A cross-sectional examination of the early-onset hypertensive disorders of pregnancy and industrial emissions of toxic metals using Kentucky birth records, 2008-2017.

This cross-sectional study assessed geospatial patterns of early-onset hypertensive disorders of pregnancy (eHDP) in primiparous mothers and exposure to industrial emissions using geocoded residential information from Kentucky live (N = 210,804) and still (N = 1,247) birth records (2008-2017) and census block group estimates of aerosol concentrations of arsenic (As), cadmium (Cd), chromium (Cr), lead (Pb), mercury (Hg), selenium (Se), and zinc (Zi) from the Risk Screening Environmental Indicators (RSEI) model. A latent class analysis allowed for the identification of four district exposure classes-As, Cd, and Pb (12.6%); Se and Zi (21.4%); Pb and Cr (8%); and low or no exposures (57.9%). Women classified as having a high probability of exposure to both Pb and Cr had a statistically significantly greater prevalence of eHDP after adjusting for demographic factors (aPR = 1.22, 95% CI: 1.04, 1.44) relative to those with low or no exposure. Our findings contribute to the emerging literature on the association of metal exposures with pregnancy outcomes.

Designing a Framework for Remote Cancer Care Through Community Co-design: Participatory Development Study.

BACKGROUND: Recent shifts to telemedicine and remote patient monitoring demonstrate the potential for new technology to transform health systems; yet, methods to design for inclusion and resilience are lacking. OBJECTIVE: The aim of this study is to design and implement a participatory framework to produce effective health care solutions through co-design with diverse stakeholders. METHODS: We developed a design framework to cocreate solutions to locally prioritized health and communication problems focused on cancer care. The framework is premised on the framing and discovery of problems through community engagement and lead-user innovation with the hypothesis that diversity and inclusion in the co-design process generate more innovative and resilient solutions. Discovery, design, and development were implemented through structured phases with design studios at various locations in urban and rural Kentucky, including Appalachia, each building from prior work. In the final design studio, working prototypes were developed and tested. Outputs were assessed using the System Usability Scale as well as semistructured user feedback. RESULTS: We co-designed, developed, and tested a mobile app (myPath) and service model for distress surveillance and cancer care coordination following the LAUNCH (Linking and Amplifying User-Centered Networks through Connected Health) framework. The problem of awareness, navigation, and communication through cancer care was selected by the community after framing areas for opportunity based on significant geographic disparities in cancer and health burden resource and broadband access. The codeveloped digital myPath app showed the highest perceived combined usability (mean 81.9, SD 15.2) compared with the current gold standard of distress management for patients with cancer, the paper-based National Comprehensive Cancer Network Distress Thermometer (mean 74.2, SD 15.8). Testing of the System Usability Scale subscales showed that the myPath app had significantly better usability than the paper Distress Thermometer (t63=2.611; P=.01), whereas learnability did not differ between the instruments (t63=-0.311; P=.76). Notable differences by patient and provider scoring and feedback were found. CONCLUSIONS: Participatory problem definition and community-based co-design, design-with methods, may produce more acceptable and effective solutions than traditional design-for approaches.

Variation of phenotypic and physiological traits of Robinia pseudoacacia L. from 20 provenances.

To select elite Robinia pseudoacacia L. germplasm resources for production, 13 phenotypes and three physiological indicators of 214 seedlings from 20 provenances were systematically evaluated and analyzed. The leaf phenotypic and physiological coefficients of variation among the genotypes ranged from 3.741% to 19.599% and from 8.260% to 42.363%, respectively. The Kentucky provenance had the largest coefficient of variation (18.541%). The average differentiation coefficients between and within provenances were 34.161% and 38.756%, respectively. These close percentages showed that R. pseudoacacia presented high genetic variation among and within provenances, which can be useful for assisted migration and breeding programs. Furthermore, based on the results of correlations, principal component analysis and cluster analysis, breeding improvements targeting R. pseudoacacia's ornamental value, food value, and stress resistance of were performed. Forty and 30 excellent individuals, accounting for 18.692% and 14.019%, respectively, of the total resources. They were ultimately screened, after comprehensively taking into considering leaf phenotypic traits including compound leaf length, leaflet number and leaflet area and physiological characteristics including proline and soluble protein contents. These selected individuals could provide a base material for improved variety conservation and selection.

Rebooting the ambulatory enterprise in a community medical group in Kentucky following the initial surge of COVID-19.

ABSTRACT: The novel coronavirus disease 2019 (COVID-19) pandemic has intensified globally since its origin in Wuhan, China in December 2019. Many medical groups across the United States have experienced extraordinary clinical and financial pressures due to COVID-19 as a result of a decline in elective inpatient and outpatient surgical procedures and most nonurgent elective physician visits. The current study reports how our medical group in a metropolitan community in Kentucky rebooted our ambulatory and inpatient services following the guidance of our state's phased reopening. Particular attention focused on the transition between the initial COVID-19 surge and post-COVID-19 surge and how our medical group responded to meet community needs. Ten strategies were incorporated in our medical group, including heightened communication; ambulatory telehealth; safe and clean outpatient environment; marketing; physician, other medical provider, and staff compensation; high quality patient experience; schedule optimization; rescheduling tactics; data management; and primary care versus specialty approaches. These methods are applicable to both the current rebooting stage as well as to a potential resurgence of COVID-19 in the future.

Effects of environmental conditions (temperature, pH, and glucose) on biofilm formation of Salmonella enterica serotype Kentucky and virulence gene expression.

Salmonella is a foodborne pathogen and an emerging zoonotic bacterial threat in the food industry. The aim of this study was to evaluate the biofilm formation by a cocktail culture of 3 wild isolates of Salmonella enterica serotype Kentucky on plastic (PLA), silicon rubber (SR), and chicken skin surfaces under various temperatures (4, 10, 25, 37, and 42°C) and pH values (4.0, 5.0, 6.0, 7.0, and 8.0). Then, at the optimum temperature and pH, the effects of supplementation with glucose (0, 0.025, 0.05, and 0.4% w/v) on biofilm formation were assessed on each of the surfaces. The results indicated that higher temperatures (25 to 42°C) and pH values (7.0 and 8.0) led to more robust biofilm formation than lower temperatures (4 and 10°C) and lower pH levels (4.0 to 6.0). Moreover, biofilm formation was induced by 0.025% glucose during incubation at the optimum temperature (37°C) and pH (7.0) but inhibited by 0.4% glucose. Consistent with this finding, virulence related gene (rpoS, rpoH, hilA, and avrA) expression was increased at 0.025% glucose and significantly reduced at 0.4% glucose. This results also confirmed by field emission scanning electron microscope, confocal laser scanning microscopy, and autoinducer-2 determination. This study concluded that optimum environmental conditions (temperature 37°C, pH 7.0, and 0.25% glucose) exhibited strong biofilm formation on food and food contract surfaces as well as increased the virulence gene expression levels, indicating that these environmental conditions might be threating conditions for food safety.

The Kentucky Inventory of Mindfulness Skills in Greek Undergraduate and Postgraduate Students.

The Kentucky Inventory of Mindfulness Skills (KIMS) is a widely used multidimensional tool for assessing the tendency of the individual to be mindful in everyday life. The aim of the present study was to standardize a Greek version of KIMS and to explore its psychometric properties in the Greek population. A sample of 213 Greek undergraduate and postgraduate students from various educational institutions completed the questionnaires. The Mindful Attention and Awareness Scale (MAAS), Toronto Alexithymia Scale (TAS-20), and Perceived Stress Scale (PSS-14) were used to evaluate the criterion validity of KIMS. The Principal component analysis (PCA) resulted in a four-component solution, similar to the structure of the English version of the inventory: "Observing," "Describing," "Acting with awareness," and "Accepting without judgment." All components combined accounted for 45.79% of variance. The subscales had adequate internal consistency, and their scores were correlated with MAAS, TAS, and PSS scores, indicating satisfying criterion validity. Associations between the "Observing" subscale and demographic characteristics were also revealed. This version of KIMS can be safely utilized for assessing mindfulness skills and the efficacy of mindfulness-based interventions in Greek populations.

Protocol to assess the efficacy of carnosine supplementation in mitigating the adverse cardiovascular responses to particulate matter (PM) exposure: the Nucleophilic Defense Against PM Toxicity (NEAT) trial.

INTRODUCTION: Exposure to airborne particulate matter (PM) is associated with cardiovascular disease. These outcomes are believed to originate from pulmonary oxidative stress and the systemic delivery of oxidised biomolecules (eg, aldehydes) generated in the lungs. Carnosine is an endogenous di-peptide (ß-alanine-L-histidine) which promotes physiological homeostasis in part by conjugating to and neutralising toxic aldehydes. We hypothesise that an increase of endogenous carnosine by dietary supplementation would mitigate the adverse cardiovascular outcomes associated with PM exposure in humans. METHODS AND ANALYSIS: To test this, we designed the Nucleophilic Defense Against PM Toxicity trial. This trial will enroll 240 participants over 2 years and determine if carnosine supplementation mitigates the adverse effects of PM inhalation. The participants will have low levels of endogenous carnosine to facilitate identification of supplementation-specific outcomes. At enrollment, we will measure several indices of inflammation, preclinical cardiovascular disease and physical function. Participants will be randomly allocated to carnosine or placebo groups and instructed to take their oral supplement for 12 weeks with two return clinical visits and repeated assessments during times of peak PM exposure (June-September) in Louisville, Kentucky, USA. Statistical modelling approaches will be used to assess the efficacy of carnosine supplementation in mitigating adverse outcomes. ETHICS AND DISSEMINATION: This study protocol has been approved by the Institutional Review Board at the University of Louisville. Results from this study will be disseminated at scientific conferences and in peer-reviewed publications.Trial registration: NCT03314987; Pre-results.

Nonadherence to Standard of Care for Locally Advanced Colon Cancer as a Contributory Factor for High Mortality Rates in Kentucky.

BACKGROUND: Kentucky has one of the highest mortality rates for colon cancer, despite dramatic improvements in screening. The National Comprehensive Cancer Network (NCCN) guidelines recommend operation and adjuvant chemotherapy for locally advanced (stage IIb/c and stage III) colon cancer (LACC). The purpose of this study was to determine the rate of nonadherence with current standard of care (SOC) and associated factors as possible contributors to mortality. METHODS: The Kentucky Cancer Registry database linked with administrative health claims was queried for individuals (20 years and older) diagnosed with LACC from 2007 to 2012. Bivariate and logistic regression of nonadherence was performed. Survival analysis was performed with Cox regression and Kaplan-Meier plots. RESULTS: A total of 1,404 patients with LACC were included. Approximately 42% of patients with LACC were noted to be nonadherent to SOC, with nearly all (95.7%) failing to receive adjuvant chemotherapy. After adjusting for all significant factors, we found the factors associated with nonadherence included the following: age older than 75 years, stage III colon cancer, high Charlson Comorbidity Index (3+), low poverty level, Medicaid coverage, and disability. Adherence to SOC is associated with a significant improvement in the 5-year survival rate compared with nonadherence (63.0% and 27.4%, respectively; p < 0.0001). CONCLUSIONS: Our study identified multiple factors associated with the failure of patients with LACC to receive SOC, particularly adjuvant chemotherapy, suggesting the need to focus on improving adjuvant chemotherapy compliance in specific populations. Nonadherence to LACC SOC is likely a major contributor to the persistently high mortality rates in Kentucky.

A 5-Week Seminar on the Biopsychosocial-Spiritual Model of Self-Care Improves Anxiety, Self-Compassion, Mindfulness, Depression, and Stress in Graduate Healthcare Students.

Graduate healthcare students can experience stress that affects their ability to perform academically and clinically, decreases empathy, and affects their well-being and clinical competence. The purpose of the current study was to determine the effects of a seminar on a yoga-inspired biopsychosocial-spiritual model of self-care on perceived levels of anxiety, self-compassion, mindfulness, depression, and stress in graduate healthcare students. We used a within-group repeated-measure design with baseline followed by intervention. The intervention was a 5-week seminar with 60-minute sessions that incorporated breathing, mindful movement, meditation, and education for self-care in five areas of a biopsychosocial-spiritual model (spiritual, physical, intellectual, energetic, and psychoemotional-social). The following outcomes measures assessed perceived changes in anxiety, self-compassion, mindfulness, depression, and stress: Beck Anxiety Inventory (BAI), Self-Compassion Scale-Short Form (SCS-SF), Freiburg Mindfulness Inventory (FMI), Kentucky Inventory of Mindfulness Skills (KIMS), Mindfulness Attention Awareness Scale (MAAS), Beck Depression Inventory (BDI), and Perceived Stress Scale (PSS). The Freidman test with Dunn's test post hoc pairwise comparisons was used for the BAI, SCS-SF, FMI, KIMS, and MAAS. A Wilcoxon signed-rank test was used for BDI and PSS. Twenty doctor of physical therapy students and one doctor of dental medicine student participated in the study. Significant improvements (all p < 0.05) were found for self-compassion, mindfulness, anxiety, depression, and stress. A 5-week seminar using a biopsychosocial-spiritual approach for self-care improved self-compassion and mindfulness and diminished anxiety, depression, and stress. Implementing programs that facilitate self-awareness and self-care may provide important benefits to future healthcare providers.

The use of ABC score in activation of massive transfusion: The yin and the yang.

BACKGROUND: Hemorrhage is the most common cause of early death in trauma patients. Massive transfusion protocols (MTPs) have been designed to accelerate the release of blood products but can result in waste if activated inappropriately. The Assessment of Blood Consumption (ABC) score has become a widely accepted score for MTP activation. In this study, we compared the use of ABC criteria to physician judgment in MTP activation. METHODS: Adult trauma patients treated at University of Louisville Trauma Center from January 2016 to December 2016 were studied. Activation via ABC score was assessed retrospectively from emergency department (ED) data. Location, timing of activation, percent of patients using more than 5 units of packed red blood cells, amount of product waste, factors associated with early activation by physicians, and mortality were analyzed. RESULTS: Three thousand four hundred twenty-one patients were included in this study. Only 33% of the patients who would have had MTP activation based on the ABC criteria used more than 5 units of blood products within 24 hours of admission compared with 65% of the patients in whom clinical judgment was used. Seventy-six percent of all MTP activations from clinical judgment would have been activated by the ABC criteria in the ED. Fifty-five percent of all MTP activations via clinical judgment were activated in the operating room and 41% in the ED. Eighty-one percent of activations that occurred in the operating room by physician judgment could have been activated earlier in the ED if the ABC criteria had been used. However, ABC score can lead to higher potential fresh frozen plasma waste (588 vs. 84 units) compared with physician judgment. CONCLUSIONS: The ABC criteria overestimate need for massive transfusion and can lead to increased product waste compared with physician judgment, but its use leads to earlier MTP activation. Criteria to trigger MT activation should rely on both clinical acumen and validated prediction tools. LEVEL OF EVIDENCE: Prognostic, level III.

Population-Based Analysis of Patient Age and Other Disparities in the Treatment of Ovarian Cancer in Central Appalachia and Kentucky.

OBJECTIVES: Adherence to National Comprehensive Cancer Network (NCCN) guidelines for ovarian cancer treatment improves patient outcomes. The aim of this study was to assess disparities associated with ovarian cancer treatment in the state of Kentucky and central Appalachia. METHODS: Data on patients diagnosed as having ovarian cancer from 2007 through 2011 were extracted from administrative claims-linked Kentucky Cancer Registry data. NCCN compliance was defined by stage, grade, surgical procedure, and chemotherapy. Selection criteria were reviewed carefully to ensure data quality and accuracy. Descriptive analysis, logistic regression, and Cox regression analyses were performed to examine factors associated with guidelines compliance and survival. RESULTS: Most women were aged 65 years or older (62.5%) and had high-grade (65.9%) and advanced-stage (61.0%) ovarian cancer. Two-thirds of cases (65.9%) received NCCN-recommended treatment for ovarian cancer. The hazard ratio of death for women who did not receive NCCN-compliant care was 62% higher compared with the women who did receive NCCN-compliant treatment. Results from the logistic regression showed that NCCN-compliant treatment was more likely for women aged 65 to 74 years compared with women aged 20 to 49 years, late-stage compared with early-stage cancers, receipt of care at tertiary care hospitals, and privately insured compared with Medicaid or Medicare. CONCLUSIONS: When the treatment of ovarian cancer did not follow NCCN recommendations, patients had a significantly higher risk of death. Women were less likely to receive NCCN-compliant care if they were younger (20-49 years), had early-stage disease, did not have private insurance, or had care provided at a nontertiary care hospital.

Pilot Investigation of 2 Nondiet Approaches to Improve Weight and Health.

Context • Weight loss and maintenance are associated with many health benefits, but long-term maintenance of weight loss remains elusive for many people. Overweight individuals are at higher risk than normal-weight individuals for stress-induced overeating. The use of stress-management tools in a weight loss program might decrease the physiological stress that fuels overeating and improve posttreatment maintenance of weight loss Objective • The study intended to compare the differences in outcomes between 2 approaches to achieving weight loss and changes in health-stress reduction and intuitive eating (IE)-during a 14-wk period. Design • The research team designed a small, randomized, controlled pilot study. Setting • The study took place at the University of Kentucky (Lexington, KY, USA). Participants • Men and women, aged 25 to 65 y, with a body mass index ≥30 but ≤40 kg/m2, were recruited through various outlets on a large college campus, and 33 enrolled in the study. Intervention • Participants were randomly assigned either to an IE or to a stress-reduction program (EBT) for a 7 wk intervention and a 7-wk follow-up period. Outcome Measures • Weight, blood pressure, stress, depression, and eating behaviors were measured at baseline, postintervention at week 7, and postintervention at week 14. Results • Participants were 69.7% female and 93.9% Caucasian. An intent-to-treat analysis was conducted on the main outcome of weight. At 14 wk, the EBT group had lost 4.4 ± 6.7 lb (1.99 ± 3.04 kg), and the IE group had lost 1.03 ± 6.10 lb (0.48 ± 2.77 kg). A repeated measures analysis of variance did not find any significant difference between groups for weight change (P = .36). Completers in the EBT group significantly improved blood pressure, perceived stress, and food addiction symptoms from baseline to 7 wk (P < .05). Only the changes in weight were maintained at 14 wk. Conclusions • The study suggested that the stress reduction approach may be viable as an approach to weight loss and improvements in health-related outcomes in the short term. A longer investigation of the program is warranted.

Adolescents' Perceptions of a Gardening Activity at a Juvenile Justice Center.

PURPOSE: The purpose of this study was to elicit participants' ( N = 16) perceptions of a gardening activity at a juvenile justice center and to determine whether past exposure to gardening and farmers markets was associated with their perceptions of the gardening experience. DESIGN: This cross-sectional, exploratory program evaluation was conducted in partnership with the Kentucky Department of Juvenile Justice. Adolescents completing the Cadet Leadership and Education Program participated in gardening in order to provide produce to a local farmers' market. METHOD: After the growing season, participants were asked to complete a nine-item questionnaire about the gardening activity during one of their usual classes at the facility. The questionnaire assessed perception of the experience and past exposure to gardening and farmers' markets. FINDINGS: Participants reported favorably about their participation in the activity, knowledge gained from the activity, and their intent to garden in the future. Those who had previously gardened had more favorable perception of gardening than those who had never gardened. Gardening is an inexpensive means of teaching teamwork and delayed gratification and providing a sense of empowerment and may benefit at-risk adolescents during incarceration.

Addressing Compassion Fatigue and Stress of Special Education Teachers and Professional Staff Using Mindfulness and Prayer.

Alternative therapies are promising nursing interventions for improvement of compassion fatigue in educators working in special education. A convenience sample of 27 teachers and professional staff working in special education participated in a quasi-experimental pilot study and completed a pre/posttest of demographic questions, the Perceived Stress Scale (PSS) (10-item) and Professional Quality of Life (ProQOL). All attended a presentation on stress, compassion satisfaction (CS), mindfulness, prayer, and social support. Nearly, one half received weekly electronic text message reminders encouraging use of mindfulness and prayer. All were offered support groups. Use of alternative therapies was self-selected and self-reported. Significant improvement occurred in posttest PSS scores ( p = .0485) of participants with the highest reported levels of use of mindfulness. ProQOL CS scores ( p = .0289) and PSS scores ( p = .0244) significantly improved when evaluating difference in means between groups with the highest levels and lowest levels of prayer and mindfulness. ProQOL burnout scores ( p = <.0001) increased from pretest to posttest. Findings were not significant in regard to reminders and social support.

Implementation of Rocking Chair Therapy for Veterans in Residential Substance Use Disorder Treatment [Formula: see text].

BACKGROUND: Substance use disorder (SUD) and mental health diagnosis negatively affect Veteran homelessness. OBJECTIVE: Assess the acceptance and feasibility of rocking chair therapy as a self-implemented intervention for mood and substance cravings. PICOT: For homeless Veterans in SUD treatment, how does adding vestibular stimulation by use of a rocking chair compared with treatment as usual affect levels of anxiety and substance cravings? RESULTS: Two significant findings were observed. First, a greater number of minutes spent rocking was associated with significantly greater scores on the Expectancy scale of the Alcohol Craving Questionnaire (ACQ; p = .05), suggesting participants experiencing higher urges and desires to drink rocked to self-soothe. Second, a significant association was observed between a greater number of minutes spent rocking and lower scores on the ACQ Purposefulness subscale ( p = .03), indicating greater time rocking was associated with fewer urges and desires that are connected with the intent and plan to drink. CONCLUSION: Vestibular stimulation by rocking in a rocking chair may increase the ability to self-regulate mood and substance cravings, thereby potentially reducing risk of relapse and recurrent chronic homelessness.

Selenium poisoning of fish by coal ash wastewater in Herrington Lake, Kentucky.

Selenium pollution from the E.W. Brown Electric Generating Station was investigated in Herrington Lake, KY. Coal ash wastewater is discharged as surface water overflow from ash disposal ponds into the lake via a National Pollutant Discharge Elimination System permit issued by the Kentucky Division of Water, but the permit does not restrict or limit the amount of selenium released. Unpermitted discharges occur from seeps and drainage through leaks in ash pond dams. Together, these discharges have resulted in selenium concentrations in water, sediment, benthic macroinvertebrates, and fish that are 2-9 times the level that is toxic for fish reproduction and survival. A large proportion (12.2%, or 25 times background) of juvenile largemouth bass (Micropterus salmoides, the only species examined) exhibited spinal and/or craniofacial malformations that are consistent with selenium poisoning. Teratogenic Deformity Index values indicated a 3.05% population-level impact on the bass fishery, with total selenium-induced mortality (including pre-swimup mortality) estimated to be in excess of 25% per year. These findings confirm that coal ash discharges into Herrington Lake are contributing selenium to the Lake that is poisoning fish.

Healthcare contact and treatment uptake following hepatitis C virus screening and counseling among rural Appalachian people who use drugs.

BACKGROUND: Hepatitis C virus (HCV) remains a major contributor to morbidity and mortality worldwide. Since 2009, Kentucky has led the United States in cases of acute HCV, driven largely by injection drug use in rural areas. Improved treatment regimens hold promise of mitigating the impact and transmission of HCV, but numerous barriers obstruct people who inject drugs (PWID) from receiving care, particularly in medically underserved settings. METHODS: 503 rural people who use drugs were recruited using respondent-driven sampling and received HCV screening and post-test counseling. Presence of HCV antibodies was assessed using enzyme immunoassay of dried blood samples. Sociodemographic and behavioral data were collected using computer-based questionnaires. Predictors of contacting a healthcare provider for follow-up following HCV-positive serotest and counseling were determined using discrete-time survival analysis. RESULTS: 150 (59%) of 254 participants reported contacting a healthcare provider within 18 months of positive serotest and counseling; the highest probability occurred within six months of serotesting. 35 participants (14%) reported they were seeking treatment, and 21 (8%) reported receiving treatment. In multivariate time-dependent modeling, health insurance, internet access, prior substance use treatment, meeting DSM-IV criteria for generalized anxiety disorder, and recent marijuana use increased the odds of making contact for follow-up. Participants meeting criteria for major depressive disorder and reporting prior methadone use, whether legal or illegal, were less likely to contact a provider. CONCLUSION: While only 8% received treatment after HCV-positive screening, contacting a healthcare provider was frequent in this sample of rural PWID, suggesting that the major barriers to care are likely further downstream. These findings offer insight into the determinants of engaging the cascade of medical treatment for HCV and ultimately, treatment-as-prevention. Further study and increased resources to support integrated interventions with effectiveness in other settings are recommended to mitigate the impact of HCV in this resource-deprived setting.

Palliative Care Triggers in the Intensive Care Unit: A Pilot Success Story.

There is growing recognition that electronic medical record triggers in the intensive care unit (ICU) have led to an increase in palliative care consultations. One suburban health care system adopted triggers unique to their culture and setting in a pilot study and saw an increase in palliative consultations in the ICU. Implementing triggers is often a complex and multifaceted process to adopt. This review shares the steps from concept to implementation of establishing palliative prompts in 1 ICU within an integrated health care system.

Understanding Resident Performance, Mindfulness, and Communication in Critical Care Rotations.

OBJECTIVE: Evidence from the medical literature suggests that surgical trainees can benefit from mindful practices. Surgical educators are challenged with the need to address resident core competencies, some of which may be facilitated by higher levels of mindfulness. This study explores whether mindful residents perform better than their peers as members of the health care team. DESIGN: This study employed a multiphase, multimethod design to assess resident mindfulness, communication, and clinical performance. SETTING: Academic, tertiary medical center. PARTICIPANTS: Residents (N = 51) working in an intensive care unit. In phase I, medical residents completed a self-report survey of mindfulness, communication, emotional affect, and clinical decision-making. In phase II, resident performance was assessed using independent ratings of mindfulness and clinical decision-making by attending physicians and registered nurses. RESULTS: In phase 1, a significant positive relationship was found between resident performance and mindfulness, positive affect (PA), and communication. In phase 2, attending physicians/registered nurses' perceptions of residents' mindfulness were positively correlated with communication and inversely related to negative affect (NA). The top quartile of residents for performance and mindfulness had the lowest NA. Higher-rated residents underestimated their performance/mindfulness, whereas those in the lowest quartile overestimated these factors. CONCLUSIONS: This study offers a number of implications for medical resident education. First, mindfulness was perceived to be a significant contributor to self-assessments of competency and performance. Second, both PA and NA were important to mindfulness and performance. Third, communication was associated with resident performance, mindfulness, and PA. These implications suggest that individual characteristics of mindfulness, communication, and affect, all potentially modifiable, influence care quality and safety. To improve low performers, surgical educators could screen and identify residents with inaccurate self-assessments. Residents open to feedback will improve faster and develop awareness toward situations and interactions with patients, colleagues, attending physicians, and staff.