A mixed methods study: The grief experience of registered nurses working on the frontlines during the COVID-19 pandemic.

AIM AND OBJECTIVE: The purpose of this study was to generate a conceptual definition and theory of grief for nurses working on the frontlines during the COVID-19 pandemic using grounded theory methodology. BACKGROUND: The COVID-19 pandemic has had a negative impact on nurses working on the frontlines. The increasing flow of diagnosed COVID-19 cases, diverse unknowns and demands in the treatment of patients with COVID-19, and depression related to countless deaths can trigger grief experiences. DESIGN: A mixed methods approach, including the qualitative method of grounded theory and a quantitative 30-question survey, was used in this study. METHODS: Eight focus group sessions were conducted with registered nurses working on the frontlines during the pandemic. Sessions were audio recorded and analysed using constant comparative data analysis. Following the interviews, a survey including demographics and self-report inventories was completed by participants. The COREQ checklist was used to assess study quality. RESULTS: Major concepts that emerged include 'facing a new reality', 'frustrations', 'stress' and 'coping'. Core concepts were combined into a conceptual definition of grief and a grounded theory of the experience of nurses working on the frontlines during the pandemic. Cross comparisons of qualitative and quantitative findings were made and compared with the literature. CONCLUSIONS: This study provides a better understanding of the grief experience of nurses working on the frontlines during the COVID-19 pandemic. It is necessary to recognise professional grief and develop intervention strategies that lead to grief reconciliation. RELEVANCE TO CLINICAL PRACTICE: Findings provide useful insights for healthcare administrators to provide support and develop interventions to reduce frustrations and stress of frontline registered nurses. PATIENT OR PUBLIC CONTRIBUTION: This study design involved registered nurses participating in focus group sessions. Participants detailed their experience working on the frontlines of the COVID-19 pandemic with patients, family and hospital administration.

Implementation of Daily Pharmacy Student New Medication Education During Hospitalization to Improve Patient Satisfaction.

Introduction: Studies have shown that patients would like to receive more medication education while hospitalized. Higher patient satisfaction has been correlated with lower mortality and fewer hospital readmissions. Methods: This was a quasi-experimental study. Four Doctor of Pharmacy students were assigned 1 medicine inpatient unit to provide education on new medications during the study period, June to September. The primary endpoint was the change in HCAHPS scores for the medication communication domain composite for the intervention unit and a similar control unit that was not receiving the intervention from the pre-intervention to the intervention periods. Results: A total of 124 patients were educated during the intervention period, with an average age of 65 and 2.2 new medications. Average HCAHPS scores for the medication communication domain for the intervention unit increased from 68% pre-intervention to 91% during the intervention (P = .389) while the control unit remained unchanged at 78% both pre- and during the intervention (P = .13). Conclusion: An increase in the medication communication HCAHPS score for the intervention unit was observed, while the control unit remained stable. This study has the potential to drive change by implementing pharmacy students throughout inpatient units to educate patients on new medications thereby improving patient satisfaction.

Locoregional CAR T Cells for the Treatment of CNS Tumors in Children: Investigational Drug Service Pharmacy Activities.

BACKGROUND: A major obstacle in translating the therapeutic potential of chimeric antigen receptor (CAR) T cells to children with central nervous system (CNS) tumors is the blood-brain barrier. To overcome this limitation, preclinical and clinical studies have supported the use of repeated, locoregional intracranial CAR T-cell delivery. However, there is limited literature available describing the process for the involvement of an investigational drug service (IDS) pharmacy, particularly in the setting of a children's hospital with outpatient dosing for CNS tumors. OBJECTIVES: To describe Seattle Children's Hospital's experience in clinically producing CAR T cells and the implementation of IDS pharmacy practices used to deliver more than 300 intracranial CAR T-cell doses to children, as well as to share how we refined the processing techniques from CAR T-cell generation to the thawing of fractionated doses for intracranial delivery. METHODS: Autologous CD4+ and CD8+ T cells were collected and transduced to express HER2, EGFR, or B7-H3-specific CAR T cells. Cryopreserved CAR T cells were thawed by the IDS pharmacy before intracranial delivery to patients with recurrent/refractory CNS tumors or with diffuse intrinsic pontine glioma/diffuse midline glioma. RESULTS: The use of a thaw-and-dilute procedure for cryopreserved individual CAR T-cell doses provides reliable viability and is more efficient than typical thaw-and-wash protocols. Cell viability with the thaw-and-dilute protocol was approximately 75% and was always within 10% of the viability assessed at cryopreservation. Cell viability was preserved through 6 hours after thawing, which exceeded the 1-hour time frame from thawing to infusion. CONCLUSION: As the field of adoptive immunotherapy grows and continues to bring hope to patients with fatal CNS malignancies, it is critical to focus on improving the preparatory steps for CAR T-cell delivery.

"Caring for the Uncared for": A Novel Initiative of Madras Medical College.

BACKGROUND: Every society has persons with illness who do not have any family support. Taking care of such uncared-for patients requires a well-structured system providing medical, psychological, emotional, and rehabilitory support. The first ever rehabilitation ward among government hospitals in Tamil Nadu was created at Rajiv Gandhi Government General Hospital (RGGGH), Chennai with the motto of "Caring for the uncared for." This paper highlights the organizational structure, functionality, profile of patients admitted, challenges faced, and the outcome of patients admitted in the rehabilitation ward. METHODS: A retrospective study was done on the "untended" patients, who were admitted in the rehabilitation ward at Rajiv Gandhi Government General Hospital (RGGGH), Chennai, Tamil Nadu, India from December 2020 to June 2022. Sociodemographic and clinical characteristics and outcome of the patients were analyzed. RESULTS: A total of 201 adults with physical disabilities or mixed physical and psychiatric disabilities were admitted for intensive rehabilitation. Common medical illnesses included orthopedic disorders in 80 (39.8%), followed by neurological illness in 43 (21.4%) patients. The median length of stay was 50 (24.5-103.5) days with longest stay of 447 days. Of those patients who recovered, 54 patients (26.9%) reunited with family and returned home and 125 (62.2%) patients were sent to old age homes/asylums. CONCLUSION: A dedicated ward for untended patients is the first of its kind in the state of Tamil Nadu, India. Such a venture has proved to be of benefit, considering the positive outcome in a significant proportion of the beneficiaries.

Using portfolios to introduce the clinical nurse leader to the job market.

Development of a portfolio is an effective strategy used by clinical nurse leaders (CNLs) to inform prospective employers of their specialized skills in quality improvement, patient safety, error prevention, and teamwork. The portfolio provides evidence of competence relative to the role of clinician, outcomes manager, client advocate, educator, information manager, systems analyst/risk anticipator, team manager, healthcare professional, and lifelong learner. This article describes the CNL portfolio developed by experts from the University of Tennessee Health Science Center and Methodist LeBonheur Healthcare. Examples of portfolio documents generated throughout the master's entry CNL curriculum are provided, along with student experiences using the portfolio in the employment interview process.

Implementation of a multidisciplinary inpatient opioid overdose education and naloxone distribution program at a large academic medical center.

PURPOSE: Opioid overdose-related deaths continue to rise. Despite public health efforts, there is still variability in obtainment of naloxone, a lifesaving antidote. We share our experience in the implementation of a novel opioid overdose education and naloxone distribution (OEND) program at a large academic medical center. METHODS: Collaborative efforts made by pharmacists, pharmacy students, physicians, nurses, and recovery coaches were employed in the design of the program. The service was available Monday through Friday, 9 am to 6 pm, and primarily carried out by pharmacy students on a rotating basis. Services offered included bedside delivery of naloxone and education prior to the day of discharge. In preparation for their role, the pharmacy students were required to complete a series of trainings and competency assessments. RESULTS: A total of 40 patients were included in the program evaluation. Of the completed consults 96.7% (n = 30) of patients received both counseling and naloxone delivery. Eighty percent of patients had a history of nonfatal opioid overdose, but only 37.5% had naloxone listed as a home medication. OEND services were provided to 66% of individuals with patient-directed discharges. CONCLUSION: Implementation of an inpatient OEND program by mobilizing trained student pharmacists is feasible and expands naloxone access to patients during transitions of care. A similar model could be considered in the future for the delivery of harm reduction supplies to this patient population.

Effects of a pharmacy-driven medication history program on patient outcomes.

PURPOSE: Obtaining an accurate medication history is a vital component of medication reconciliation upon admission to the hospital. Despite the importance of this task, medication histories are often inaccurate and/or incomplete. We evaluated the association of a pharmacy-driven medication history initiative on clinical outcomes of patients admitted to the general medicine service of an academic medical center. METHODS: Comparing patients who received a pharmacy-driven medication history to those who did not, a retrospective stabilized inverse probability treatment weighting propensity score analysis was used to estimate the average treatment effect of the intervention on general medical patients. Fifty-two patient baseline characteristics including demographic, operational, and clinical variables were controlled in the propensity score model. Hospital length of stay, 7-day and 30-day unplanned readmissions, and in-hospital mortality were evaluated. RESULTS: Among 11,576 eligible general medical patients, 2,234 (19.30%) received a pharmacy-driven medication history and 9,342 (80.70%) patients did not. The estimated average treatment effect of receiving a pharmacy-driven medication history was a shorter length of stay (mean, 5.88 days vs 6.53 days; P = 0.0002) and a lower in-hospital mortality rate (2.34% vs 3.72%, P = 0.001), after adjustment for differences in patient baseline characteristics. No significant difference was found for 7-day or 30-day all-cause readmission rates. CONCLUSION: Pharmacy-driven medication histories reduced length of stay and in-hospital mortality in patients admitted to the general medical service at an academic medical center but did not change 7-day and 30-day all-cause readmission rates. Further research via a large, multisite randomized controlled trial is needed to confirm our findings.

VirE2: a unique ssDNA-compacting molecular machine.

The translocation of single-stranded DNA (ssDNA) across membranes of two cells is a fundamental biological process occurring in both bacterial conjugation and Agrobacterium pathogenesis. Whereas bacterial conjugation spreads antibiotic resistance, Agrobacterium facilitates efficient interkingdom transfer of ssDNA from its cytoplasm to the host plant cell nucleus. These processes rely on the Type IV secretion system (T4SS), an active multiprotein channel spanning the bacterial inner and outer membranes. T4SSs export specific proteins, among them relaxases, which covalently bind to the 5' end of the translocated ssDNA and mediate ssDNA export. In Agrobacterium tumefaciens, another exported protein-VirE2-enhances ssDNA transfer efficiency 2000-fold. VirE2 binds cooperatively to the transferred ssDNA (T-DNA) and forms a compact helical structure, mediating T-DNA import into the host cell nucleus. We demonstrated-using single-molecule techniques-that by cooperatively binding to ssDNA, VirE2 proteins act as a powerful molecular machine. VirE2 actively pulls ssDNA and is capable of working against 50-pN loads without the need for external energy sources. Combining biochemical and cell biology data, we suggest that, in vivo, VirE2 binding to ssDNA allows an efficient import and pulling of ssDNA into the host. These findings provide a new insight into the ssDNA translocation mechanism from the recipient cell perspective. Efficient translocation only relies on the presence of ssDNA binding proteins in the recipient cell that compacts ssDNA upon binding. This facilitated transfer could hence be a more general ssDNA import mechanism also occurring in bacterial conjugation and DNA uptake processes.

Consistency of global recommendations regarding open versus laparoscopic surgery during the COVID-19 pandemic: a systematic review.

BACKGROUND: Throughout the COVID-19 pandemic, there has been worldwide debate regarding whether open surgery should be performed in preference to laparoscopic surgery due to the theoretical higher risk of viral aerosolization by the release of pneumoperitoneum. We aimed to assess the consistency of national and international surgical society recommendations regarding the choice of surgical approach; assess the quality of evidence of viral emission in surgical aerosol; and assess the quality of evidence comparing aerosol generation by different surgical energy devices. METHODS: A systematic review of PubMed, Medline, Embase and Cochrane databases was performed. Three search strategies were employed. Twenty-eight studies were included in the final analysis and quality appraised. Confidence in review findings was assessed using the GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) tool. RESULTS: Worldwide recommendations regarding open versus laparoscopic surgery are consistent, with a majority recommending that surgical approach is decided on a case-by-case, risk minimization approach. There is limited, low-quality evidence that viral particles can be emitted in surgical aerosol. There is a paucity of literature on the quantity of aerosol produced by different surgical energy devices, and no evidence to support the use of certain surgical instruments to minimize aerosol production. CONCLUSIONS: There is considerable consistency among worldwide recommendations regarding the choice of surgical approach, although the evidence base is lacking. To inform clinical recommendations, further research examining viral emission, transmission, infectivity and amount of surgical aerosol produced is required.

Pediatric Quality Improvement (QI) Virtual Practicum: Adapting a QI Simulator.

Introduction: Pediatric residencies are expected to arm trainees with skills in quality improvement (QI) that allow trainees to systematically enhance their own practice. Simulation has been shown to be effective in teaching QI, but there are no published QI simulation tools that target pediatric learners. Methods: We adapted a previously developed QI simulation to include a case relevant for pediatric residents. Participants devised interventions using basic QI principles with iterative feedback from facilitators with knowledge of QI methodology. Changes in resident knowledge, attitudes about the curriculum, and depth of engagement in QI were assessed using pre- and posttests, surveys, and assessment of independent QI activities performed prior to graduation, respectively. Results: Eighty-two residents completed the simulation. Of the 76 residents who completed both the pre- and posttests, which each had a total possible score of 28 points, 68% had improved posttest scores, with an average score increase of 2.6 points (SD = 0.6, p < .001). Improvements were most pronounced for residents that scored in the lowest quartile on the pretest. After the simulation, residents reported greater confidence in and likelihood of completing a QI initiative. There was no difference in the level of involvement in future independent QI activities completed by residents who were simulation participants compared with nonparticipants. Discussion: Adapting a previously published QI simulation for pediatric residents was feasible and effective, and the QI simulation was well-liked by learners. Those with lower baseline QI knowledge may have the most to gain from this simulation.

Impact of societal restrictions and lockdown on trauma admissions during the COVID-19 pandemic: a single-centre cross-sectional observational study.

BACKGROUND: Societal restrictions and lockdown during the coronavirus (COVID-19) pandemic have had a significant impact on the volume and nature of trauma admissions. We assessed the impact of COVID-19 related societal restrictions and lockdown on trauma admissions to single level 1 trauma centre in Westmead, Australia. We hypothesized that the number of trauma admissions would decrease and number of admissions due to self-harm and assault (specifically domestic violence) would increase. METHODS: Data was collected from the prospectively maintained Westmead Hospital Trauma Registry. The primary outcome compared was the average number of trauma admissions during March and April during years 2016 to 2020. Analysis of variance was used to analyse means. Pairwise differences among group means were evaluated with Tukey's honestly significant difference test. Secondary outcomes compared were in-hospital interventions and patient outcomes. RESULTS: There was a 23-34% decrease (P = 0.018) in the mean monthly average trauma admissions during March/April 2020 compared with previous years 2016-2019. In addition, there was a 40-52% decrease (P = 0.025) and 13-29% decrease (P = 0.020) in admissions due to road traffic collisions and falls respectively. CONCLUSION: There was a significant decrease in the overall number of trauma-related admissions during the COVID-19-related period of societal restrictions and lockdown. This was due to a decrease in minor traumas, falls and road traffic collisions. There was no difference in the number of admissions secondary to major traumas, self-harm or assault.

Evaluation of the use of erythropoietin-stimulating agents in a hospital setting to assess the necessity of a protocol-driven anemia management service.

Erythropoietin-stimulating agents (ESA) have revolutionized the management of anemia. However, these agents are not always utilized with proper monitoring parameters, which can present significant safety concerns, unwarranted drug expenditures, and decreased ESA efficacy. This retrospective study assessed the utilization of all ESAs in non-intensive care unit hospitalized patients at a large academic medical center from August 18, 2018, to August 31, 2018, using established guideline-based assessment criteria. Among the 167 doses of ESA evaluated, 86% (n = 144) were utilized in accordance with guideline-based assessment criteria regarding laboratory monitoring of iron studies. However, 24% (n = 40) of ESA doses were administered to patients with active, untreated iron deficiency at the time of administration. Although most ESA doses were utilized in accordance with the guideline-based criteria, interventions can be implemented to further improve anemia treatment. Implementing a protocol-driven anemia management service is one strategy that can improve patient care, advance patient safety, and be cost-beneficial.

Subclinical seizures in children diagnosed with localization-related epilepsy: clinical and EEG characteristics.

OBJECTIVE: Subclinical seizures (SCSs) are characterized by paroxysmal rhythmic epileptiform discharges that evolve in time and space in the absence of objective clinical manifestation or report of a seizure. The aim of this study was to evaluate the frequency and characteristics of SCSs in children with localization-related epilepsy (LRE). METHODS: The results of video/EEG monitoring were reviewed to identify patients with SCS. We identified 187 children diagnosed with LRE, in 32 of whom SCSs were reported in the EEG recording. RESULTS: SCSs were reported only in the children who had received a diagnosis of either symptomatic or cryptogenic LRE. All children had a history of clinical seizure(s). The ictal onset of SCSs was most frequent from the temporal and frontal lobes. SCSs were lateralized to the left hemispheres in 19, right hemisphere in 8, and both hemispheres independently in 5 children. SCSs were more often reported in young children, and associated with a history of developmental delay, infantile spasms, and frequent seizures. EEG abnormalities included background slowing and lack of normal sleep architecture in addition to the epileptiform activity. Seizure freedom was reported less often in children with SCSs. Six patients seizure free at the time of the admission were found to have SCSs. CONCLUSION: Subclinical seizures are not uncommon in children with LRE, in particular, with younger age, developmental disability, and medically refractory clinical course. Video/EEG monitoring will be informative in selected children with LRE to assess the seizure frequency more accurately.

Prevalence and Risk Factors of Hypovitaminosis-D in Children with Cognitive and Movement Disorders.

OBJECTIVES: To document the prevalence of hypovitaminosis-D in children with intellectual and movement disorders and to identify the risk factors in vitamin D deficient children. METHODS: This is a cross-sectional study on 90 children with neurodevelopmental disabilities. The prevalence of hypovitaminosis-D and the risk factors such as sun exposure, age-appropriate mobility, diet, skin color and anti-epileptic medications were examined in children with cognitive disorders and movement disorders. RESULTS: The mean serum vitamin D level in children with cognitive disability (n = 46) was found to be 26.7 ± 16.3 ng/L and in the children with movement disability (n = 44) it was 27.9 ± 10.5 ng/L. Though the risk factors were found in greater numbers in children in the deficient group (vitamin D < 30 ng/L), the difference between the two groups was not significant. Of the 90 children, 86 (95.5%) had at least one sign of vitamin D deficiency. Lowest levels of vitamin D were seen in autistic spectrum disorder and learning disabilities in the Cognitive Disability group and hemiplegia in the Movement Disability group. CONCLUSIONS: The prevalence of vitamin D deficiency in children with neurodevelopmental disabilities was 72.2%, with 76.1% in the cognitive disability group and 68.2% in the movement disability group. The risk factors were more common in vitamin D deficient children.

Independent Variables of Dental Erosion among Tertiary Care Hospital Patients of a Developing Country.

BACKGROUND AND AIM: Dental erosion is a multifactorial condition, which is mostly influenced by environmental factors. The aim of this study was to determine the prevalence of dental erosion, its associated risk factors, and their correlation with severity of the condition. MATERIALS AND METHODS: A total of 430 patients who attended the outpatient section of Government Dental College, Thiruvananthapuram, Kerala, India, were selected by systematic sampling method. Erosion was diagnosed by clinical examination and graded using Basic Erosive Wear Examination (BEWE) index. A pretested structured questionnaire on age, gender, medical history, medication history, and food habits was used. RESULTS AND CONCLUSION: Among the study population, 44% (95% confidence interval, 39.3%-48.7%) had dental erosion. Age above 45 years (79.7%, P = 0.000), male population (50%, P = 0.032), residents of rural area (49.1%, P = 0.000), patients with asthma (84.2%, P = 0.000), diabetes (90.9%, P = 0.000), gastroesophageal reflux disorder (91.7%, P = 0.001), and frequent consumption of orange (68.9%, P = 0.000) were identified as factors associated with erosion. The prevalence of dental erosion in the community was high. Results of the study established that better awareness of the condition, better facilities for its early diagnosis in the community, and development of proper preventive strategies are required to reduce the severity of dental erosion.

Assessment of risk of fasting during Ramadan under optimal diabetes care, in high-risk patients with diabetes and coronary heart disease through the use of FreeStyle Libre flash continuous glucose monitor (FSL-CGMS).

AIM: Most of Muslims patients with diabetes and Coronary Heart Disease (CHD) elect to fast in Ramadan, but the actual risk in this subset of patients with diabetes is largely unknown. We aimed to understand the safety of fasting in CHD patients with diabetes insisting on fasting Ramadan under optimal care. We also monitored the change in biophysical and biochemical parameters of these patients before and after Ramadan. We conducted this prospective study in a tertiary care hospital in Dubai during Ramadan 2016, (June 6th till July 5th). PATIENTS AND METHODS: 21 Patients with T2DM with stable known CHD during the three months prior to study and insisted on fasting despite advice against it were recruited for the study. All patients received continuous glucose monitoring with free style libre monitoring device (FSL-CGM) during and outside Ramadan period. We recorded DM or CVD-related emergency visit or hospitalisation, change in BMI, systolic and diastolic BP, lipids profile, e-GFR, HBA1c, and frequency of hypoglycemia during Ramadan fasting and not -fasting period. RESULTS: This is first study using CGM in CHD patients with diabetes who observe fast in Ramadan. Patients had a significantly higher incidence (3.2 ±â€¯2.8 vs 1.1 ±â€¯1.6 episodes, p = 0.033) and prolonged duration of hypoglycemia (117.8 ±â€¯87.2, 49.1 ±â€¯59.1 min p 0.022) during fasting compared to non-fasting respectively. No significant alteration was seen in BMI, SBP and DBP, lipid profile and renal function. There is a significant improvement in HBA1c during Ramadan. CONCLUSION: We could not associate any adverse cardiovascular effects with fasting Ramadan in patients with stable CHD under optimal diabetes care. FSL-CGMS data showed higher frequency of hypoglycemia during Ramadan fasting. Studies with larger sample size are needed for further validation of these findings.

The frequency of non-epileptic spells in children: results of video-EEG monitoring in a tertiary care center.

RATIONALE: the diagnosis of non-epileptic spells (NES) in children can be challenging, even for experienced clinicians. Our objective was to describe the characteristics of such events. METHODS: this was a retrospective study conducted from January 2004 to December 2006. Inclusion criteria were age >1 month and <18 years and the diagnosis of NES established by video-EEG monitoring. RESULTS: among 746 monitored children (1203 recorded video-EEG sessions), 109 (14.6%) had NES. The mean age of patients with NES was 6.6 years (range 0.1-18). Seventy patients were diagnosed with NES alone; the remaining 39 with both NES and epilepsy. Developmental delay was more frequent among patients with a co-morbid diagnosis of epilepsy (p<0.001). Similar clinical events were reported in both of these groups, save for crying spells/irritability which was more common in children with epilepsy. Frequent manifestations of NES included staring spells in preschool children, crying/irritability, tremor and eye deviation in young children and preschoolers, and limb shaking in adolescents. All of the patients with epilepsy and 19 (27%) of those without epilepsy were receiving antiepileptic drugs. CONCLUSION: our data highlights the importance of accurate diagnosis of NES toward the appropriate treatment of affected children.