Preparing healthcare professional students for rural, regional and remote practice: demonstrating the effectiveness of an interprofessional simulation learning experience.

Undertaking an authentic interprofessional simulation experience may be a useful and consistent strategy for healthcare professional students to build competencies required for a rural healthcare context. An observational comparative study design was adopted to evaluate a clinical simulation experience created to develop the interprofessional competencies of a sample of healthcare professional students at a regional university situated on multiple campuses in New South Wales (NSW), Australia. Over 200 students across three campuses of the university were involved in a simulation experience that included four interprofessional activities. Of these students, 189 (89%) agreed to participate in the study. The healthcare professional students who participated in the study were from second year occupational therapy, physiotherapy, and podiatry, and third year speech pathology programs. Retrospective pre and post self-assessed interprofessional collaborative competencies were compared for all students using the revised Interprofessional Collaborative Attainment Survey (ICCAS). Results demonstrated a statistically significant improvement in self-perceived scores using the validated revised ICCAS survey. The findings of this study suggest that carefully designed and authentic interprofessional simulation experiences can facilitate the development of competencies required for effective interprofessional practice, which are necessary for successful rural practice.

Shedding Light on Telemedicine & Online Prescribing: The Need to Balance Access to Health Care and Quality of Care.

The issue of online prescribing through the use of telemedicine raises ethical concerns. In particular, several studies suggest a correlation between telemedicine and overprescribing. Meanwhile, new developments in the law also have the potential to significantly impact online prescribing using telemedicine. In the absence of concrete federal guidance and a continued delay in issuing required federal regulations, states have developed their own laws, which vary considerably, regarding the ability of physicians to engage in online prescribing through telemedicine. As legal developments open doors for physicians to prescribe through telemedicine, current evidence of overprescribing, although limited, suggests the need to carefully balance access to health care and quality of care in this context, especially when crafting innovative legislative responses.This article attempts to explore this dynamic issue by closely evaluating the research on overprescribing involving telemedicine and the ethical issues surrounding online prescribing. It will continue by analyzing the current legal landscape for online prescribing for telemedicine at both the federal and state levels. Next, this article will examine ethics opinions offered by medical groups that touch this issue. Finally, this article will suggest several recommendations for law and policy moving forward by shedding light on the ethical issues surrounding telemedicine and online prescribing and how to strike a balance between access and quality of care.

Sustainability and Outcomes of a Suicide Prevention Program for Nurses.

BACKGROUND: We now know that nurses are at greater risk for suicide than others in the general population. It is known that job stressors are prevalent in nurses who die by suicide. Yet, little is known about targeted suicide prevention for nurses. The first nurse-centric Healer Education Assessment and Referral (HEAR) suicide prevention program was piloted for 6 months in 2016. The HEAR program was effective in identifying at-risk nurses. AIM: The purpose of this paper is to report the 3-year sustainability and outcomes of this nurse suicide prevention program. METHODS: Descriptive statistics are provided of program outcomes over the course of 3 years. RESULTS: Over the 3 years, 527 nurses have taken advantage of the screening portion of the program. Of these, 254 (48%) were Tier 1 high risk, and 270 (51.2%) were Tier 2 moderate risk. A startling 48 (9%) had expressed thoughts of taking their own life, 51 (9.7%) had a previous suicide attempt, whereas only 79 (15%) were receiving counseling or therapy. One hundred seventy-six nurses received support from therapists electronically, over the phone, or in person; 98 nurses accepted referral for treatment. The number of group emotional debriefs rose from eight in 2016 to 15 in 2017 to 38 in fiscal year 2019. Many of the debriefs are now requested (vs. offered), demonstrating the development of a culture open to reaching out for mental health treatment. LINKING EVIDENCE TO ACTION: The initial success of this pilot program has been sustained. A nurse suicide prevention program of education, assessment, and referral is feasible, well-received, proactively identifies nurses with reported suicidality and facilitates referral for care. The HEAR program has provided service to physicians and residents for 10 years and now supports effectiveness in nurses. The HEAR program is portable and ready for replication at other institutions.

Quantitative tools for implementing the new definition of significant portion of the range in the U.S. Endangered Species Act.

In 2014, the Fish and Wildlife Service (FWS) and National Marine Fisheries Service announced a new policy interpretation for the U.S. Endangered Species Act (ESA). According to the act, a species must be listed as threatened or endangered if it is determined to be threatened or endangered in a significant portion of its range (SPR). The 2014 policy seeks to provide consistency by establishing that a portion of the range should be considered significant if the associated individuals' "removal would cause the entire species to become endangered or threatened." We reviewed 20 quantitative techniques used to assess whether a portion of a species' range is significant according to the new guidance. Our assessments are based on the 3R criteria-redundancy (i.e., buffering from catastrophe), resiliency (i.e., ability to withstand stochasticity), and representation (i.e., ability to evolve)-that the FWS uses to determine if a species merits listing. We identified data needs for each quantitative technique and considered which methods could be implemented given the data limitations typical of rare species. We also identified proxies for the 3Rs that may be used with limited data. To assess potential data availability, we evaluated 7 example species by accessing data in their species status assessments, which document all the information used during a listing decision. In all species, an SPR could be evaluated with at least one metric for each of the 3Rs robustly or with substantial assumptions. Resiliency assessments appeared most constrained by limited data, and many species lacked information on connectivity between subpopulations, genetic variation, and spatial variability in vital rates. These data gaps will likely make SPR assessments for species with complex life histories or that cross national boundaries difficult. Although we reviewed techniques for the ESA, other countries require identification of significant areas and could benefit from this research.

Recreation economics to inform migratory species conservation: Case study of the northern pintail.

Quantification of the economic value provided by migratory species can aid in targeting management efforts and funding to locations yielding the greatest benefits to society and species conservation. Here we illustrate a key step in this process by estimating hunting and birding values of the northern pintail (Anas acuta) within primary breeding and wintering habitats used during the species' annual migratory cycle in North America. We used published information on user expenditures and net economic values (consumer surplus) for recreational viewing and hunting to determine the economic value of pintail-based recreation in three primary breeding areas and two primary wintering areas. Summed expenditures and consumer surplus for northern pintail viewing were annually valued at $70M, and annual sport hunting totaled $31M (2014 USD). Expenditures for viewing ($42M) were more than twice as high than those for hunting ($18M). Estimates of consumer surplus, defined as the amount consumers are willing to pay above their current expenditures, were $15M greater for viewing ($28M) than for hunting ($13M). We discovered substantial annual consumer surplus ($41M) available for pintail conservation from birders and hunters. We also found spatial differences in economic value among the primary regions used by pintails, with viewing generally valued more in breeding regions than in wintering regions and the reverse being true for hunting. The economic value of pintail-based recreation in the Western wintering region ($26M) exceeded that in any other region by at least a factor of three. Our approach of developing regionally explicit economic values can be extended to other taxonomic groups, and is particularly suitable for migratory game birds because of the availability of large amounts of data. When combined with habitat-linked population models, regionally explicit values could inform development of more effective conservation finance and policy mechanisms to enhance environmental management and societal benefits across the geographically dispersed areas used by migratory species.

Willingness to Pay for Conservation of Transborder Migratory Species: A Case Study of the Mexican Free-Tailed Bat in the United States and Mexico.

We estimated U.S. and Mexican citizens' willingness to pay (WTP) for protecting habitat for a transborder migratory species, the Mexican free-tailed bat (Tadarida brasiliensis mexicana), using the contingent valuation method. Few contingent valuation surveys have evaluated whether households in one country would pay to protect habitat in another country. This study addresses that gap. In our study, Mexican respondents were asked about their WTP for conservation of Mexican free-tailed bat habitat in Mexico and in the United States. Similarly, U.S. respondents were asked about their WTP for conservation in the United States and in Mexico. U.S. households would pay $30 annually to protect habitat in the United States and $24 annually to protect habitat in Mexico. Mexican households would pay $8 annually to protect habitat in Mexico and $5 annually to protect habitat in the United States. In both countries, these WTP amounts rose significantly for increasing the size of the bat population rather than simply stabilizing the current bat population. The ratio of Mexican household WTP relative to U.S. household WTP is nearly identical to that of Mexican household income relative to U.S. household income. This suggests that the perceived economic benefits received from the bats is similar in Mexico and the United States, and that scaling WTP by relative income in international benefit transfer may be plausible.

Integrative analyses reveal signaling pathways underlying familial breast cancer susceptibility.

The signaling events that drive familial breast cancer (FBC) risk remain poorly understood. While the majority of genomic studies have focused on genetic risk variants, known risk variants account for at most 30% of FBC cases. Considering that multiple genes may influence FBC risk, we hypothesized that a pathway-based strategy examining different data types from multiple tissues could elucidate the biological basis for FBC. In this study, we performed integrated analyses of gene expression and exome-sequencing data from peripheral blood mononuclear cells and showed that cell adhesion pathways are significantly and consistently dysregulated in women who develop FBC. The dysregulation of cell adhesion pathways in high-risk women was also identified by pathway-based profiling applied to normal breast tissue data from two independent cohorts. The results of our genomic analyses were validated in normal primary mammary epithelial cells from high-risk and control women, using cell-based functional assays, drug-response assays, fluorescence microscopy, and Western blotting assays. Both genomic and cell-based experiments indicate that cell-cell and cell-extracellular matrix adhesion processes seem to be disrupted in non-malignant cells of women at high risk for FBC and suggest a potential role for these processes in FBC development.

Electron microscopy elucidates eosinophil degranulation patterns in patients with eosinophilic esophagitis.

BACKGROUND: In patients with eosinophilic esophagitis (EoE), eosinophils accumulate and release granule proteins onto esophageal epithelium. However, little is understood about the mechanism of eosinophil degranulation. OBJECTIVE: To determine and quantify eosinophil degranulation patterns, we studied esophageal biopsy specimens from both the proximal and distal esophagi of 9 randomly selected patients with EoE. METHODS: The specimens were fixed in glutaraldehyde, embedded, sectioned, and imaged by means of transmission electron microscopy. Eosinophils and their granules were identified by their distinctive morphology, and all eosinophils and granules were imaged. A total of 1672 images from 18 esophageal specimens were evaluated and graded. Eosinophils were categorized based on membrane integrity and by cytoplasmic vesiculation as evidence of piecemeal degranulation. Granules were categorized based on reversal of staining (eosinophil granule core lightening) and localization within and outside the cells. RESULTS: The results revealed that greater than 98% of eosinophils infiltrating the esophagus in patients with EoE demonstrate morphologic abnormalities ranging from granule changes with reversal of staining to marked cytoplasmic vesiculation to loss of cellular membrane integrity with cytolytic disruption and release of intact membrane-bound granules into the tissues. Approximately 81% of eosinophils showed membrane disruption. Extracellular granules were abundant in at least 70% of the images, and approximately 50% of these granules showed reversal of staining. On the basis of the prominence of tubulovesicular development, piecemeal degranulation appears closely related to the other morphologic changes seen in patients with EoE. CONCLUSION: These findings reveal that eosinophils in esophageal biopsy specimens from patients with EoE are abnormal, with greater than 80% showing cytolysis, and therefore that evaluation by means of light microscopy after hematoxylin and eosin staining might not accurately reflect eosinophil involvement.

Potential for spatial coexistence of a transboundary migratory species and wind energy development.

Global expansion in wind energy development is a notable achievement of the international community's effort to reduce carbon emissions during energy production. However, the increasing number of wind turbines have unintended consequences for migratory birds and bats. Wind turbine curtailment and other mitigation strategies can reduce fatalities, but improved spatial and temporal data are needed to identify the most effective way for wind energy development and volant migratory species to coexist. Mexican free-tailed bats (Tadarida brasiliensis mexicana) account for a large proportion of known bat fatalities at wind facilities in the southwestern US. We examined the geographic concordance between existing wind energy generation facilities, areas of high wind potential amenable for future deployment of wind facilities, and seasonally suitable habitat for these bats. We used ecological niche modeling to determine species distribution during each of 4 seasons. We used a multi-criteria GIS-based approach to produce a wind turbine siting suitability map. We identified seasonal locations with highest and lowest potential for the species' probability of occurrence, providing a potential explanation for the higher observed fatalities during fall migration. Thirty percent of 33,606 wind turbines within the southwestern US occurred in highly suitable areas for Mexican free-tailed bats, primarily in west Texas. There is also broad spatial overlap between areas of high wind potential and areas of suitable habitat for Mexican free-tailed bats. Because of this high degree of overlap, our results indicate that post-construction strategies, such as curtailing the timing of operations and deterrents, would be more effective for bat conservation than strategic siting of new wind energy installations.

From the membrane to the nucleus and back again: bifunctional focal adhesion proteins.

Cell substratum adhesion influences a variety of processes including motility, proliferation and survival. In recent years, it has become clear that there are proteins that are capable of shuttling between cell adhesion zones and the nucleus, providing a mechanism for transcellular coordination and communication. Recent findings have given insight into the physiological signals that trigger trafficking of focal adhesion constituents to the nucleus, where they make diverse contributions to the control of gene expression.

The Current State of U.S. Regulation of Electronic Monitoring to Combat Elder Abuse and Its Future.

The incidence of elder abuse has led to a growing trend of states taking various methods to regulate the use of electronic monitoring in institutional settings through programs, guidelines, regulations, and laws. This article attempts evaluate how the regulation of electronic monitoring has evolved and may be advanced in the future with the anticipated increase of elder abuse.

Exploring the impact of a 'Clients-as-Tutors Program on speech-language pathology students' and graduates understanding of client-centred practice.

PURPOSE: This study explored the impact of an Australian regional university's Clients-as-Tutors Program (CTP) on speech-language pathology students' perception and understanding of client-centred practice. METHOD: Two focus group interviews comprising three final-year students and four newly graduated speech-language pathologists who had completed the CTP. An inductive thematic analysis was undertaken to identify salient themes. RESULT: Three themes were identified: (a) learning from theory, (b) learning from others, and (c) learning from yourself. These themes represented all participants' experiences in the CTP, yet there were unique, individual journeys that each participant experienced. CONCLUSION: Findings from this study have the capacity to affect change in how client-centred practice is taught at universities across speech-language pathology and other health courses, to disrupt the traditional power structure between client and clinician, and to provide an evidence base for the role of experiential learning in this area.

Development of the Palliative Care Law and Policy GPS to Assess National Policies in Palliative Care.

Background: State policy-making to address disparities in access to and quality of palliative care is increasing. Yet, there is no mechanism to systematically assess palliative care policies nationally. Methods: We describe the development of the Palliative Care Law and Policy GPS by the Center to Advance Palliative Care and the Yale Solomon Center for Health Law and Policy. The GPS is an online, searchable repository of national palliative care policies. We developed the GPS by conducting a systematic search of Lexis+, LegiScan, and state health departments for palliative care-related statutes and proposed legislation, categorizing policies into workforce, payment, quality/standards, clinical skill-building, public awareness, telehealth, and pediatric palliative care, and creating an interactive website. Conclusions and Implications: The GPS is a critical tool that can advance palliative care research, practice, and policy. Next steps include the expansion of data from 2010 onward as well as gathering state-level regulations and partially automating search and updating functions.

Reconnecting the Patient: Why Telehealth Policy Solutions Must Consider the Deepening Digital Divide.

This Article attempts to untangle the complicated web of providing telehealth to those populations it is potentially capable of further alienating from access to healthcare including: 1) race/minority populations, 2) aging adults, 3) individuals with disabilities, 4) non-English speakers, 5) individuals living in rural areas, 6) socioeconomic class, and 7) children, in order to advance the argument that telehealth can be successful in providing healthcare access to these populations. Rather than suggesting that telehealth simply "cannot work" for these populations, instead this Article considers how telehealth can and must meet the needs of these individuals through technology, access, and policy developments. First, this Article explains how telehealth is defined and how the definition has and can continue to influence policy development. Next, this Article explores the issues surrounding the "digital divide" and how this relates to telehealth use. Then this Article discusses how access to technology impacts particular populations. This Article then considers legislation and policy developments both at the federal and state level that have emerged thus far that could help overcome challenges of accessibility, affordability, and usability. Finally, this Article offers policy recommendations for ensuring that the delivery of telehealth can be accessible to those populations with potentially less access to technology to ensure telehealth's successful availability and use for these populations can continue beyond Covid-19.

Phosphorylation of the small heat shock protein HspB1 regulates cytoskeletal recruitment and cell motility.

The small heat shock protein HspB1, also known as Hsp25/27, is a ubiquitously expressed molecular chaperone that responds to mechanical cues. Uniaxial cyclic stretch activates the p38 mitogen-activated protein kinase (MAPK) signaling cascade and increases the phosphorylation of HspB1. Similar to the mechanosensitive cytoskeletal regulator zyxin, phospho-HspB1 is recruited to features of the stretch-stimulated actin cytoskeleton. To evaluate the role of HspB1 and its phosphoregulation in modulating cell function, we utilized CRISPR/Cas9-edited HspB1-null cells and determined they were altered in behaviors such as actin cytoskeletal remodeling, cell spreading, and cell motility. In our model system, expression of WT HspB1, but not nonphosphorylatable HspB1, rescued certain characteristics of the HspB1-null cells including the enhanced cell motility of HspB1-null cells and the deficient actin reinforcement of stretch-stimulated HspB1-null cells. The recruitment of HspB1 to high-tension structures in geometrically constrained cells, such as actin comet tails emanating from focal adhesions, also required a phosphorylatable HspB1. We show that mechanical signals activate posttranslational regulation of the molecular chaperone, HspB1, and are required for normal cell behaviors including actin cytoskeletal remodeling, cell spreading, and cell migration.

Nuclear pore complexes concentrate on Actin/LINC/Lamin nuclear lines in response to mechanical stress in a SUN1 dependent manner.

Formation of robust actomyosin stress fibers (SF) in response to cell stretch plays a key role in the transfer of information from the cytoplasm into the nucleus. Actin/LINC/Lamin (ALL) nuclear lines provide mechanical linkage between the actin cytoskeleton and the lamin nucleoskeleton across the nuclear envelope. To understand the establishment of ALL lines, we used live cell imaging of cells exposed to cyclic stretch. We discovered that nuclear pore complexes (NPCs) concentrate along ALL lines that are generated in response to uniaxial cyclic stretch. The ALL-associated NPCs display increased fluorescence intensity of nucleoporins Pom121, TPR and Nup153 relative to nucleoporins that are distal to the ALL lines. Here we test the hypothesis that a LINC complex component of ALL lines, SUN1 is involved in the integration of NPCs with ALL lines. We generated CRISPR SUN1 knockdown and knockout cell lines and show that SUN1 is essential for normal integration of NPCs to ALL lines. Loss or elimination of SUN1 significantly diminishes NPC/ALL line integration, demonstrating a key role for SUN1 in the recruitment or stabilization of NPCs to a discrete subdomain of the nuclear envelope at ALL lines. This work provides new insight into the mechanism by which cells respond to mechanical force through nuclear envelope remodeling.

Relationship between burnout and Major Depressive Disorder in health professionals: A HEAR report.

BACKGROUND: Burnout is a "normal" albeit concerning response to workplace stress, whereas Major Depressive Disorder (MDD) is a serious illness associated with impairment and suicide risk. Because of symptomatic overlap between the two conditions and MDD-associated stigma, individuals reporting work-related stress and depression often are "diagnosed" with burnout at the expense of recognizing and treating MDD. Our study aimed to leverage organizational implementation of the American Foundation of Suicide Prevention's Interactive Screening Program to elucidate relationships among burnout, depression, and other suicide risk factors. METHODS: 2281 of about 30,000 (~7.6 %) medical trainees, staff, and faculty responded to an anonymous online stress and depression questionnaire. Respondents were grouped into four cohorts: screened positive for burnout alone (n = 439, 19 %), depression alone (n = 268, 12 %), both conditions (n = 759, 33 %), or neither condition (n = 817, 36 %), and compared on multiple measures of distress and other suicide risk factors. RESULTS: Burnout alone and depression alone each predicted greater distress and suicide risk compared with neither condition. Depression was a stronger predictor than burnout and demonstrated a consistent association with other suicide risk factors regardless of whether burnout was present. In contrast, burnout was not consistently associated with other suicide risk factors when depression was present. LIMITATIONS: The sample was limited to one state-supported academic medical center; to individuals who elected to take the online survey; and relied on a single item, non-validated measure of burnout. CONCLUSION: When emotional distress is reported by healthcare workers, attention should not stop at "burnout," as burnout frequently comingles with clinical depression, a serious and treatable mental health condition.

Genetic ablation of zyxin causes Mena/VASP mislocalization, increased motility, and deficits in actin remodeling.

Focal adhesions are specialized regions of the cell surface where integrin receptors and associated proteins link the extracellular matrix to the actin cytoskeleton. To define the cellular role of the focal adhesion protein zyxin, we characterized the phenotype of fibroblasts in which the zyxin gene was deleted by homologous recombination. Zyxin-null fibroblasts display enhanced integrin-dependent adhesion and are more migratory than wild-type fibroblasts, displaying reduced dependence on extracellular matrix cues. We identified differences in the profiles of 75- and 80-kD tyrosine-phosphorylated proteins in the zyxin-null cells. Tandem array mass spectrometry identified both modified proteins as isoforms of the actomyosin regulator caldesmon, a protein known to influence contractility, stress fiber formation, and motility. Zyxin-null fibroblasts also show deficits in actin stress fiber remodeling and exhibit changes in the molecular composition of focal adhesions, most notably by severely reduced accumulation of Ena/VASP proteins. We postulate that zyxin cooperates with Ena/VASP proteins and caldesmon to influence integrin-dependent cell motility and actin stress fiber remodeling.

Supervillin modulation of focal adhesions involving TRIP6/ZRP-1.

Cell-substrate contacts, called focal adhesions (FAs), are dynamic in rapidly moving cells. We show that supervillin (SV)--a peripheral membrane protein that binds myosin II and F-actin in such cells--negatively regulates stress fibers, FAs, and cell-substrate adhesion. The major FA regulatory sequence within SV (SV342-571) binds to the LIM domains of two proteins in the zyxin family, thyroid receptor-interacting protein 6 (TRIP6) and lipoma-preferred partner (LPP), but not to zyxin itself. SV and TRIP6 colocalize within large FAs, where TRIP6 may help recruit SV. RNAi-mediated decreases in either protein increase cell adhesion to fibronectin. TRIP6 partially rescues SV effects on stress fibers and FAs, apparently by mislocating SV away from FAs. Thus, SV interactions with TRIP6 at FAs promote loss of FA structure and function. SV and TRIP6 binding partners suggest several specific mechanisms through which the SV-TRIP6 interaction may regulate FA maturation and/or disassembly.

When ecosystem services crash: preparing for big, fast, patchy climate change.

Assessments of adaptation options generally focus on incremental, homogeneous ecosystem responses to climate even though climate change impacts can be big, fast, and patchy across a region. Regional drought-induced tree die-off in semiarid woodlands highlights how an ecosystem crash fundamentally alters most ecosystem services and poses management challenges. Building on previous research showing how choice of location is linked to adaptive capacity and vulnerability, we developed a framework showing how the options for retaining desired ecosystem services in the face of sudden crashes depend on how portable the service is and whether the stakeholder is flexible with regard to the location where they receive their services. Stakeholders using portable services, or stakeholders who can move to other locations to obtain services, may be more resilient to ecosystem crashes. Our framework suggests that entering into cooperative networks with regionally distributed stakeholders is key to building resilience to big, fast, patchy crashes.