ESTABLISHMENT OF ECHOCARDIOGRAPHIC PARAMETERS OF CLINICALLY HEALTHY FLORIDA MANATEES (TRICHECHUS MANATUS LATIROSTRIS).

A standardized echocardiographic technique was recently established for the Florida manatee (Trichechus manatus latirostris). There are no available published data on normal echocardiographic parameters in any Sirenian species. The purpose of this study was to report reference parameters for various echocardiographic measurements. These parameters are intended to serve as a comparison for future research into the prevalence of cardiac diseases in the manatee and to aid in diagnosing animals with suspected cardiac disease in rehabilitation facilities. Annual health assessments of free-ranging manatees in Crystal River National Wildlife Refuge, Florida, and pre-release health assessments of rehabilitated manatees at Tampa's Lowry Park Zoo permitted comparison of echocardiographic measurements in adult (n=14), subadult (n=7), and calf (n=8) animals under manual restraint.

Readiness for employment: perceptions of mental health service users.

Work is good for both physical and mental health, and access to work is a basic human right. People with mental health conditions want to work and with the right support can work but are often excluded from the workplace. We explored factors influencing individual's perceptions of their readiness for employment. Participants' narratives focused particularly on personal causation and it's inter-reactions with other aspects of volition, habituation and the environment and highlight a number of key areas, which are discussed in relation to service provision. Sheltered workshops offer support and some structure and routine but may limit an individual's readiness for employment. Services should be evidence based and focused on real work opportunities which fit with individual's interests and values. Occupational therapy theory offers a unique and valuable perspective in understanding perceptions of readiness for employment and occupational therapists offer valid and useful assessments and interventions for vocational rehabilitation.

Vocational rehabilitation: facilitating evidence based practice through participatory action research.

BACKGROUND: Improving vocational rehabilitation in line with the current evidence base is an area of considerable interest. Aims To describe the strategies used by a multidisciplinary team in the initial stages of a participatory action research (PAR) approach to improving a vocational rehabilitation service. METHOD: A literature review and PAR process were completed. One hundred and fifteen participants engaged in multifaceted data collection and analysis, building consensus around key principles for a new vocational rehabilitation service. RESULTS: A synthesis of our literature review and PAR process was developed into a set of principles for practice which we plan to implement across the service. CONCLUSIONS: We have developed methodologies in interdisciplinary collaborations spanning statutory and non-statutory services. We have developed a set of principles for practice and detailed plans for implementation are being drawn up to inform provision in the future.

Clinical outcome of pediatric medulloblastoma patients with Li-Fraumeni syndrome.

BACKGROUND: The prognosis for Li-Fraumeni syndrome (LFS) patients with medulloblastoma (MB) is poor. Comprehensive clinical data for this patient group is lacking, challenging the development of novel therapeutic strategies. Here, we present clinical and molecular data on a retrospective cohort of pediatric LFS MB patients. METHODS: In this multinational, multicenter retrospective cohort study, LFS patients under 21 years with MB and class 5 or class 4 constitutional TP53 variants were included. TP53 mutation status, methylation subgroup, treatment, progression free- (PFS) and overall survival (OS), recurrence patterns, and incidence of subsequent neoplasms were evaluated. RESULTS: The study evaluated 47 LFS individuals diagnosed with MB, mainly classified as DNA methylation subgroup "SHH_3" (86%). The majority (74%) of constitutional TP53 variants represented missense variants. The 2- and 5-year (y-) PFS were 36% and 20%, and 2- and 5y-OS were 53% and 23%, respectively. Patients who received postoperative radiotherapy (RT) (2y-PFS: 44%, 2y-OS: 60%) or chemotherapy before RT (2y-PFS: 32%, 2y-OS: 48%) had significantly better clinical outcome then patients who were not treated with RT (2y-PFS: 0%, 2y-OS: 25%). Patients treated according to protocols including high-intensity chemotherapy and patients who received only maintenance-type chemotherapy showed similar outcomes (2y-PFS: 42% and 35%, 2y-OS: 68% and 53%, respectively). CONCLUSIONS: LFS MB patients have a dismal prognosis. In the presented cohort use of RT significantly increased survival rates, whereas chemotherapy intensity did not influence their clinical outcome. Prospective collection of clinical data and development of novel treatments are required to improve the outcome of LFS MB patients.

Interprofessional learning and virtual communities: an opportunity for the future.

As various agencies increasingly advocate interprofessional care (IPC), it is paramount that the educational implications of this approach are considered. Interprofessional learning (IPL) is necessary for IPC and this paper argues that an emerging educational model, narrative-based virtual communities (VCs), meets this goal. We therefore argue for the fusion of narrative pedagogy with the VC approach to further the IPL agenda. Using stories to teach is not new. Technological innovations now make the possibility of using narrative, a way to enable students to experience greater reality in complex situations. Recently, two multimedia VCs have been developed. Here, we review the use of "The Neighborhood" and "Stilwell", as IPL tools. Early evaluation of these communities has been very positive and they offer a unique and innovative approach to IPL in ways that immerse learners from many professions into the context of the lives of individuals requiring health and social care, and the people who provide that service. Thus, it is possible to more fully realize and teach about collaboration and partnerships among professionals and patients.

Hysteroscopy and episiotomy in a rescued, cold-stressed Florida manatee (Trichechus manatus latirostris) for diagnosis and treatment of a retained fetal skeleton.

A rescued female manatee was observed expelling a fetal bone from the vulva. The manatee was anesthetized and diagnosed with uterine retention of a fetal skeleton by ultrasound and hysteroscopy. Episiotomy was performed to gain manual access to the vagina and uterus for removal of the skeleton. Second intention healing of the episiotomy site produced excellent results. Rescued female manatees should receive a thorough reproductive tract evaluation since presence of retained fetal tissues might not be evident in blood or hormone analyses. Retention of a whole or partial dead fetus can be life-threatening to manatees, and retained tissues should be removed as early as possible.

Endocrine, immune and renal toxicity in male largemouth bass after chronic exposure to glyphosate and Rodeo®.

Glyphosate is the most used herbicide worldwide, with no historical comparison. It is used for genetically modified crops, and particularly in Florida, it is used as a sugar cane ripener. An aquatic formulation (Rodeo®) is used to treat aquatic weeds in waterbodies and drainage canals. Because of its extended use, glyphosate can run off or be sprayed directly into waterbodies, and chronically expose aquatic wildlife. Exposure in animal models has been associated with kidney and liver damage and glyphosate has been suggested as an endocrine disruptor. We exposed adult male largemouth bass for 21 days to two doses of glyphosate and Rodeo® (chemically equivalent concentration of glyphosate) at 0.5 mg L-1 and 10 mg L-1 and to a clean water control (n=4 fish/tank in quadruplicate). Concentrations during the experiment were corroborated with UHPLC-MS/MS. Total RNA was isolated from the trunk kidney and head kidney. RNA-seq was performed for the high doses compared to controls. Transcripts were analyzed with fish and mammalian pathway analyses software. Transcripts mapped to Zebrafish metabolic pathways using PaintOmics showed steroid hormone biosynthesis in the trunk kidney as the most significantly enriched pathway. Steroid hormones were measured in plasma by UHPLC-MS/MS. Total androgens were significantly reduced at 0.5 mg L-1 of glyphosate and at equivalent concentrations in Rodeo® compared to controls. 11-ketotestosterone and estrone concentrations were significantly reduced in all doses. A gene involved in the conversion of testosterone to 11-ketotestosterone was down-regulated by glyphosate. Using the mammalian pathway analysis algorithm, cellular processes associated with T-cell activation/development and intracellular pH were significantly enriched in the trunk kidney by glyphosate and Rodeo® exposure. Endocrine disruption was corroborated at the hormone and gene expression levels. Rodeo® and glyphosate share gene expression pathways, however, Rodeo® had more pronounced effects in largemouth bass.

Key characteristics of knowledge transfer and exchange in healthcare: integrative literature review.

AIM: This paper presents the results of a review of literature relating to knowledge transfer and exchange in healthcare. BACKGROUND: Treatment, planning and policy decisions in contemporary nursing and healthcare should be based on sound evidence wherever possible, but research knowledge remains generally underused. Knowledge transfer and exchange initiatives aim to facilitate the accessibility, application and production of evidence and may provide solutions to this challenge. This review was conducted to help inform the design and implementation of knowledge transfer and exchange activities for a large healthcare organization. DATA SOURCES: Databases: ASSIA, Business Source Premier, CINAHL, PsychInfo, Medline and the Cochrane Database of Systematic Reviews. REVIEW METHODS: An integrative literature review was carried out including an extensive literature search. English language systematic reviews, literature reviews, primary quantitative and qualitative papers and grey literature of high relevance evaluating, describing or discussing knowledge transfer or exchange activities in healthcare were included for review (January 1990-September 2009). FINDINGS: Thirty-three papers were reviewed (four systematic reviews, nine literature reviews, one environmental scan, nine empirical studies and ten case studies). CONCLUSION: Robust research into knowledge transfer and exchange in healthcare is limited. Analysis of a wide range of evidence indicates a number of commonly featured characteristics but further evaluation of these activities would benefit their application in facilitating evidence-based practice in nursing.

Child sexual abuse: a new approach to professional education.

Child sexual abuse is a highly emotive subject and nurses have a key role to play in caring for survivors. Educating students about this role is difficult because a conventional classroom approach does not prepare students adequately or give them sufficient insight into the experiences of victims. The Stilwell virtual simulation model is a radical new approach which aims to assist learning by immersing students in a realistic multimedia simulation of a typical community. This model allows insightful learning about difficult areas such as child sexual abuse. Its use and contribution to learning in this area are discussed.

Liquid nitrogen ingestion leading to massive pneumoperitoneum without identifiable gastrointestinal perforation.

BACKGROUND: Liquid nitrogen (LN) ingestion is unusual, but may be encountered by poison centers, emergency physicians, and general surgeons. Unique properties of LN produce a characteristic pattern of injury. CASE REPORT: A 19-year-old male college student presented to the Emergency Department complaining of abdominal pain and "bloating" after drinking LN. His presentation vital signs were remarkable only for mild tachypnea and tachycardia. On physical examination, he had mild respiratory difficulty due to abdominal distention. His abdomen was tense and distended. Abdominal X-ray studies revealed a massive pneumoperitoneum. At laparotomy, he was found to have a large amount of peritoneal gas. No perforation was identified. After surgery, the patient made an uneventful recovery and was discharged 5 days later. At 2-week clinic follow-up, he was doing well without complications. DISCUSSION: Nitrogen is a colorless, odorless gas at room temperature. Due to its low boiling point (-195 degrees C), LN rapidly evaporates when in contact with body surface temperatures. Therefore, ingested LN causes damage by two mechanisms: rapid freezing injury upon mucosal contact and rapid volume expansion as nitrogen gas is formed. Patients who ingest LN may develop gastrointestinal perforation and massive pneumoperitoneum. Because rapid gas formation may allow large volumes to escape from tiny perforations, the exact site of perforation may never be identified. CONCLUSION: In cases of LN ingestion, mucosal injury and rapid gas formation can cause massive pneumoperitoneum. Although laparotomy is recommended for all patients with signs of perforation, the site of injury may never be identified.

Collaborating across the pond: the diffusion of virtual communities for nursing education.

Over the past decade, there have been significant changes in nursing education, particularly in teaching practice. This change has fueled interest in developing new and innovative approaches to teaching and curriculum. This article describes the shared experiences of two nurse educators on opposite sides of the Atlantic Ocean who have spent the last 4 years immersed in the process of developing and diffusing virtual communities for nursing education. Diffusion of innovations theory is used as a framework for this narrative. Nurse educators should have an awareness of the phases, steps, and challenges that can be expected during the process of innovation diffusion, including implications for education practice.

Using a simulated learning environment.

Stilwell is a simulation environment designed for postgraduate emergency care staff. It encourages participants to make less obvious diagnoses of patients who have presented to emergency departments, and to consider a wide range of factors when making treatment and management decisions.

Lifetime Prevalence and Correlates of Patient-Perceived Medical Errors Experienced in the U.S. Ambulatory Setting: A Population-Based Study.

Background: The rate of safety harm self-perceived medical errors and harms reported in the U.S. ambulatory system is not well characterized. Objectives: To determine the prevalence of U.S. adult ambulatory care patient self-perceived safety harms and to gauge the degree of association between harms with various patient characteristics and outcomes. Methods: A large U.S. cross-sectional online survey of 9206 ambulatory care adults was assessed for their perception of medical errors and harms during care (misdiagnosis, mistakes in care, and wrong or delayed treatment) and also included patient demographics, health status, comorbidities, insurance status, income, barriers to care (affordability, transportation, and family and social support), number of visits to primary health care services in the past 12 months, and use of urgent or emergency care in the last 12 months. Results: The overall rate of self-perceived medical errors and harms among adult patients in the ambulatory care setting was 36%. Female patients, independent of age, and those with multiple comorbidities or barriers to care, reported the highest number of medical errors. Utilization of multiple providers was associated with a greater number of reported medical errors, often resulting in changing health care providers. Patients who reported having trouble affording health care or navigating the system to receive care also reported higher levels of harm. They were cared for by multiple providers, often switch providers, and their care is associated with greater utilization of health care resources. Patients reporting the highest rates of harm had greater use of hospital and emergency room care. Conclusions: This large U.S. adult ambulatory care study provides evidence that patient self-perceived medical errors and harms reported by patients are common. Patient self-perceived medical errors and harms occur most commonly in women, with poor health, limitation of activities, and who have three or more comorbidities.

Cancer therapy shapes the fitness landscape of clonal hematopoiesis.

Acquired mutations are pervasive across normal tissues. However, understanding of the processes that drive transformation of certain clones to cancer is limited. Here we study this phenomenon in the context of clonal hematopoiesis (CH) and the development of therapy-related myeloid neoplasms (tMNs). We find that mutations are selected differentially based on exposures. Mutations in ASXL1 are enriched in current or former smokers, whereas cancer therapy with radiation, platinum and topoisomerase II inhibitors preferentially selects for mutations in DNA damage response genes (TP53, PPM1D, CHEK2). Sequential sampling provides definitive evidence that DNA damage response clones outcompete other clones when exposed to certain therapies. Among cases in which CH was previously detected, the CH mutation was present at tMN diagnosis. We identify the molecular characteristics of CH that increase risk of tMN. The increasing implementation of clinical sequencing at diagnosis provides an opportunity to identify patients at risk of tMN for prevention strategies.

Sustained expression of human cytomegalovirus glycoprotein B (UL55) in the seeds of homozygous rice plants.

Production of recombinant subunit vaccines in transgenic plants may be a means of reducing vaccine costs while increasing availability and safety. A plant-derived product found safe and effective for oral administration would provide additional advantages when used as a vaccine. Outstanding issues with the technology include transgene stability through successive generations and consistent bioproduction. We previously reported expression of glycoprotein B (gB) of human cytomegalovirus in seeds of transgenic tobacco. Here the goal was to determine if gB could be similarly expressed in rice, and if so, to examine expression over several plant generations. Results show that immunoreactive gB was successfully expressed in transgenic rice seeds, with sustained expression over three generations. The gB contained several neutralizing epitopes and was stable over 27 months.

Gait analysis and hip extensor function early post total hip replacement.

OBJECTIVE: The purpose of this study was to systematically evaluate the sagittal kinematic and kinetic gait patterns in patients in this early post-operative period, to describe them and to better understand the deficiencies in that gait pattern that may help to develop targeted rehabilitation strategies. METHODS: This study evaluated early gait patterns in 10 patients with isolated unilateral hip osteoarthritis who were post-operative for total hip replacement. Kinetic and kinematic assessments - focusing on sagittal plane abnormalities - were performed at 2 weeks pre-operatively and 8 weeks post-operatively. RESULTS: Our results demonstrated that while clinical scoring for pain and functional ability significantly improved post-operatively, as did clinical assessment of range of motion passively, this did not translate to the degree of dynamic improvement in gait. Step length and stride length did not improve significantly. Lack of hip extension in terminal stance associated with excessive anterior pelvic tilt persisted and was associated with a worsening in hip extensor power post-operatively. CONCLUSION: Based on our results, post-operative rehabilitation programmes should include extensor muscle exercises to increase power and to retain the operative gain in passive range of motion, which would help to improve gait patterns.

Services for children with developmental co-ordination disorder: an evaluation against best practice principles.

PURPOSE: The National Health Service in Scotland published a best practice framework to support occupational therapists and physiotherapists to deliver effective services for children with developmental co-ordination disorder (DCD); however, adherence is variable. To highlight areas for development, this study compared the care pathway within a paediatric DCD service against the NHS Scotland framework. METHODS: A partnership of researchers and clinicians based in the United Kingdom conducted a qualitative study with 37 participants (N = 13 interview participants, N = 24 workshop participants). In-depth interviews and/or workshops were used to map the DCD service against the NHS framework. Identified gaps were aligned with four key stages of the care pathway. Qualitative analysis software was used to analyse the data. RESULTS: Core principles to guide future development were identified for each phase of the pathway. These core principles related to the NHS framework and focused on issues such as involving the family, defining clear pathways and enhancing children's participation. Participants identified potential strategies for service improvement such as developing community-based interventions and information provision. CONCLUSION: Challenges when providing services for children with DCD include confusing service pathways and poor partnership working. It is, therefore, important that clinicians utilise collaborative working strategies that support children's participation. IMPLICATIONS FOR REHABILITATION: There are numerous challenges related to the implementation of best practice principles into the provision of therapy services for children with developmental coordination disorder (DCD). It is important that AHPs seek ways of engaging parents and educational professionals at all stages of the care pathway in order to ensure optimum service provision for the child. Addressing participation is an important aspect and community-based strategies may be particularly beneficial, both as a preventative activity and as an intervention approach.

Evaluation of NO(x) flue gas analyzers for accuracy and their applicability for low-concentration measurements.

The requirements of the Texas State Implementation Plan of the U.S. Clean Air Act for the Houston-Galveston Ozone Nonattainment Area stipulate large reductions in oxides of nitrogen (NO(x)) emissions. A large number of sources at Dow Chemical Co. sites within the nonattainment area may require the addition of continuous emission monitoring systems (CEMS) for online analysis of NO(x), CO, and O2. At the outset of this work, it was not known whether the analyzers could accurately measure NO(x) as low as 2 ppm. Therefore, NO(x) CEMS analyzers from five different companies were evaluated for their ability to reliably measure NO(x) in the 2-20 ppm range. Testing was performed with a laboratory apparatus that accurately simulated different mixtures of flue gas and, on a limited basis, simulated a dual-train sampling system on a gas turbine. The results indicate that this method is a reasonable approach for analyzer testing and reveal important technical performance aspects for accurate NO(x) measurements. Several commercial analyzers, if installed in a CEMS application with sampling conditioning components similar to those used in this study, can meet the U.S. Environmental Protection Agency's measurement data quality requirements for accuracy.

Nurse practitioner education: what level?

In the debate about what level of qualification nurse practitioners in the UK should possess, the authors argue that honours degree status is sufficient preparation for clinical practice. However, they also argue that a master's degree should be the standard for nurse practitioners developing highly specialised and advanced roles.

Setting up a nurse practitioner service.

In this article the authors argue that nurse practitioners must undergo a formal course of education that teaches them to be politically and professionally aware, clinically competent, develops their interpersonal skills and enables them to attain the confidence to express their views and needs. This, together with their skills of assessment and diagnosis, makes nurse practitioners marketable members of the healthcare team.