The impact of birth settings on pregnancy outcomes in the United States.

In the United States, 98.3% of patients give birth in hospitals, 1.1% give birth at home, and 0.5% give birth in freestanding birth centers. This review investigated the impact of birth settings on birth outcomes in the United States. Presently, there are insufficient data to evaluate levels of maternal mortality and severe morbidity according to place of birth. Out-of-hospital births are associated with fewer interventions such as episiotomies, epidural anesthesia, operative deliveries, and cesarean deliveries. When compared with hospital births, there are increased rates of avoidable adverse perinatal outcomes in out-of-hospital births in the United States, both for those with and without risk factors. In one recent study, the neonatal mortality rates were significantly elevated for all planned home births: 13.66 per 10,000 live births (242/177,156; odds ratio, 4.19; 95% confidence interval, 3.62-4.84; P<.0001) vs 3.27 per 10,000 live births for in-hospital Certified Nurse-Midwife-attended births (745/2,280,044; odds ratio, 1). These differences increased further when patients were stratified by recognized risk factors such as breech presentation, multiple gestations, nulliparity, advanced maternal age, and postterm pregnancy. Causes of the increased perinatal morbidity and mortality include deliveries of patients with increased risks, absence of standardized criteria to exclude high-risk deliveries, and that most midwives attending out-of-hospital births in the United States do not meet the gold standard for midwifery regulation, the International Confederation of Midwives' Global Standards for Midwifery Education. As part of the informed consent process, pregnant patients interested in out-of-hospital births should be informed of its increased perinatal risks. Hospital births should be supported for all patients, especially those with increased risks.

A Study of the Use of Psychopharmacologic Agents by Acutely Medically Ill Older Adults.

This retrospective study sought to investigate issues related to the safety of psychopharmacological agents used by acutely medically ill hospitalized older adults. It explored if there were any associations between commonly prescribed psychiatric medications that medically ill hospitalized older adults received and adverse events. It also sought to compare the safety of antidepressants, sedative/hypnotics, and antipsychotics, when used as a standing (on a preset schedule) and as needed pro re nata (PRN) basis. The study found that psychopharmacological agents are frequently prescribed for medically ill hospitalized older adults. No statistically significant difference was found as far as safety was concerned. The number of PRN medications that were used, and the total number of medications was associated with increased risk of transfer within the hospital to a higher level of care or transfer upon discharge to long-term-care/rehabilitation or hospice. Overall, the use of psychopharmacological agents did not appear to be related to serious adverse events.

Nurse Educators' Gentle Hands.

As COVID-19 placed unprecedented demands on healthcare systems across the country, nurses were deployed to care for severely ill patients in acute and intensive care units at rates never imagined. Especially challenging for nursing staff was being witness to patients' deaths daily. This article describes the implementation and outcomes of an innovative initiative entitled Gentle Hands, in which a nurse educator team performed postmortem care for unit nurses during a COVID-19 hospital surge.

A review on double tract reconstruction after proximal gastrectomy for proximal gastric cancer.

Gastric cancer remains one of the deadliest malignancies on the planet, accounting for the fourth highest cause of death by cancer worldwide. While trends indicate that its incidence is decreasing globally, it remains a concern, particularly when identified at an advanced stage with a high mortality rate. The best treatment option for early proximal stomach cancer has been identified as surgical resection followed by an acceptable reconstructive procedure. One such surgical management called Double Tract Reconstruction (DTR), has piqued surgeons' interest. DTR has been found to be a potential reconstructive strategy for reducing esophagogastric reflux or post-gastrectomy gastritis and esophagitis. Not only does this technique ensure adequate vitamin B12 maintenance post surgically, but it is also a safe and effective procedure. According to several researchers, the benefits may be comparable to those of total gastrectomy as it relates to, post-operative recovery time, operation time, intraoperative complications, and early complications. DTR is still being studied, and gastrointestinal surgeons worldwide are looking for new ways to improve this method and increase overall survival of gastric cancer.

The role of calcium release activated calcium channels in osteoclast differentiation.

Osteoclasts are specialized macrophage derivatives that secrete acid and proteinases to mobilize bone for mineral homeostasis, growth, and replacement or repair. Osteoclast differentiation generally requires the monocyte growth factor m-CSF and the TNF-family cytokine RANKL, although differentiation is regulated by many other cytokines and by intracellular signals, including Ca(2+). Studies of osteoclast differentiation in vitro were performed using human monocytic precursors stimulated with m-CSF and RANKL, revealing significant loss in both the expression and function of the required components of store-operated Ca(2+) entry over the course of osteoclast differentiation. However, inhibition of CRAC using either the pharmacological agent 3,4-dichloropropioanilide (DCPA) or by knockdown of Orai1 severely inhibited formation of multinucleated osteoclasts. In contrast, no effect of CRAC channel inhibition was observed on expression of the osteoclast protein tartrate resistant acid phosphatase (TRAP). Our findings suggest that despite the fact that they are down-regulated during osteoclast differentiation, CRAC channels are required for cell fusion, a late event in osteoclast differentiation. Since osteoclasts cannot function properly without multinucleation, selective CRAC inhibitors may have utility in management of hyperresorptive states.

The Living Experience of Feeling Playful.

The purpose of this study was to investigate the living experience of feeling playful. Parse's research method was used to answer the question: What is the structure of the living experience of feeling playful? The participants were 10 persons, ages 9 to 83, living in the United States. The central finding of the study is the living experience of feeling playful is entertaining amusements amid burdens with uplifting endeavors strengthening affiliations with blissful moments of unfettered unfolding. The living experience of feeling playful is discussed in relation to the principles of the humanbecoming paradigm and in relation to how it can inform further research.

The Methodist Hospital CCU: a Beacon unit of excellence.

This article features the Coronary Care Unit of The Methodist Hospital of Houston, Texas. This unit was one of the first Beacon Critical Care Units recognized by the American Association of Critical Care Nurses. This article focuses on how to achieve this award. The Coronary Care Unit nursing infrastructure is described, and specific unit examples are included.

The toxicity of the N-hydroxy and 6-hydroxy metabolites of 3,4-dichloropropionanilide does not depend on calcium release-activated calcium channel inhibition.

Each year ~1 billion kg of herbicides are used worldwide to control the unwanted growth of plants. In the United States, over a quarter of a billion kg of herbicides are used, representing 28% of worldwide use. (Kiely, T., Donaldson, D., and Grube, A. [2004]. Pesticide Industry Sales and Usage. 2000 and 2001 Market Estimates. Available at: http://www.epa.gov/pesticides/pestsales/01pestsales/market_estimates2001.pdf. Accessed October 25, 2012.) Propanil (3,4-dichloropropionanilide [DCPA]) is a commonly used herbicide in the United States, with 2-4 million kg applied annually to 2 million acres of crop land. The immunomodulatory effects of DCPA have been well documented, but limited data are available on the effects of its metabolites. (Salazar, K. D., Ustyugova, I. V., Brundage, K. M., Barnett, J. B., and Schafer, R. [2008]. A review of the immunotoxicity of the pesticide 3,4-dichloropropionanalide. J. Toxicol. Environ. Health B Crit. Rev. 11, 630-645.) In mammals, hepatic enzymes metabolize DCPA, resulting in the production of 3,4-dichloroaniline (DCA). Further biotransformation of DCA leads to the production of 6-hydroxy-3,4-dichloroaniline (6OH-DCA) and N-hydroxy-3,4-dichloroaniline (NOH-DCA). We report, for the first time, the immunotoxic effects of DCPA metabolites on T-cell function. Human Jurkat T cells were exposed to varying concentrations of DCPA or its metabolites and assayed for effects on T-cell function. In addition, fluorine analogs of DCPA and DCA were investigated to determine the relative role of chlorine substituents on T-cell immunotoxicity. Here we report that exposure of Jurkat T cells to DCPA and DCA alters IL-2 secretion, nuclear factor of activated T cells (NFAT) activity, and calcium influx. However, exposure to 6OH-DCA and NOH-DCA reduces IL-2 secretion and NFAT activity but has no effect on calcium flux. When both chlorines in DCPA and DCA were substituted with fluorines all effects were abrogated. Our data indicate that metabolites of DCPA have differential effects on T-cell function and the presence of chlorines plays an important role in eliciting these effects.

3,4-Dichloropropionanilide (DCPA) inhibits T-cell activation by altering the intracellular calcium concentration following store depletion.

Stimulation of T cells through the T-cell receptor results in the activation of a series of signaling pathways that leads to the secretion of interleukin (IL)-2 and cell proliferation. Influx of calcium (Ca(2+)) from the extracellular environment, following internal Ca(2+) store depletion, provides the elevated and sustained intracellular calcium concentration ([Ca(2+)](i)) critical for optimal T-cell activation. Our laboratory has documented that exposure to the herbicide 3,4-dichloropropionanilide (DCPA) inhibits intracellular signaling events that have one or more Ca(2+) dependent steps. Herein we report that DCPA attenuates the normal elevated and sustained [Ca(2+)](i) that follows internal store depletion in the human leukemic Jurkat T cell line and primary mouse T cells. DCPA did not alter the depletion of internal Ca(2+) stores when stimulated by anti-CD3 or thapsigargin demonstrating that early inositol 1,4,5-triphosphate-mediated signaling and depletion of Ca(2+) stores were unaffected. 2-Aminoethyldiphenol borate (2-APB) is known to alter the store-operated Ca(2+) (SOC) influx that follows Ca(2+) store depletion. Exposure of Jurkat cells to either DCPA or 50 microM 2-APB attenuated the increase in [Ca(2+)](i) following thapsigargin or anti-CD3 induced store depletion in a similar manner. At low concentrations, 2-APB enhances SOC influx but this enhancement is abrogated in the presence of DCPA. This alteration in [Ca(2+)](i), when exposed to DCPA, significantly reduces nuclear levels of nuclear factor of activated T cells (NFAT) and IL-2 secretion. The plasma membrane polarization profile is not altered by DCPA exposure. Taken together, these data indicate that DCPA inhibits T-cell activation by altering Ca(2+) homeostasis following store depletion.