Vitamin D status and variable responses to supplements depend in part on genetic factors in adults with cystic fibrosis.

Vitamin D sufficiency has been difficult to achieve consistently in patients with cystic fibrosis (CF), even with robust oral supplements. To assess vitamin D status and resistance to supplementation, we studied 80 adults using 25-hydroxyvitamin D (25OHD) determinations and whole genome sequencing to construct polygenic risk scores (PRS) that aggregate variants associated with vitamin D status. The results revealed that 30 % of patients were below the threshold of 30 ng/mL and thus should be regarded as insufficient despite normal vitamin E status, a reflection of adherence to fat soluble vitamin supplementation. The PRS values were significantly correlated with 25OHD concentrations, confirming our results in children with CF, and indicating that genetic factors play a role and have implications for therapy.

Genetic factors help explain the variable responses of young children with cystic fibrosis to vitamin D supplements.

BACKGROUND & AIMS: Children with cystic fibrosis (CF) are susceptible to fat-soluble vitamin deficiencies unless supplemented, but even large doses of vitamin D may not prevent low 25-hydroxyvitamin D (25OHD) concentrations. The explanation for these vitamin D non-responders has been elusive. We utilized data from whole genome sequencing (WGS) to test the hypothesis that genetic variations predict responsiveness to vitamin D supplementation in a prospective cohort study of children with CF in the first 3 years of life. METHODS: One hundred and one infants born during 2012-2017 and diagnosed with CF through newborn screening were studied. Serum 25OHD concentrations and vitamin D supplement doses were assessed during early infancy and annually thereafter. WGS was performed, the resultant variant calling files processed, and the summary statistics from a recent genome-wide association study were utilized to construct a polygenic risk score (PRS) for each subject. RESULTS: Overall, the prevalence of vitamin D insufficiency (<30 ng/mL) was 21% in the first 3 years of life. Among the 70 subjects who always adhered to vitamin D supplement doses recommended by the US CF Foundation guidelines, 89% were responders (achieved vitamin D sufficiency) by 3 years of age, while 11% were transient or non-responders. Multiple regression analysis revealed that PRS was a significant predictor of 25OHD concentrations (p < 0.001) and the likelihood of being an earlier responder in the first 3 years of life (p < 0.01). A limited SNP analysis revealed variants in four important genes (GC, LIPC, CYP24A1, and PDE3B) that were shown to be associated with 25OHD concentrations and vitamin D responder status. Other determinants included vitamin D supplement dose, season at 25OHD measurement, and pancreatic functional status. CONCLUSIONS: Applying WGS in conjunction with utilizing a PRS approach revealed genetic variations that partially explain the unresponsiveness of some children with CF to vitamin D supplementation. Our findings suggest that a nutrigenomics strategy could help promote personalized treatment in CF.

International, multi-disciplinary, cross-section study of pain knowledge and attitudes in nursing, midwifery and allied health professions students.

BACKGROUND: Persistent pain is a highly prevalent, global cause of disability. Research suggests that many healthcare professionals are not well equipped to manage pain, and this may be attributable at least in part to undergraduate education. The primary aim of this study was to quantify and compare first and final year nursing, midwifery and allied health professional (NMAHP) students' pain related knowledge and attitudes. The secondary aim was to explore what factors influence students' pain related knowledge and attitudes. METHODS: In this cross-sectional study, 1154 first and final year healthcare students, from 12 universities in five different countries completed the Revised Neurophysiology of Pain Quiz (RNPQ) [knowledge] and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS) [attitudes]. RESULTS: Physiotherapy was the only student group with statistically and clinically improved pain related knowledge [mean difference, 95% CI] (3.4, 3.0 to 3.9, p = 0.01) and attitudes (-17.2, -19.2 to 15.2, p = 0.01) between first and final year. Pain education teaching varied considerably from course to course (0 to 40 h), with greater levels of pain related knowledge and attitudes associated with higher volumes of pain specific teaching. CONCLUSIONS: There was little difference in pain knowledge and attitudes between all first and final year NMAHP students other than physiotherapy. This suggests that for most NMAHP disciplines, undergraduate teaching has little or no impact on students' understanding of pain. There is an urgent need to enhance pain education provision at the undergraduate level in NMAHPs. TRIAL REGISTRATION: The study protocol was prospectively registered at ClinicalTrials.Gov NCT03522857 .

Exploring how key performance indicators influence nursing and midwifery practice: A mixed-methods study.

AIMS: To scope the key performance indicators (KPIs) used in nursing and midwifery across the United Kingdom and Republic of Ireland and explore how they influence practice in healthcare organizations. DESIGN: The study adopted a sequential, exploratory mixed-methods design. METHODS: Phase 1 incorporated a multiple-choice questionnaire completed by 77 Directors of Nursing recruited using voluntary response sampling. In phase 2, 35 nurses and midwives who were working at executive, senior manager and clinical levels, participated in semi-structured interviews. Data collection of both phases was conducted from January 2016 to October 2016. FINDINGS: Quantitative data revealed over 100 nursing and midwifery-specific KPIs. National requirements were a deciding factor in KPI selection, while clinical involvement was mainly through data collection. Respondents stated that they used patient experience KPIs, but only one was assessed as valid. Thematic analysis identified two themes: The leadership challenge (including 'voiceless in the national conversation', 'aligning KPIs in the practice context' and 'listening to those who matter'); and taking action (including 'establishing ownership and engaging staff', 'checks and balances' and 'closing the loop'). CONCLUSION: The large volume of KPI measurement taking place makes meaningful evaluation of performance and quality of care difficult, both in and across organizations. Nurses and midwives require enhanced knowledge of the nature and purpose of KPIs, as evidence gained from KPI data collection is insufficient to lead to improvements in practice. A practice context that encourages collective leadership, where multiple sources of evidence are gathered and everyone is included in KPI evaluation and subsequent decision-making, is key. IMPACT: This study adds to the body of evidence on KPI understanding. It informs the future effective management of indicators that will facilitate the delivery of meaningful care and reduce the cost, time and effort invested in the implementation of KPIs and data management.

Exploring psychological safety as a component of facilitation within the Promoting Action on Research Implementation in Health Services framework.

AIMS AND OBJECTIVES: To explore holistic facilitation as an approach to enable the healthcare team to critically analyse practice and enhance patient care. BACKGROUND: Globally, the challenge of changing healthcare practices for enhanced patient care is the focus of much attention. Facilitation is emerging as an important approach to assist healthcare teams to explore and improve their practice. Within the Promoting Action on Research Implementation in Health Services framework, which has been tested in an international arena, facilitation is a key element of operationalising collaborative changes in practice. This study uses the framework to explore holistic facilitation and the concept of psychological safety. DESIGN: An Emancipatory Action Research approach was used. METHODS: Facilitated critical reflection was undertaken with the healthcare team working in an abdominal surgical unit. In addition, the lead researcher maintained a reflexive journal. Data were analysed using thematic analysis. Eighty-five per cent (n = 48) of nursing staff and individual participants from other parts of the healthcare team (n = 3) participated in the two-year study. RESULTS: Data revealed 14 sub-themes that impacted upon the culture of the unit. These were as follows: support, leadership, oppressed behaviours, communication, interruptions, power imbalance, horizontal violence, threat, autonomy, distorted perceptions, vulnerability, value, trust and time. Psychological safety, leadership and oppressed behaviours emerged as three key themes in the practice context. CONCLUSIONS: There is a need to create psychologically safe spaces in environments where insufficient support, weak leadership and oppressed behaviours are apparent. Psychological safety enables individuals to feel safe to engage in difficult conversations and consider changes to practice. In a theoretical contribution to the area of facilitation, it is proposed that the additional element of psychological safety needs to be incorporated into facilitation models, in particular, the Promoting Action on Research Implementation in Health Services framework, to more accurately reflect the complexities of working with healthcare teams. RELEVANCE TO PRACTICE: The pressure on healthcare environments continues to increase. To achieve the necessary skills to lead and develop services requires more than simply highlighting what is wrong with practice. Creating psychologically safe spaces, using holistic facilitation, is essential to enabling healthcare teams to critically analyse practice and enhance patient care.

Determining factors that have an impact upon effective evidence-based pain management with older people, following colorectal surgery: an ethnographic study.

AIM: The aim of this project was to examine pain management practices with older people admitted to the colorectal unit of an acute hospital trust. BACKGROUND: Although pain assessment and management are judged to be a priority, little research has examined the care older people receive in the acute surgical setting. Thus, pain in older people (65 years and over) can be under recognized and unrelieved. With the number of older people requiring surgery increasing, it is important to identify factors in the practice context that enhance or inhibit effective pain management. DESIGN: The project drew upon an in-depth ethnographic approach. METHOD: Sixty-two hours of around the clock, non-participant observation of nursing practice was completed. Thirty-nine (78%) nurses and forty-six (42%) patients were observed. Seven (6%) additional patients participated in pre- and postoperative interviews and 35 (90%) nurses completed the Nursing Work Index--Revised Questionnaire. FINDINGS: Holistic pain assessment for older people was found to be deficient in the acute surgical setting. Nurses appeared unaware of the importance of addressing the particular pain needs of older patients. Inflexible analgesic prescriptions provided the mainstay treatment of pain, with minimal consideration given to non-pharmacological strategies. Older people wanted to be active participants in their care. However, existing pain management practices disempowered older patients, making them reluctant or unable to discuss their pain with ward staff. CONCLUSION: Comprehensive pain assessment, improved documentation and proficient communication, inclusive of older patients, are necessary to improve pain management practices. It is imperative that patients, nurses, doctors and Acute Pain Service work in collaboration to challenge pain management practices and implement change. RELEVANCE TO CLINICAL PRACTICE: The project demonstrated some of the multiple and complex factors that affect the older persons' pain experience and identified three action research cycles for further development work.