creatinine, and was associated with higher grades for serum creatinine increases and creatinine clearance reductions. Linear regression analyses showed an association between H2O2 production and serum creatinine, creatinine clearance, and BUN levels. These results were observed for 5 days following cisplatin administration. In conclusion, H2O2 production was significantly related to changes in all renal parameters that were evaluated, following the cisplatin infusion.

Peri-implant and periodontal microbiome diversity in aggressive periodontitis patients: a pilot study.

AIM: To investigate the bacterial microbiome in periodontal and peri-implant biofilms deriving from aggressive periodontitis patients (AgP) in conditions of health and disease. MATERIAL AND METHODS: Ninety-one plaque samples were collected from 18 patients previously diagnosed and treated for AgP. The samples were taken from (i) 24 residual periodontal pockets (TD) (n = 6 patients), (ii) 24 healthy periodontal sites (TH) (n = 6 patients), (iii) 24 dental sites from the same implant patients (TM) (n = 6 patients), (iv) 5 peri-implantitis sites (II) (n = 2 patients), (v) 6 peri-mucositis sites (IM) (n = 2 patients) and (vi) 8 healthy implant sites (IH) (n = 2 patients). All subjects underwent periodontal clinical and radiographic assessments. Bacterial DNA was extracted, PCR amplified using 16S rRNA gene V5-V7 primers (barcoded amplicons 785F;1175R), purified, pooled at equimolar concentrations and sequenced (MiSeq, Illumina) yielding 250 bp paired-end reads. The 16S rRNA reads were filtered, assembled and analysed. RESULTS: The genera Propionibacterium, Paludibacter, Staphylococcus, Filifactor, Mogibacterium, Bradyrhizobium and Acinetobacter were unique to peri-implant sites (P = 0.05). In TM samples, different proportions and bacterial spp. were found when compared with the same patients' samples at implant sites. Specifically, Actinomyces (P = 0.013) and Corynebacterium (P = 0.030) genera showed to be significantly more abundant in the TM group when compared to the II. The highest phylogenetic diversity was observed in residual periodontal pocket sites (TD). Increased annual tooth loss rate and residual pocketing was related to high proportions of the genera Actinomyces, Porphyromonas, Prevotella, Streptococcus, Actinomycetaceae, TM7-3, Selenomonas, and Dialister, Treponema, Parvimonas and Peptostreptococcus in the TD group. CONCLUSION: Within the limitations of this pilot study, the periodontal and peri-implant microbiome presents a dissimilar taxonomic composition across different niches within AgP patients. The host response, the habitat structure and the vast coexistence of strains and species surrounding implants and teeth in health and disease are likely to be shaping the heterogeneous composition of the subgingival biofilms. The TM7 phylum was found only in TD cases. The investigation of the impact of periodontal and peri-implant keystone species on these complex ecosystems in states of health and disease seems to be essential.

Toward Meaningful Care Plan Clinical Decision Support: Feasibility and Effects of a Simulated Pilot Study.

BACKGROUND: Clinical decision support (CDS) tools-with easily understood and actionable information, at the point of care-are needed to help registered nurses (RNs) make evidence-based decisions. Not clear are the optimal formats of CDS tools. Thorough, preclinical testing is desirable to avoid costly errors associated with premature implementation in electronic health records. OBJECTIVE: The aims of this study were to determine feasibility of the protocol designed to compare multiple CDS formats and evaluate effects of numeracy and graph literacy on RN adoption of best practices and care planning time in a simulated environment. METHODS: In this pilot study, 60 RNs were randomly assigned to one of four CDS conditions (control, text, text + graph, and text + table) and asked to adjust the plan of care for two patient scenarios over three shifts. Fourteen best practices were identified for the two patients and sent as suggestions with evidence to the three CDS groups. Best practice adoption rates, care planning time, and their relationship to the RN's numeracy and graph literacy scores were assessed. RESULTS: CDS groups had a higher adoption rate of best practices (p < .001) across all shifts and decreased care planning time in shifts 2 (p = .01) and 3 (p = .02) compared with the control group. Higher numeracy and graph literacy were associated with shorter care planning times under text + table (p = .05) and text + graph (p = .01) conditions. No significant differences were found between the three CDS groups on adoption rate and care planning time. DISCUSSION: This pilot study shows the feasibility of our protocol. Findings show preliminary evidence that CDS improves the efficiency and effectiveness of care planning decisions and that the optimal format may depend on individual RN characteristics. We recommend a study with sufficient power to compare different CDS formats and assess the impact of potential covariates on adoption rates and care planning time.

Association of Catalase and Glutathione Peroxidase 1 Polymorphisms with Chronic Hepatitis C Outcome.

The hepatic damage caused by hepatitis C virus (HCV) infection is associated with the host immune response and viral regulatory factors. Catalase (CAT) and glutathione peroxidase 1 (GPX1) are antioxidant enzymes located in the peroxisomes and mitochondria, respectively, and are responsible for the control of intracellular hydrogen peroxide levels. Polymorphisms in CAT (C-262T) and GPX1 (Pro198Leu) are correlated with serum levels and enzyme activity. This study aimed to investigate the association of genetic polymorphisms of CAT C-262T (rs1001179) and GPX1 Pro198Leu (rs1050450) with different stages of liver fibrosis and development of hepatocellular carcinoma (HCC). This study included 445 patients with chronic hepatitis C, of whom 139 patients had mild fibrosis (F0-F1), 200 had moderate/severe fibrosis (F2-F4), and 106 had HCC. Genotyping of SNPs was performed by real-time PCR using TaqMan probes. The Pro/Pro genotype of GPX1 was significantly associated with fibrosis severity, HCC, Child Pugh score, and BCLC staging. Additionally, patients carrying both CT+TT genotypes in the CAT gene and the Pro/Pro genotype in the GPX1 gene had higher risk for developing moderate/severe fibrosis or HCC (p = 0.009, OR 2.40 and p = 0.002, OR 3.56, respectively). CAT and GPX1 polymorphisms may be implicated in the severity of liver fibrosis and HCC caused by HCV.

An in vitro study on disinfection of titanium surfaces.

OBJECTIVE: The aim of this in vitro study was to evaluate the efficacy of different methods used for the decontamination of titanium surfaces previously infected with a Staphylococcus aureus biofilm. MATERIALS AND METHODS: S. aureus biofilms were grown on three different titanium surfaces (n = 114); polished, sandblasted large-grit acid-etched (SLA) and SLActive. The experimental groups were divided into six different disinfection modalities as follows: (i) rinsing with phosphate-buffered saline, (ii) rinsing with chlorhexidine digluconate 0.2% (CHX), (iii) application of photodynamic therapy (PDT), (iv) use of cotton pellet, (v) use of titanium brush (TiB) and (vi) the use of TiB and PDT. The decontamination effect of each modality was evaluated by microbial culture analysis and by scanning electron microscopy imaging. Two-way analysis of variance (ANOVA) and Bonferroni's post hoc comparisons were used to compare mean differences between colony-forming units per millilitre (CFU/ml) values, surfaces and treatments (P < 0.025). RESULTS: This study demonstrated that the combination protocol (TiB and PDT) was the most effective in reducing S. aureus (P < 0.025) on polished (2.0 × 103  CFU/Disc) and SLA surface (6.9 × 103  CFU/Disc). On the SLActive surface, the combination treatment was not significantly different to the TiB group (1.0 × 105 CFU/Disc) or the PDT group (2.0 × 105 CFU/Disc). CONCLUSION: The combined technique of TiB and PDT was shown to be an efficient method in reducing the number of S. aureus in both polished and rough titanium surfaces. These findings prompt further investigations in titanium decontamination techniques with a combination of TiB and PDT within a natural microcosm bacterial environment.

Experimental models for contamination of titanium surfaces and disinfection protocols.

AIM: The aim of this pilot study was to describe an in vitro model of peri-implantitis microcosm for contamination of titanium surfaces and an in vivo model for evaluating different disinfection strategies of titanium surfaces. MATERIALS AND METHODS: Biofilms were grown in vitro for 30 days on sandblasted large-grit acid-etched (SLA) Ti discs (n = 69) in a constant depth film fermentor (CDFF) associated with peri-implantitis conditions. Four Swedish loop rabbits were randomly allocated in three test groups (T1 , T2 , T3 ) and one control group (C). In group C, two sterile SLA Ti discs were implanted/fixed in each tibia. In the test groups (to evaluate the potential of different surface disinfection techniques), one sterile and three previously disinfected SLA Ti discs were placed following different disinfection protocols: group T1 : the discs were treated with a titanium brush - TiB; group T2 : the discs were treated with the combination of TiB and photodynamic therapy; and group T3 : the discs were treated with TiB and 1%NaOCl plus 0.2%CHX. Tensile strength test and qualitative histological analysis were performed on all 16 discs after 4 weeks of healing. RESULTS: Thirty days following CDFF emulating peri-implantitis microcosm, all SLA Ti discs had a mean total viable aerobes and facultative anaerobes count of 8.06 log10  CFU/biofilm and anaerobes 8.32 log10  CFU/biofilm. Before implantation/fixation on the tibia, differences of log10  CFU/biofilm counts between control and test groups after post hoc adjustment were highly significant (P < 0.001). In the in vivo analysis, group C exhibited the highest tensile strength (67.60 N [25.64-127.02]) and the histological sections revealed the presence of dense mature bone in direct contact with the disc surface. The analysis at the test groups showed that T2 presented with the highest tensile strength in comparison with the other two test groups. CONCLUSIONS: The in vitro model used in this study provides a valuable and reproducible tool for evaluating the in vitro dynamics of the peri-implantitis microcosm biofilm and for contaminating in a reproducible manner titanium surfaces. At the same time, the in vivo model used in this study provides a standardised mode of evaluating disinfection modalities of previously infected titanium surfaces.

A systematic review of implant outcomes in treated periodontitis patients.

OBJECTIVES: To investigate the effect of treated periodontitis on implant outcomes in partially edentulous individuals compared with periodontally healthy patients. MATERIAL AND METHODS: Longitudinal studies reporting on implant survival, success, incidence of peri-implantitis, bone loss and periodontal status, and on partially dentate patients with a history of treated periodontitis were included. RESULTS: The search yielded 14,917 citations. Twenty-seven publications met the inclusion criteria for qualitative data synthesis. Implant success and survival were higher in periodontally healthy patients, whilst bone loss and incidence of peri-implantitis was increased in patients with history of treated periodontitis. There was a higher tendency for implant loss and biological complications in patients previously presenting with severe forms of periodontitis. The strength of the evidence was limited by the heterogeneity of the included studies in terms of study design, population, therapy, unit of analysis, inconsistent definition of baselines and outcomes, as well as by the inadequate reporting of statistical analysis and accounting for confounding factors; thus, meta-analysis could not be performed. CONCLUSIONS: Implants placed in patients treated for periodontal disease are associated with higher incidence of biological complications and lower success and survival rates than those placed in periodontally healthy patients. Severe forms of periodontal disease are associated with higher rates of implant loss. However, it is critical to develop well-designed, long-term prospective studies to provide further substantive evidence on the association of these outcomes.

Clinical validation of the NANDA-I diagnosis of impaired memory in elderly patients.

PURPOSE: The aim of this study was to perform a clinical validation of the defining characteristics of impaired memory (IM) in elderly patients at a long-term care institution. METHODS: A sample of 123 elderly patients was evaluated with a questionnaire designed to identify IM according to the NANDA-I taxonomy. Accuracy measures were calculated for the total sample and for males and females separately. RESULTS: Sensitivity and specificity values indicated that: (1) inability to learn new skills is useful in screening IM, and (2) forgets to perform a behavior at a scheduled time, forgetfulness, inability to learn new information, inability to recall events, and inability to recall factual information are confirmatory indicators. CONCLUSION: Specific factors can affect the manifestation of IM by elderly patients. The results may be useful in improving diagnostic accuracy and efficiency of the IM nursing diagnosis.

Ineffective airway clearance in adult patients after thoracic and upper abdominal surgery.

AIM: The aim of this study is to analyze the accuracy of the defining characteristics of ineffective airway clearance (IAC) in patients after thoracic and upper abdominal surgery. BACKGROUND: Although numerous studies have described the most prevalent respiratory NANDA-I diagnoses, only few investigates the precision of nursing assessments. METHODS: A cross-sectional study was conducted with 192 patients in a surgical clinic. Accuracy measures were obtained by the latent class analysis method. RESULTS: IAC was present in 46.73% of the sample. The defining characteristics with better predictive capacity were changes in respiratory rate and changes in respiratory rhythm. However, other defining characteristics also had high specificity, such as restlessness, cyanosis, excessive sputum, wide-eyed, orthopnea, adventitious breathing sounds, ineffective cough, and difficulty vocalizing. CONCLUSION: Results can contribute to the improvement of nursing assessments by providing information about the key clinical indicators of IAC.

Ineffective breathing pattern in cardiac postoperative patients: Diagnostic accuracy study.

PURPOSE: The aim of this study was to analyze the accuracy of the defining characteristics of ineffective breathing pattern (IBP) in postoperative cardiac patients. METHODS: A diagnostic accuracy study was performed with 98 patients. Measures of sensitivity, specificity, predictive values, likelihood ratios, diagnostic odds ratio, and area under the ROC curve were calculated. RESULTS: IBP was present in 23.5% of the patients. Alterations in depth of breathing (sensitivity 96%, negative likelihood ratio 0.11%) and pursed-lip breathing (sensitivity 99%, negative likelihood ratio 0.07%) were the most sensitive defining characteristics for IBP, while altered chest excursion (specificity 97%, positive likelihood ratio 11.41%) and prolonged expiration phase (specificity 99%, positive likelihood ratio 42.39%) were the most specific. CONCLUSION: Some clinical indicators were more related to the presence or absence of IBP than others. Knowledge of such measures can help nurses to assess patients more accurately.

Nurses' Numeracy and Graphical Literacy: Informing Studies of Clinical Decision Support Interfaces.

We present findings of a comparative study of numeracy and graph literacy in a representative group of 60 practicing nurses. This article focuses on a fundamental concern related to the effectiveness of numeric information displayed in various features in the electronic health record during clinical workflow. Our findings suggest the need to consider numeracy and graph literacy when presenting numerical information as well as the potential for tailoring numeric display types to an individual's cognitive strengths.

Systematic review and meta-analysis of the accuracy of clinical indicators for ineffective airway clearance.

AIM: To report quantitative evidence for the accuracy of the defining characteristics of ineffective airway clearance in different settings and populations. BACKGROUND: Defining characteristics are tests used by nurses to clinically indicate the presence or absence of a particular nursing diagnosis. A few studies have reported the accuracy of certain defining characteristics of ineffective airway clearance, but these studies address specific populations with particular needs. DESIGN: A systematic review with meta-analysis was conducted to provide a synthesis and critical appraisal of the included studies. DATA SOURCES: The electronic databases CINAHL, PubMed, Scopus and LILACS were searched using a systematic search strategy for studies published in any year. The last search was performed on 31 July 2013. REVIEW METHODS: Using the recommendations from Cochrane Collaboration for Systematic Reviews of Diagnostic Test Accuracy and the Standards for Reporting of Diagnostic Accuracy (STARD), a systematic review was conducted using studies investigating the presence of ineffective airway clearance and its defining characteristics. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used to evaluate the quality of the studies. RESULTS: Seven papers met the search criteria. The studies were developed in different clinical settings and most of them fulfilled QUADAS criteria. Summary measures indicated the following defining characteristics with higher accuracy values: adventitious breath sounds, changes in respiratory rate, difficult vocalizing, diminished breath sounds, dyspnoea, ineffective cough, orthopnoea and restlessness. CONCLUSION: This systematic review showed that the variability in clinical indicators of ineffective airway clearance is related to differences in the clinical settings and patients.

Defining the key clinical indicators for ineffective breathing pattern in paediatric patients: a meta-analysis of accuracy studies.

AIMS AND OBJECTIVES: The purpose of this study was to identify the key clinical indicators of ineffective breathing pattern among paediatric patients. BACKGROUND: When nurses perform clinical reasoning, certain characteristics represent the clinical indicators necessary to confirm the presence of a particular diagnosis. Some quantitative studies have reported the prevalence of ineffective breathing pattern in different samples of patients. However, these findings should be synthesised. DESIGN: Meta-analysis of quantitative nursing studies. METHODS: Studies were identified via systematic searches of CINAHL, LILACS, PubMed and Scopus using the key search terms 'ineffective', 'breathing' and 'pattern'. Additional quality-related inclusion criteria were gleaned from the Cochrane Collaboration for Systematic Reviews of Diagnostic Test Accuracy, the Standards for Reporting of Diagnostic Accuracy and the Quality Assessment of Diagnostic Accuracy Studies. The pertinent results from each study were extracted and analysed via meta-analysis. RESULTS: Six studies using paediatric populations met the inclusion criteria. Summary measures indicated that the following defining characteristics had the highest accuracy values for ineffective breathing pattern among children: bradypnoea, dyspnoea, nasal flaring, orthopnoea, tachypnoea and the use of accessory muscles to breathe. CONCLUSION: This meta-analysis provides information regarding the accuracy of the clinical indicators of ineffective breathing pattern from studies sampling diverse paediatric populations. RELEVANCE TO CLINICAL PRACTICE: Nurses can better use clinical indicators to infer the presence of ineffective breathing pattern when they are aware of the most relevant defining characteristics. Nursing students and professionals can also improve their critical thinking abilities and diagnostic reasoning based on these findings.

Use of Simulation to Study Nurses' Acceptance and Nonacceptance of Clinical Decision Support Suggestions.

Our long-term goal was to ensure nurse clinical decision support works as intended before full deployment in clinical practice. As part of a broader effort, this pilot project explored factors influencing acceptance/nonacceptance of eight clinical decision support suggestions displayed in an electronic health record-based nursing plan of care software prototype. A diverse sample of 21 nurses participated in this high-fidelity clinical simulation experience and completed a questionnaire to assess reasons for accepting/not accepting the clinical decision support suggestions. Of 168 total suggestions displayed during the experiment (eight for each of the 21 nurses), 123 (73.2%) were accepted, and 45 (26.8%) were not accepted. The mode number of acceptances by nurses was seven of eight, with only two of 21 nurses accepting all. The main reason for clinical decision support acceptance was the nurse's belief that the suggestions were good for the patient (100%), with other features providing secondary reinforcement. Reasons for nonacceptance were less clear, with fewer than half of the subjects indicating low confidence in the evidence. This study provides preliminary evidence that high-quality simulation and targeted questionnaires about specific clinical decision support selections offer a cost-effective means for testing before full deployment in clinical practice.