U.S. Parental Vaccine Hesitancy and the COVID-19 Vaccine: A Scoping Review.

Parental vaccine hesitancy has been a hotly debated issue long before the COVID-19 pandemic. Still, the emergence of a new vaccine during this public health crisis made even pro-vaccine individuals reconsider vaccines for their children. This scoping review was conducted to understand why parents expressed hesitancy towards the COVID-19 vaccine for children under 12 years old. The search included primary sources of evidence published in English from 2020-2022. A final 41 articles met the criteria. Overall, more vaccine-hesitant characteristics were non-white, female, lower education level, lower income, on public insurance, conservative political affiliation, younger age, and rural residence. Concerns affecting confidence in the vaccine were the risk of possible side effects and lack of trust in the development of the emergency approval of the vaccine. School nurses can acknowledge parental fears and provide parents with evidence-based information when communicating with them about vaccinations.

Situational Awareness and Proactive Engagement Predict Higher Time in Range in Adolescents and Young Adults Using Hybrid Closed-Loop.

Background: Adolescents and young adults with type 1 diabetes have high HbA1c levels and often struggle with self-management behaviors and attention to diabetes care. Hybrid closed-loop systems (HCL) like the t:slim X2 with Control-IQ technology (Control-IQ) can help improve glycemic control. The purpose of this study is to assess adolescents' situational awareness of their glucose control and engagement with the Control-IQ system to determine significant factors in daily glycemic control. Methods: Adolescents (15-25 years) using Control-IQ participated in a 2-week prospective study, gathering detailed information about Control-IQ system engagements (boluses, alerts, and so on) and asking the participants' age and gender about their awareness of glucose levels 2-3 times/day without checking. Mixed models assessed which behaviors and awareness items correlated with time in range (TIR, 70-180 mg/dl, 3.9-10.0 mmol/L). Results: Eighteen adolescents/young adults (mean age 18 ± 1.86 years and 86% White non-Hispanic) completed the study. Situational awareness of glucose levels did not correlate with time since the last glucose check (p = 0.8). In multivariable modeling, lower TIR was predicted on days when adolescents underestimated their glucose levels (r = -0.22), received more CGM alerts (r = -0.31), and had more pump engagements (r = -0.27). A higher TIR was predicted when adolescents responded to CGM alerts (r = 0.20) and entered carbohydrates into the bolus calculator (r = 0.49). Conclusion: Situational awareness is an independent predictor of TIR and may provide insight into patterns of attention and focus that could positively influence glycemic outcomes in adolescents. Proactive engagements predict better TIR, whereas reactive engagement predicted lower TIR. Future interventions could be designed to train users to develop awareness and expertise in effective diabetes self-management.

Stress Impact and Care for COVID-19: Pilot Education and Support Course Decreases Burnout Among Nursing Students.

BACKGROUND: Nurses and nursing students have been at the forefront of the fight against COVID-19, often working in conditions that produce stress injuries and burnout. Early recognition and mitigation of stress and emotional trauma help prevent burnout. AIMS: To evaluate the effectiveness of an online 8-hour stress awareness course and associated 1-hour support group in reducing stress and burnout among nursing students. METHODS: We conducted a program evaluation for an online stress awareness pilot course offered to nursing students. The course, and associated support groups led by trained psychiatric mental health nurse practitioner students, included a common language for talking about stress, screening tools for recognizing stress injuries, and strategies for improving self-care. Students completed pre- and post-course surveys. Outcome measures included changes on course learning objectives, level of burnout, health-related locus of control, and experiences of stress and coping. RESULTS: Nursing students (n = 360) enrolled in the course, and 224 (62%) completed pre- and post-course surveys. Sixty percent rated the course excellent or very good. Depression Anxiety and Stress Scales and Impact of Event Scale Revised scores were within established normal ranges. There was a significant increase in all nine course learning objectives (p < .001) and decreased signs of stress (p < .001). Students' level of burnout decreased by odds ratio = 0.58 (95% CI: [0.4, 0.9], p < .006). CONCLUSIONS: Nursing leaders can use psychoeducational strategies to mitigate the impact of stress, build confidence, and support nursing students entering the workforce during these unprecedented times.

Novel predictors of daily fluctuations in glycemia and self-management in adolescents and young adults with type 1 diabetes.

AIMS: To understand morning biopsychosocial factors that predict glycemia, adherence, and goal attainment in adolescents and young adults (AYA) with type 1 diabetes (T1D) on a daily basis. METHODS: Eight-eight AYA (mean 17.6 ± 2.6 years, 54% female, HbA1c 7.9 ± 1.4%, diabetes duration 8.5 ± 4.5 years) with T1D who use Continuous Glucose Monitoring (CGM) completed a 2-week prospective study. Participants chose a self-management goal to focus on during participation. For six days, participants prospectively completed a 25-item Engagement Prediction Survey to assess biopsychosocial factors to predict daily diabetes outcomes and an end-of-day Goal Survey. Lasso and mixed-model regression were used to determine items in the Engagement Prediction Survey most predictive of perceived goal attainment, CGM Time-in-Range (TIR, 70-180 mg/dl), sensor mean glucose, number of insulin boluses and hyperglycemia response (bolus within 30 min of high alert or glucose <200 mg/dl within 2 hours). RESULTS: A 7-item model (including current glucose, planning/wanting to manage diabetes, wanting to skip self-management, feeling good about self, health perception and support needs) explained 16.7% of the daily variance in TIR, 18.6% of mean sensor glucose, 2.1% of the number of boluses, 14% of hyperglycemia response, and 28.7% of goal attainment perceptions. The mean absolute change in day-to-day TIR was 16%, sensor glucose was 30 mg/dl, and the number of boluses was 2. AYA reported more positive Engagement Prediction Survey responses on mornings when they awoke with lower glucose levels. CONCLUSIONS: Morning biopsychosocial state factors predict glycemic and adherence outcomes in AYA with diabetes and could be a novel intervention target for future behavioural interventions.

Predicting optimal use of continuous glucose monitors in adolescents with type 1 diabetes: It's about benefit and burden.

PURPOSE: Youth with type 1 diabetes (T1D) often use Continuous Glucose Monitoring (CGM) devices; however, many do not wear them consistently enough to obtain optimal glycemic benefit. This study aimed to identify demographic and psychosocial predictors of optimal CGM use in adolescents with T1D to inform nurse-led interventions to improve adherence. DESIGN AND METHODS: Cross-sectional survey data from youth (12-19 years) using CGM were analyzed to determine whether perceived benefits/burdens of CGM, self-efficacy, and coping predicted being a "CGM Optimizer" (wearing CGM 6-7 days/week) or "CGM Sub-user." RESULTS: Of 282 adolescents (54% female), 161 were CGM Optimizers and 121 were CGM Sub-Users. Optimizers were younger (15.91 ± 2.17 years vs. 16.79 ± 2.17, p = 0.001), more likely non-Hispanic White (91.9% vs 83.5%, p = 0.029), and more likely to have private insurance (82.0% vs. 69.4%, p = 0.009). Every 1-point increase on Benefits of CGM scale was associated with 2.8 times greater odds of being an Optimizer (OR = 2.82, 95% CI 1.548-5.132, p = 0.001), and every 1-point increase on the Burdens of CGM scale was associated with a 52% decrease in odds (OR = 0.48, 95% CI = 0.283-0.800, p = 0.005), with final logistic regression model (including only these two predictors) explaining 22.3% of variance. CONCLUSION: CGM Optimizing adolescents were more likely to perceive higher benefit and lower burden of CGM. PRACTICAL IMPLICATIONS: Nurse-led interventions to promote benefits of CGM and mitigate burden may help youth increase adherence with CGM to achieve glycemic benefit.

Comorbidity of Lifetime History of Abuse and Trauma With Opioid Use Disorder: Implications for Nursing Assessment and Care.

BACKGROUND: Opioid use disorder (OUD) is a public health crisis and is challenging to treat. Previous research has shown correlations between OUD, abuse/trauma, and chronic pain. AIMS: The purpose of this study was to investigate history of lifetime sexual, physical, and/or emotional abuse among participants in a medication-assisted treatment (MAT) program for OUD, and to investigate associations between abuse history and chronic pain. METHODS: This is a secondary analysis of intake data from a 2-year, nonexperimental cohort treatment program of patients with OUD in rural Colorado. De-identified data were provided by 476 adult MAT patients using the Adult Addiction Severity Index (ASI-6). The ASI-6 includes three yes/no questions about history of abuse (emotional, physical, and sexual), with separate scoring for "past 30 days" and "lifetime" abuse. RESULTS: Lifetime history among MAT program for OUD patients was 23% for sexual abuse, 43% for physical abuse, and 58% for emotional abuse. History of physical abuse was significantly associated with having a chronic pain diagnosis, χ2 = 4.49, p = .03, and also with higher reported pain levels, t(460) = 2.71, p = .007. CONCLUSION: Lifetime history of physical abuse was associated with OUD and chronic pain, yet standard pain assessments do not assess these factors. In health care settings, the implementation of standardized trauma-informed screening tools, prompt recognition of abuse/trauma history, and adjunct psychological interventions may reduce stigma, reduce opioid use escalation, and help patients overcome OUD.

Applying two minds theory to self-management of Type 1 diabetes.

Two minds theory (TMT) offers a new approach to changing health behavior. Here, TMT is applied to self-management of Type 1 diabetes. TMT can be conceptualized as a cycle where a stimulus produces an immediate Intuitive system response leading to health behavior, followed by a conscious narrative system response that is temporally delayed. Narrative responses do not produce behaviors directly but instead lead to conscious beliefs about past events and behavioral intentions for the future, both of which become part of the material considered by the intuitive system in selecting future behaviors. Because of the temporal delay between intuitive behavior and narrative interpretation, and the nonconscious nature of intuitive thought, there is often a gap between intentions and behaviors. This has implications for nursing practice. First, nurses should consider that patient-reported impressions of the past or future are fundamentally narrative system responses and understand that these may be less predictive of behavior than biopsychosocial measures that are more temporally immediate. Second, nurses can use TMT to inform new strategies for behavior change interventions. For diabetes self-management, nurses can encourage individuals to leverage environmental cues to prompt self-management (tricking the intuitive system), provide rewards for self-management (training the intuitive system), or engage the narrative system via planning, reframing, or attention practices for healthier future decisions. Overall, the TMT addresses the gap between intentions and behavior and should be further developed to inform behavioral health interventions.

Comorbid mental health disorders in persons living with HIV: Adherence to antiretroviral therapy.

This is a secondary data analysis exploring adherence to antiretroviral therapy (ART) in persons living with HIV (PLWH) with a comorbid mental health disorder. Logistic regression analyses indicated that PLWH who had reliable housing were over six times more adherent than those with unreliable housing. Descriptive odds ratio analyses showed directional relationships for ART adherence with coping, employment, and social support. These results indicate areas for future investigation in PLWH and comorbid mental health disorders, and the potential to find ways to foster certain emotional or living conditions that promote ART adherence.

Temporal Immediacy: A Two-System Theory of Mind for Understanding and Changing Health Behaviors.

BACKGROUND: Health promotion and chronic disease management both require behavior change, but people find it hard to change behavior despite having good intentions. The problem arises because patients' narratives about experiences and intentions are filtered through memory and language. These narratives inaccurately reflect intuitive decision-making or actual behaviors. OBJECTIVES: We propose a principle-temporal immediacy-as a moderator variable that explains which of two mental systems (narrative or intuitive) will be activated in any given situation. We reviewed multiple scientific areas to test temporal immediacy as an explanation for findings. METHODS: In an iterative process, we used evidence from philosophy, cognitive neuroscience, behavioral economics, symptom science, and ecological momentary assessment to develop our theoretical perspective. These perspectives each suggest two cognitive systems that differ in their level of temporal immediacy: an intuitive system that produces behavior in response to everyday states and a narrative system that interprets and explains these experiences after the fact. FINDINGS: Writers from Plato onward describe two competing influences on behavior-often with moral overtones. People tend to identify with the language-based narrative system and blame unhelpful results on the less accessible intuitive system, but neither is completely rational, and the intuitive system has strengths based on speed and serial processing. The systems differ based on temporal immediacy-the description of an experience as either "now" or "usually"-with the intuitive system generating behaviors automatically in real time and the narrative system producing beliefs about the past or future. DISCUSSION: The principle of temporal immediacy is a tool to integrate nursing science with other disciplinary traditions and to improve research and practice. Interventions should build on each system's strengths, rather than treating the intuitive system as a barrier for the narrative system to overcome. Nursing researchers need to study the roles and effects of both systems.

Prospective State and Trait Predictors of Daily Medication Adherence Behavior in HIV.

BACKGROUND: Many persons living with HIV (PLWH) are nonadherent to medication. Trait level measures that ask about predictors of adherence in the abstract may not adequately capture state level daily variability that more directly impacts adherence. OBJECTIVES: This preliminary study was designed to test six predictors of electronically monitored adherence at both the state and trait levels and to compare their relative effects. METHODS: Using a smartphone, 87 PLWH completed randomly cued daily surveys on thoughts, mood, stress, coping, social support, and treatment motivation. All participants also completed baseline surveys on each construct. These state and trait variables were tested as prospective predictors of next-day adherence in multilevel models, and their relative importance was quantified. The analysis sample consisted of 53 PLWH who stored their most frequent antiretroviral medication in a bottle that time-stamped openings to measure adherence. RESULTS: Higher state level motivation, OR = 1.55, 95% CI [1.07, 2.24], and negative mood, OR = 1.33, 95% CI [1.07, 1.63], predicted greater adherence the following day. Importantly, these effects were only found at the state level. Trait level control beliefs predicted greater adherence, OR = 1.65, 95% CI [1.17, 2.35], but contrary to prediction, validated trait level measures of mood, stress, coping, social support, and motivation did not. DISCUSSION: Trait and state level measures predicted adherence, but there were differences between them. Motivation for treatment and negative mood predicted adherence when measured the preceding day, but not as aggregate measures. At the trait level, only control beliefs predicted adherence. Researchers should consider state level variations in mood and motivation as possible explanations for nonadherence. Interventions could be developed to target state level variables.

Screening, Brief Intervention, and Referral to Treatment in a rural Ryan White Part C HIV clinic.

About 24% of people living with HIV nationally are identified as needing treatment for alcohol or illicit drug use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) has evolved as a strategy to assess and intervene with substance abuse behaviors in various clinical settings. However, less is known about the processes and outcomes of using the SBIRT intervention in outpatient HIV clinics. This paper presents a descriptive analysis of de-identified existing SBIRT results data from an outpatient HIV clinic located in western Colorado. From 2008 to 2013, a total of 1616 SBIRT evaluations were done, which included duplicate patients because some individual patients were screened more than once in a given year. Over this time period, 37-49% of encounters per year were notable for tobacco use, 8-21% for alcohol use, 6-16% for marijuana use, 3-9% for amphetamine use, and 0-2% for illicit opioid use. Unique, unduplicated patient data from 2013 revealed 40% of patients used tobacco, 16% used alcohol, and 11% used methamphetamine. Analyses highlighted that the majority of our patient population (58% in 2013) used and/or abused tobacco, alcohol, and/or illicit substances. An alarming finding was the increase in methamphetamine use over time with more than 50-fold prevalence of use in our population compared to national rates.

Bidirectional Relationships Between Fatigue and Everyday Experiences in Persons Living With HIV.

Fatigue symptoms are very common among persons living with HIV (PLWH). Fatigue is related to functional and psychological problems and to treatment nonadherence. Using secondary data from ecological momentary assessment, we examined fatigue as a predictor of PLWH everyday experiences. In bidirectional analyses based on the shape shifters model, we also examined these experiences as predictors of fatigue. Data were examined from 67 PLWH who completed daily surveys on a handheld computer. Brief validated scales were used to assess participants' control beliefs, mood, stress, coping, social support, experience of stigma, and motivation. At the beginning and end of the study, fatigue was measured with two CES-D items that have been used in past HIV symptom research. Multilevel models and logistic regression were used to test reciprocal predictive relationships between variables. Moderate to severe fatigue affected 45% of PLWH in the study. Initial fatigue predicted PLWH subsequent overall level of control beliefs, mood, stress, coping, and social support, all p < .05. These state variables remained relatively constant over time, regardless of participants' initial fatigue. In tests for reciprocal relationships with 33 PLWH, average daily stress, OR = 4.74, and stigma, OR = 4.86, also predicted later fatigue. Fatigue predicted several daily survey variables including stress and social support. Stress and support in turn predicted fatigue at a later time, suggesting a self-perpetuating cycle but also a possible avenue for intervention. Future studies should examine daily variation in fatigue among PLWH and its relation to other everyday experiences and behaviors. © 2016 Wiley Periodicals, Inc.

Probing the chemical mechanism of saccharopine reductase from Saccharomyces cerevisiae using site-directed mutagenesis.

Saccharopine reductase catalyzes the reductive amination of l-α-aminoadipate-δ-semialdehyde with l-glutamate to give saccharopine. Two mechanisms have been proposed for the reductase, one that makes use of enzyme side chains as acid-base catalytic groups, and a second, in which the reaction is catalyzed by enzyme-bound reactants. Site-directed mutagenesis was used to change acid-base candidates in the active site of the reductase to eliminate their ionizable side chain. Thus, the D126A, C154S and Y99F and several double mutant enzymes were prepared. Kinetic parameters in the direction of glutamate formation exhibited modest decreases, inconsistent with the loss of an acid-base catalyst. The pH-rate profiles obtained with all mutant enzymes decrease at low and high pH, suggesting acid and base catalytic groups are still present in all enzymes. Solvent kinetic deuterium isotope effects are all larger than those observed for wild type enzyme, and approximately equal to one another, suggesting the slow step is the same as that of wild type enzyme, a conformational change to open the site and release products (in the direction of saccharopine formation). Overall, the acid-base chemistry is likely catalyzed by bound reactants, with the exception of deprotonation of the α-amine of glutamate, which likely requires an enzyme residue.

Evidence for an induced conformational change in the catalytic mechanism of homoisocitrate dehydrogenase for Saccharomyces cerevisiae: Characterization of the D271N mutant enzyme.

Homoisocitrate dehydrogenase (HIcDH) catalyzes the NAD(+)-dependent oxidative decarboxylation of HIc to α-ketoadipate, the fourth step in the α-aminoadipate pathway responsible for the de novo synthesis of l-lysine in fungi. A mechanism has been proposed for the enzyme that makes use of a Lys-Tyr pair as acid-base catalysts, with Lys acting as a base to accept a proton from the α-hydroxyl of homoisocitrate, and Tyr acting as an acid to protonate the C3 of the enol of α-ketoadipate in the enolization reaction. Three conserved aspartate residues, D243, D267 and D271, coordinate Mg(2+), which is also coordinated to the α-carboxylate and α-hydroxyl of homoisocitrate. On the basis of kinetic isotope effects, it was proposed that a conformational change to close the active site and organize the active site for catalysis contributed to rate limitation of the overall reaction of the Saccharomyces cerevisiae HIcDH (Lin, Y., Volkman, J., Nicholas, K. M., Yamamoto, T., Eguchi, T., Nimmo, S. L., West, A. H., and Cook, P. F. (2008) Biochemistry47, 4169-4180.). In order to test this hypothesis, site-directed mutagenesis was used to change D271, a metal ion ligand and binding determinant for MgHIc, to N. The mutant enzyme was characterized using initial rate studies. A decrease of 520-fold was observed in V and V/KMgHIc, suggesting the same step(s) limit the reaction at limiting and saturating MgHIc concentrations. Solvent kinetic deuterium isotope effects (SKIE) and viscosity effects are consistent with a rate-limiting pre-catalytic conformational change at saturating reactant concentrations. In addition, at limiting MgHIc, an inverse (SKIE) of 0.7 coupled to a significant normal effect of viscosogen (2.1) indicates equilibrium binding of MgHIc prior to the rate-limiting conformational change. The maximum rate exhibits a small partial change at high pH suggesting a pH-dependent conformational change, while V/KMgHIc exhibits the same partial change observed in V, and a decrease at low pH with a pKa of 6 reflecting the requirement for the unprotonated form of MgHIc to bind to enzyme. However, neither parameter reflects the pH dependence of the chemical reaction. This pH independence of the chemical reaction over the range 5.5-9.5 is consistent with the much slower conformational change that would effectively perturb the observed pK values for catalytic groups to lower and higher pH. In other words, the pH dependence of the chemical reaction will only be observed when chemistry becomes slower than the rate of the conformational change. Data support the hypothesis of the existence of a pre-catalytic conformational change coupled to the binding of MgHIc.

Predictors of adherence to glaucoma treatment in a multisite study.

BACKGROUND: Poor adherence hinders glaucoma treatment. Studies have identified demographic and clinical predictors of adherence but fewer psychological variables. PURPOSE: We examined predictors from four health behavior theories and past research. METHODS: In the baseline phase of a three-site adherence study, before any intervention, 201 participants used electronic Medication Event Monitoring System (MEMS) bottles to monitor eyedrop use for 2 months, and completed questionnaires including self-reported adherence. RESULTS: MEMS showed 79% adherence and self-report 94% (0.5-1.5 missed weekly doses), but they correlated only r(s) = 0.31. Self-efficacy, motivation, dose frequency, and nonminority race/ethnicity predicted 35% of variance in MEMS. Cues to action, self-efficacy, and intention predicted 20% of variance in self-reported adherence. CONCLUSIONS: Self-efficacy, motivation, intention, cues to action, dose frequency, and race/ethnicity each independently predicted adherence. Predictors from all theories were supported in bivariate analyses, but additional study is needed. Researchers and clinicians should consider psychological predictors of adherence. (ClinicalTrials.gov ID# NCT01409421.).

Transition from Pediatric to Adult Specialty Care for Adolescents and Young Adults with Refractory Epilepsy: A Quality Improvement Approach.

Adolescents and young adults with refractory epilepsy are particularly vulnerable to serious medical and psychosocial challenges during transition from pediatric to adult care. Quality improvement methods were used to address the transition process on an academic medical campus. Outcomes achieved were decreased time from referral to first appointment in the adult clinic, H=8.2, p=0.004, r=0.43; and increased social work referrals using decision support, z=10.0, p=0.0006, OR=6.13. As measured by the 13-item Patient Activation Measure, pre-post change in patient activation as an outcome of self-management education was not statistically significant.

Fine tuning of the active site modulates specificity in the interaction of O-acetylserine sulfhydrylase isozymes with serine acetyltransferase.

O-acetylserine sulfhydrylase (OASS) catalyzes the synthesis of l-cysteine in the last step of the reductive sulfate assimilation pathway in microorganisms. Its activity is inhibited by the interaction with serine acetyltransferase (SAT), the preceding enzyme in the metabolic pathway. Inhibition is exerted by the insertion of SAT C-terminal peptide into the OASS active site. This action is effective only on the A isozyme, the prevalent form in enteric bacteria under aerobic conditions, but not on the B-isozyme, the form expressed under anaerobic conditions. We have investigated the active site determinants that modulate the interaction specificity by comparing the binding affinity of thirteen pentapeptides, derived from the C-terminal sequences of SAT of the closely related species Haemophilus influenzae and Salmonella typhimurium, towards the corresponding OASS-A, and towards S. typhimurium OASS-B. We have found that subtle changes in protein active sites have profound effects on protein-peptide recognition. Furthermore, affinity is strongly dependent on the pentapeptide sequence, signaling the relevance of P3-P4-P5 for the strength of binding, and P1-P2 mainly for specificity. The presence of an aromatic residue at P3 results in high affinity peptides with K(diss) in the micromolar and submicromolar range, regardless of the species. An acidic residue, like aspartate at P4, further strengthens the interaction and results in the higher affinity ligand of S. typhimurium OASS-A described to date. Since OASS knocked-out bacteria exhibit a significantly decreased fitness, this investigation provides key information for the development of selective OASS inhibitors, potentially useful as novel antibiotic agents.

Inhibition of human γ-glutamyl transpeptidase: development of more potent, physiologically relevant, uncompetitive inhibitors.

GGT (γ-glutamyl transpeptidase) is an essential enzyme for maintaining cysteine homoeostasis, leukotriene synthesis, metabolism of glutathione conjugates and catabolism of extracellular glutathione. Overexpression of GGT has been implicated in many pathologies, and clinical inhibitors of GGT are under development for use in the treatment of asthma, cancer and other diseases. Inhibitors are generally characterized using synthetic GGT substrates. The present study of uncompetitive inhibitors of GGT, has revealed that the potency with which compounds inhibit GGT activity in the standard biochemical assay does not correlate with the potency with which they inhibit the physiological reaction catalysed by GGT. Kinetic studies provided insight into the mechanism of inhibition. Modifications to the sulfobenzene or distal benzene ring of the uncompetitive inhibitor OU749 affected activity. One of the most potent inhibitors was identified among a novel group of analogues with an amine group para on the benzosulfonamide ring. New more potent uncompetitive inhibitors of the physiological GGT reaction were found to be less toxic than the glutamine analogues that have been tested clinically. Development of non-toxic inhibitors is essential for exploiting GGT as a therapeutic target.

Utility of the theory of planned behavior to predict nursing staff blood pressure monitoring behaviours.

AIMS AND OBJECTIVES: To evaluate constructs from the theory of planned behavior (TPB, Ajzen 2002) - attitudes, sense of control, subjective norms and intentions - as predictors of accuracy in blood pressure monitoring. BACKGROUND: Despite numerous initiatives aimed at teaching blood pressure measurement techniques, many healthcare providers measure blood pressures incorrectly. DESIGN: Descriptive, cohort design. METHODS: Medical assistants and licensed practical nurses were asked to complete a questionnaire on TPB variables. These nursing staff's patients had their blood pressures measured and completed a survey about techniques used to measure their blood pressure. We correlated nursing staff's responses on the TBP questionnaire with their intention to measure an accurate blood pressure and with the difference between their actual blood pressure measurement and a second measurement taken by a researcher immediately after the clinic visit. Patients' perceptions of MAs' and LPNs' blood pressure measurement techniques were examined descriptively. RESULTS: Perceived control and social norm predicted intention to measure an accurate blood pressure, with a negative relationship between knowledge and intention. Consistent with the TPB, intention was the only significant predictor of blood pressure measurement accuracy. CONCLUSIONS: Theory of planned behavior constructs predicted the healthcare providers' intention to measure blood pressure accurately and intention predicted the actual accuracy of systolic blood pressure measurement. However, participants' knowledge about blood pressure measurement had an unexpected negative relationship with their intentions. RELEVANCE TO CLINICAL PRACTICE: These findings have important implications for nursing education departments and organisations which traditionally invest significant time and effort in annual competency training focused on knowledge enhancement by staff. This study suggests that a better strategy might involve efforts to enhance providers' intention to change, particularly by changing social norms or increasing perceived control of the behaviour by nursing staff.

Walking Exercise Sustainability Through Telehealth for Veterans With Lower-Limb Amputation: A Study Protocol.

OBJECTIVE: This randomized controlled superiority trial will determine if an 18-month telehealth walking exercise self-management program produces clinically meaningful changes in walking exercise sustainability compared to attention-control education for veterans living with lower-limb amputation. METHODS: Seventy-eight participants with lower-limb amputation (traumatic or nontraumatic) aged 50 to 89 years will be enrolled. Two groups will complete 6 one-on-one intervention sessions, and 6 group sessions over an 18-month intervention period. The experimental arm will receive a self-management program focusing on increasing walking exercise and the control group will receive attention-control education specific to healthy aging. Daily walking step count (primary outcome) will be continuously monitored using an accelerometer over the 18-month study period. Secondary outcomes are designed to assess potential translation of the walking exercise intervention into conventional amputation care across the Veteran Affairs Amputation System of Care. These secondary outcomes include measures of intervention reach, efficacy, likelihood of clinical adoption, potential for clinical implementation, and ability of participants to maintain long-term exercise behavior. IMPACT: The unique rehabilitation paradigm used in this study addresses the problem of chronic sedentary lifestyles following lower-limb amputation through a telehealth home-based walking exercise self-management model. The approach includes 18 months of exercise support from clinicians and peers. Trial results will provide rehabilitation knowledge necessary for implementing clinical translation of self-management interventions to sustain walking exercise for veterans living with lower-limb amputation, resulting in a healthier lifestyle.