Moderate intensity exercise in pregnant patients with cardiovascular disease: A pilot study.

BACKGROUND: Exercise in pregnancy has proven health benefits, yet the safety of exercise in patients with pre-existing cardiovascular disease (CVD) has not been established. Our aim was to determine the feasibility and safety profile of moderate intensity exercise during pregnancy in patients with CVD, compared with those without CVD. METHODS: This is a prospective single center pilot study of a moderate intensity exercise regimen, with data collection through wearable fitness trackers and personal exercise logs in pregnant patients with and without pre-existing CVD. The primary outcome was Doppler umbilical artery systolic to diastolic (S/D) ratio measured between 32 and 34 weeks' gestation. The secondary outcomes were adverse maternal and fetal events, trends in wearable fitness tracker data, C-reactive protein levels, and weight changes. RESULTS: At baseline, the CVD group (62% congenital heart disease) took part in more prepregnancy walking, less weightlifting, and had a higher body mass index compared to the control group, and on average walked 539 fewer steps per day during pregnancy than the control group. Resting heart rate (HR) was found to increase in both groups up to 30 weeks' gestation. The cardiovascular disease group displayed an overall lower exercise intensity, as measured by the ability to increase HR with exercise over resting heart rate 1 hour prior to exercise at study baseline (45% vs 59% P < .001). Umbilical artery S/D ratio was normal in both groups. No differences were seen in adverse events between groups. CONCLUSIONS: This pilot study of moderate intensity exercise in pregnant individuals with pre-existing CVD demonstrated that patients with CVD were not able to increase their HR during exercise throughout pregnancy compared to those in the control group. Although a small study group, this data supports the hypothesis that exercise interventions during pregnancy for patients with CVD are feasible without evidence abnormal fetal Doppler profiles. Further studies using wearable fitness trackers may provide the opportunity to understand how to safely tailor exercise programs to pregnant individuals with CVD.

Quality Assurance in Higher Education: Evaluation of Adjunct Clinical Faculty.

ABSTRACT: The clinical experience is often thought of as an opportunity to tie theory to practice. However, with the current shortage of full-time nursing faculty and the increased dependence on adjunct faculty, how do administrators ensure quality? The purpose of this exploratory descriptive study was to determine the evaluation practices of administrators from accredited universities. Administrators' (n = 26) methods of evaluation were collected via survey with follow-up interviews. Several themes emerged that may assist with the identification of issues in the evaluation of adjunct clinical faculty.

Standardized outcomes in reproductive cardiovascular care: The STORCC initiative.

BACKGROUND: Validated protocols for diagnostic testing and management of pregnant women with cardiovascular disease (CVD) do not exist. Our objective was to establish a prospective standardized protocol for the clinical evaluation of pregnant women with CVD. METHODS: The Standardized Outcomes in Reproductive Cardiovascular Care (STORCC) initiative prospectively enrolled pregnant women with CVD into a standardized diagnostic testing and assessment protocol. Detailed cardiac and obstetric data were collected during the antepartum, intrapartum, and postpartum periods. Each woman was assigned a STORCC color code of perceived risk at a monthly multidisciplinary conference. RESULTS: In 250 pregnancies of 207 women with CVD, the standardized care protocol was followed in 136 and routine care in 114. The median age of the subjects was 32 years, and the most common form of heart disease was congenital heart disease (77%). Women enrolled in standardized care protocol had high compliance with second- and third-trimester visits (93%) and postpartum visits (76%). Maternal cardiac complications occurred in 10%. The STORCC cardiac and obstetric color codes predicted adverse outcomes within each respective category (P = .02, .01). CONCLUSIONS: The STORCC protocol for prospective diagnostic testing and follow-up of pregnant women with CVD was successfully established, and compliance was high. The strength of a standardized testing and care protocol as well as detailed classification of labor and delivery characteristics allows for robust analyses into specific questions regarding testing protocols, and mode and timing of delivery.

Piroplasms in brown hyaenas (Parahyaena brunnea) and spotted hyaenas (Crocuta crocuta) in Namibia and South Africa are closely related to Babesia lengau.

The objective of our study was identification and molecular characterization of piroplasms and rickettsias occurring in brown (Parahyaena brunnea) and spotted hyaenas (Crocuta crocuta) from various localities in Namibia and South Africa. Whole blood (n = 59) and skin (n = 3) specimens from brown (n = 15) and spotted hyaenas (n = 47) were screened for the presence of Babesia, Theileria, Ehrlichia and Anaplasma species using the reverse line blot (RLB) hybridization technique. PCR products of 52/62 (83.9%) of the specimens hybridized only with the Theileria/Babesia genus-specific probes and not with any of the species-specific probes, suggesting the presence of a novel species or variant of a species. No Ehrlichia and/or Anaplasma species DNA could be detected. A parasite 18S ribosomal RNA gene of brown (n = 3) and spotted hyaena (n = 6) specimens was subsequently amplified and cloned, and the recombinants were sequenced. Homologous sequence searches of databases indicated that the obtained sequences were most closely related to Babesia lengau, originally described from cheetahs (Acinonyx jubatus). Observed sequence similarities were subsequently confirmed by phylogenetic analyses which showed that the obtained hyaena sequences formed a monophyletic group with B. lengau, B abesia conradae and sequences previously isolated from humans and wildlife in the western USA. Within the B. lengau clade, the obtained sequences and the published B. lengau sequences were grouped into six distinct groups, of which groups I to V represented novel B. lengau genotypes and/or gene variants. We suggest that these genotypes cannot be classified as new Babesia species, but rather as variants of B. lengau. This is the first report of occurrence of piroplasms in brown hyaenas.

NICHE Recommended Care of the Critically Ill Older Adult.

Nurses Improving Care for Healthsystem Elders provides evidence-based best practices for the care of the hospitalized older adult. Older adults are a vulnerable population at greater risk of functional decline during and after hospitalization, safety concerns related to polypharmacy, ineffective pain management, and population-specific physiological responses to medications. Family members of hospitalized older adults are also vulnerable and may experience postintensive care syndrome. This manuscript explores the application of Nurses Improving Care for Healthsystem Elders standards through a case study approach to optimize patient/family-centered care of the critically ill older adult.

Using evidence to overcome obstacles to family presence.

Family presence is advocated by many professional organizations and recommended in practice guidelines. However, firmly held beliefs often prevent full implementation of family presence on rounds and with visiting. This article will review the evidence surrounding common concerns that family presence will increase infection, have adverse effects on the physiologic status of the patient, defer from teaching opportunities, or otherwise interfere with rounds. The notion that families need to be encouraged to go home to rest is also explored. A case study describing 1 unit's efforts to improve family presence is described. Strategies to overcome obstacles inhibiting family presence will be provided.

Coursing hyenas and stalking lions: The potential for inter- and intraspecific interactions.

Resource partitioning promotes coexistence among guild members, and carnivores reduce interference competition through behavioral mechanisms that promote spatio-temporal separation. We analyzed sympatric lion and spotted hyena movements and activity patterns to ascertain the mechanisms facilitating their coexistence within semi-arid and wetland ecosystems. We identified recurrent high-use (revisitation) and extended stay (duration) areas within home ranges, as well as correlated movement-derived measures of inter- and intraspecific interactions with environmental variables. Spatial overlaps among lions and hyenas expanded during the wet season, and occurred at edges of home ranges, around water-points, along pathways between patches of high-use areas. Lions shared more of their home ranges with spotted hyenas in arid ecosystems, but shared more of their ranges with conspecifics in mesic environments. Despite shared space use, we found evidence for subtle temporal differences in the nocturnal movement and activity patterns between the two predators, suggesting a fine localized-scale avoidance strategy. Revisitation frequency and duration within home ranges were influenced by interspecific interactions, after land cover categories and diel cycles. Intraspecific interactions were also important for lions and, important for hyenas were moon illumination and ungulates attracted to former anthrax carcass sites in Etosha, with distance to water in Chobe/Linyanti. Recursion and duration according to locales of competitor probabilities were similar among female lions and both sexes of hyenas, but different for male lions. Our results suggest that lions and spotted hyenas mediate the potential for interference competition through subtle differences in temporal activity, fine-scale habitat use differentiation, and localized reactive-avoidance behaviors. These findings enhance our understanding of the potential effects of interspecific interactions among large carnivore space-use patterns within an apex predator system and show adaptability across heterogeneous and homogeneous environments. Future conservation plans should emphasize the importance of inter- and intraspecific competition within large carnivore communities, particularly moderating such effects within increasingly fragmented landscapes.

Impact of Simulation on Undergraduate Student Outcomes.

BACKGROUND: Clinical reasoning is a cognitive and metacognitive process that is essential for positive patient outcomes. Simulation experiences provide situations and reflection where students can build clinical reasoning. PURPOSE: This study examined the impact of a higher number of simulation experiences on undergraduate student outcomes. METHODS: A retrospective comparison study examined differences between group grade point average, Assessment Technologies Institute (ATI) predictor, and National Council Licensure Examination (NCLEX) scores ( P < .05). A sample of 395 students was included in data analysis. RESULTS: No differences were noted in grade point average or NCLEX pass rates. However, students who completed a simulation elective had significantly higher ATI predictor scores. Cohen's d (0.39) approached a medium effect size. CONCLUSIONS: Incorporating higher levels of in-person simulation through creative delivery models can improve student outcomes. Simulations may enhance students' clinical reasoning skills.

Genetic diversity of vector-borne pathogens in spotted and brown hyenas from Namibia and Tanzania relates to ecological conditions rather than host taxonomy.

BACKGROUND: Improved knowledge on vector-borne pathogens in wildlife will help determine their effect on host species at the population and individual level and whether these are affected by anthropogenic factors such as global climate change and landscape changes. Here, samples from brown hyenas (Parahyaena brunnea) from Namibia (BHNA) and spotted hyenas (Crocuta crocuta) from Namibia (SHNA) and Tanzania (SHTZ) were screened for vector-borne pathogens to assess the frequency and genetic diversity of pathogens and the effect of ecological conditions and host taxonomy on this diversity. METHODS: Tissue samples from BHNA (n = 17), SHNA (n = 19) and SHTZ (n = 25) were analysed by PCRs targeting Anaplasmataceae, Rickettsia spp., piroplasms, specifically Babesia lengau-like piroplasms, Hepatozoidae and filarioids. After sequencing, maximum-likelihood phylogenetic analyses were conducted. RESULTS: The relative frequency of Anaplasmataceae was significantly higher in BHNA (82.4%) and SHNA (100.0%) than in SHTZ (32.0%). Only Anaplasma phagocytophilum/platys-like and Anaplasma bovis-like sequences were detected. Rickettsia raoultii was found in one BHNA and three SHTZ. This is the first report of R. raoultii from sub-Saharan Africa. Babesia lengau-like piroplasms were found in 70.6% of BHNA, 88.9% of SHNA and 32.0% of SHTZ, showing higher sequence diversity than B. lengau from South African cheetahs (Acinonyx jubatus). In one SHTZ, a Babesia vogeli-like sequence was identified. Hepatozoon felis-like parasites were identified in 64.7% of BHNA, 36.8% of SHNA and 44.0% of SHTZ. Phylogenetic analysis placed the sequences outside the major H. felis cluster originating from wild and domestic felids. Filarioids were detected in 47.1% of BHNA, 47.4% of SHNA and 36.0% of SHTZ. Phylogenetic analysis revealed high genetic diversity and suggested the presence of several undescribed species. Co-infections were frequently detected in SHNA and BHNA (BHNA median 3 pathogens, range 1-4; SHNA median 3 pathogens, range 2-4) and significantly rarer in SHTZ (median 1, range 0-4, 9 individuals uninfected). CONCLUSIONS: The frequencies of all pathogens groups were high, and except for Rickettsia, multiple species and genotypes were identified for each pathogen group. Ecological conditions explained pathogen identity and diversity better than host taxonomy.

Nursing Students' Perceptions of Just Culture in Nursing Programs: A Multisite Study.

BACKGROUND: While just culture is embraced in the clinical setting, just culture has not been systematically incorporated into nursing education. PURPOSE: The purpose of this study was to assess prelicensure nursing student perceptions of just culture in academia. METHODS: Following a quantitative, descriptive design, the Just Culture Assessment Tool for Nursing Education (JCAT-NE) was used to measure just culture across multiple (N = 15) nursing programs. RESULTS: The majority of JCAT-NE respondents (78%) reported their program has a safety reporting system, 15.4% had involvement in a safety-related event, and 12% submitted an error report. The JCAT-NE mean total score was 127.4 (SD, 23.6), with a statistically significant total score decline as students progressed from the beginning (133.6 [SD, 20.52]) to the middle (129.77 [SD, 23.6]) and end (122.2 [SD, 25.43]) of their programs (χ[2] = 25.09, P < .001). CONCLUSIONS: The results from this study are a call to action for nursing education to emphasize the tenets of just culture, error reporting, and quality improvement.

The effects of pregnancy on right ventricular remodeling in women with repaired tetralogy of Fallot.

OBJECTIVES: The aim of this study was to better understand the quantitative volumetric changes associated with pregnancy in women with repaired tetralogy of Fallot (TOF), utilizing sequential cardiovascular magnetic resonance (CMR) imaging. BACKGROUND: An increasing number of women with repaired TOF are reaching childbearing age. Limited echocardiographic studies suggest accelerated remodeling of the right ventricle (RV) in women with repaired TOF after pregnancy. METHODS: Sequential CMRs from a group of women with repaired TOF who completed pregnancy and from a matched comparison group of nulliparous women with repaired TOF were evaluated. The two groups were matched according to baseline QRS duration, RV end-diastolic volume (EDV), age at CMR and time between CMRs. Longitudinal change of CMR parameters was compared between the groups. RESULTS: Thirteen women (mean age 26.6 ± 7.4 years) with repaired TOF who completed pregnancy and 26 nulliparous women with repaired TOF (mean age 22.6 ± 8.0 years) were included in this analysis. The rate of increase of RV EDV in the pregnancy group was higher than the comparison group (4.1 ± 1.1 ml/m(2)/year vs. 1.6 ± 0.6 ml/m(2)/year, p=0.07). RV EF did not change significantly in either group. No definitive interaction between degree of pulmonary regurgitation and increase of RV EDV was identified. CONCLUSIONS: Women with repaired TOF who have completed pregnancy appear to experience an accelerated rate of right ventricular remodeling, defined as an increase in end-diastolic volume; however RV systolic function does not deteriorate. Further investigations with a prospective study design, larger cohorts, and longer follow-up are needed to confirm these initial observations.

Environmental issues affecting elder abuse victims in their reception of community based services.

This study examined the dominant factors that predict the utilization of services by 129 identified elder abuse victims who reside in the community. Utilizing the Andersen Model, services accepted or rejected were analyzed from individual, family and environmental perspectives. Results indicated that service utilization is related to three "need" factors: (1) Victim has cognitive and ADL impairments, (2) Victim has poor health status (self rated), and (3) The abuser is financially dependent on the victim and is also the primary caregiver of the victim. "Enabling" factor (1) Victim lives alone. "Predisposing" factors (1) Abuser is substance abuser and (2) Abuser is female. A great proportion of the elder abuse victims in this study accepted services from an agency that provided a single entry point into the service system and had highly trained personnel utilizing a case management approach.