Tissue distribution and temporal and spatial assessment of per- and polyfluoroalkyl substances (PFAS) in smallmouth bass (Micropterus dolomieu) in the mid-Atlantic United States.

Per- and polyfluoroalkyl substances (PFAS) have become an environmental issue worldwide. A first step to assessing potential adverse effects on fish populations is to determine if concentrations of concern are present in a region and if so, in which watersheds. Hence, plasma from adult smallmouth bass Micropterus dolomieu collected at 10 sites within 4 river systems in the mid-Atlantic region of the United States, from 2014 to 2019, was analyzed for 13 PFAS. These analyses were directed at better understanding the presence and associations with land use attributes in an important sportfish. Four substances, PFOS, PFDA, PFUnA, and PFDoA, were detected in every plasma sample, with PFOS having the highest concentrations. Sites with mean plasma concentrations of PFOS below 100 ng/ml had the lowest percentage of developed landcover in the upstream catchments. Sites with moderate plasma concentrations (mean PFOS concentrations between 220 and 240 ng/ml) had low (< 7.0) percentages of developed land use but high (> 30) percentages of agricultural land use. Sites with mean plasma concentrations of PFOS > 350 ng/ml had the highest percentage of developed land use and the highest number PFAS facilities that included military installations and airports. Four of the sites were part of a long-term monitoring project, and PFAS concentrations of samples collected in spring 2017, 2018, and 2019 were compared. Significant annual differences in plasma concentrations were noted that may relate to sources and climatic factors. Samples were also collected at two sites for tissue (plasma, whole blood, liver, gonad, muscle) distribution analyses with an expanded analyte list of 28 PFAS. Relative tissue distributions were not consistent even within one species of similar ages. Although the long-chained legacy PFAS were generally detected more frequently and at higher concentrations, emerging compounds such as 6:2 FTS and GEN X were detected in a variety of tissues.

Focused Team Engagements to Enhance Interprofessional Collaboration and Safety Behaviors among Novice Nurses and Medical Residents.

Background: Team communication remains a challenge in hospital settings. Hospital-based teams are diverse, team composition changes daily, and team members are frequently not co-located. Novice nurses and medical residents entering the workforce during the coronavirus 2019 pandemic experienced higher communication challenges than before and lacked adequate opportunities for interprofessional learning and communication. Method: We evaluated perceptions of safety and communication among novice nurses and medical residents after a 1-hour focused team engagement consisting of an interprofessional virtual simulation and debrief. We conducted a retrospective pre/post survey to measure perceptions of interprofessional collaboration using the Interprofessional Socialization and Valuing Scale. Results: Sixty-eight pediatric nurse residents and medical residents participated in the survey. Overall, the focused team engagements significantly improve participants' perceptions of interprofessional collaboration, with participants showing statistically significant improvement in seven of nine retrospective pre/post survey questions. When analyzing by discipline, nurse residents show stronger gains than medical residents. Conclusions: The interprofessional structured debriefings encourage nurses and medical residents to collaborate and discuss important safety topics away from bedside stressors. After completing the virtual simulation, the outcomes show improved perceptions of interprofessional collaboration and enhanced knowledge of safety techniques.

Temporal analysis of water chemistry and smallmouth bass (Micropterus dolomieu) health at two sites with divergent land use in the Susquehanna River watershed, Pennsylvania, USA.

Monitoring wild fish health and exposure effects in impacted rivers and streams with differing land use has become a valuable research tool. Smallmouth bass (Micropterus dolomieu) are a sensitive, indicator species that exhibit signs of immunosuppression and endocrine disruption in response to water quality changes and contaminant exposure. To determine the impact of agriculture and development on smallmouth bass health, two sites (a developed/agriculture site and a forested site) in the Susquehanna River watershed, Pennsylvania were selected where bass and water chemistry were sampled from 2015 to 2019. Smallmouth bass were sampled for histopathology to assess parasite and macrophage aggregate density in the liver and spleen, condition factor (Ktl), hepatic gene transcript abundance, hepatosomatic index (HSI), and a health assessment index (HAI). Land use at the developed/agriculture site included greater pesticide application rates and phytoestrogen crop cover and more detections and higher concentrations of pesticides, wastewater-associated contaminants, hormones, phytoestrogens, and mycotoxins than at the forested site. Additionally, at the developed/agriculture site, indicators of molecular changes, including oxidative stress, immune/inflammation, and lipid metabolism-related hepatic gene transcripts, were associated with more contaminants and land use variables. At both sites, there were multiple associations of contaminants with liver and/or spleen macrophage aggregate density, indicating that changes at the molecular level seemed to be a better indicator of exposures unique to each site. The findings illustrate the importance of timing for land management practices, the complex mixtures aquatic animals are exposed to, and the temporal changes in contaminant concentration. Agricultural practices that affect hepatic gene transcripts associated with immune function and disease resistance were demonstrated which could negatively affect smallmouth bass populations.

Splenic hemangioendothelial neoplasm in a captive Northern Snakehead from the Potomac River.

OBJECTIVE: At the U.S. Geological Survey Leetown Research Laboratory in Kearneysville, West Virginia, an approximately 3-year-old, captive-held Northern Snakehead Channa argus with clinical signs of abdominal distention died and was necropsied 1 day after an examination under anesthesia. A mass discovered in the midcoelomic cavity, presumed to be deformed spleen, was comprised of large, pseudocystic structures that contained considerable volumes of opaque, straw-colored fluid. METHODS: A histopathological evaluation revealed that the tissue consisted of foci of small capillaries, nodular areas of proliferating, pleomorphic endothelial cells, and areas of necrosis within the pseudocyst wall. Positive nuclear and nonspecific immunolabeling with a vascular marker, cluster of differentiation 31, was concentrated in and around vascular spaces. RESULT: Based on these observations, the tumor has been putatively identified as a hemangioendothelial neoplasm. CONCLUSION: This would represent the first report of a vascular tumor in a Northern Snakehead and, globally, one of the few described neoplasms identified in a member of the Channidae family.

The Impact of a Perioperative Elective on Practice Workforce Development: Content Analysis.

PURPOSE: Developing strategies to educate, employ, and retain newly graduated nurses in perioperative (periop) settings is paramount to addressing a succession crisis with unprecedented vacancy rates. The purpose of this study was to explore the impact of a prelicensure periop elective on the decision of participants to seek and accept a periop position upon graduation and to describe their transition to practice experience. DESIGN: This study used qualitative descriptive methodology. METHODS: Virtual semistructured interviews were conducted in 2021 with 20 recent graduates of an accelerated prelicensure nursing program who completed a periop elective course. Questions focused on if they did or did not seek and accept a periop position upon graduation and, for those who accepted, explored their transition to practice experience. Data were coded using conventional and directed content analyses. FINDINGS: Three themes emerged via conventional content analysis: the impact of a prelicensure periop elective, the periop environment, and recommendations for faculty and hiring managers. Concerning directed content analyses, participants used the coping factors of situation, self, support, and strategies to navigate career transitions. CONCLUSIONS: A periop elective course delivered through academic-practice partnerships appears to be a successful strategy to address the succession crisis. Graduates were prepared to make informed decisions about entering the periop specialty.

A multi-level assessment of biological effects associated with mercury concentrations in smallmouth bass, Micropterus dolomieu.

Total mercury (THg) was measured in muscle (fillet) and liver tissue of adult smallmouth bass Micropterus dolomieu collected at multiple sites in the Potomac and Susquehanna River drainages within the Chesapeake Bay watershed. Smallmouth bass in these drainages have experienced episodic mortality events, a high prevalence of skin lesions and reproductive endocrine disruption (intersex or testicular oocytes and plasma vitellogenin in males). A multi-level assessment of general and reproductive health including indicators at the organismal, organ, cellular and molecular levels was conducted on adult smallmouth bass during the spring (prespawn) season. Concentrations of THg were correlated with increased visible abnormalities, increased macrophage aggregates and tissue parasite burdens. In male bass positive correlations of THg were observed with plasma vitellogenin and hepatic transcript abundance of estrogen receptor ß1 and androgen receptor α, while there was a negative association with estrogen receptors α and ß2 and androgen receptors ß. In female bass there was a negative correlation between THg and plasma vitellogenin as well as hepatic transcript abundance of vitellogenin, choriogenin, estrogen receptor ß2 and 17ß hydroxysteroid dehydrogenase. Associations of THg concentrations with various biological indicators suggest mercury may be an important environmental stressor contributing to the observed adverse effects in smallmouth bass populations.

An Examination of the Career Choices of Nursing Graduates After Completing a Perioperative Elective.

In light of the perioperative nursing shortage, academic leaders at a mid-Atlantic school of nursing and leaders of three health care systems implemented an academic-practice partnership with the goal of increasing interest in this specialty. Nursing researchers used a descriptive study design to collect data from nursing alumni who participated in the perioperative elective between 2017 and 2021. They found that 25 (38%) of 65 graduates who participated in the elective entered perioperative nursing and 38 (68%) of 56 graduates who answered a question on considering future employment as a perioperative nurse indicated they would do so regardless of their current employment status. Graduates who participated in the elective and experienced a perioperative capstone placement had low anticipated turnover scores and intended to remain in a perioperative position. Academic and health care leaders should consider academic-practice partnerships as a strategy to recruit and retain perioperative nurses.

A case study: temporal trends of environmental stressors and reproductive health of smallmouth bass (Micropterus dolomieu) from a site in the Potomac River Watershed, Maryland, USA.

Decades of poor reproductive success and young-of-the-year survival, combined with adult mortality events, have led to a decline in the smallmouth bass (SMB; Micropterus dolomieu) population in sections of the Potomac River. Previous studies have identified numerous biologic and environmental stressors associated with negative effects on SMB health. To better understand the impact of these stressors, this study was conducted at the confluence of Antietam Creek and the Potomac River from 2013 to 2019 to identify temporal changes associated with SMB reproductive health. Surface water samples were collected and analyzed for over 300 organic contaminants, including pesticides, phytoestrogens, pharmaceuticals, hormones and total estrogenicity (E2Eq). Adult SMB were collected and sampled for multiple endpoints, including gene transcripts associated with reproduction (molecular), histopathology (cellular), and organosomatic indices (tissue). In males, biomarkers of estrogenic endocrine disruption, including testicular oocytes (TO) and plasma vitellogenin (Vtg) were assessed. Numerous agriculture-related contaminants or land use patterns were associated with gene transcript abundance in both male and female SMB. Positive associations between pesticides in the immediate catchment with TO severity and E2Eq with plasma Vtg in males were identified. In males, the prevalence of TO and detectable levels of plasma Vtg, liver vitellogenin transcripts (vtg) and testis vtg were high throughout the study. Peaks of complex mixtures of numerous contaminants occurred during the spring/early summer when spawning and early development occurs and to a lesser extent in fall/winter during recrudescence. Management practices to reduce exposure during these critical and sensitive periods may enhance reproductive health of these economically important sportfishes.

Potential health effects of contaminant mixtures from point and nonpoint sources on fish and frogs in the New Jersey Pinelands.

Aquatic ecosystems convey complex contaminant mixtures from anthropogenic pollution on a global scale. Point (e.g., municipal wastewater) and nonpoint sources (e.g., stormwater runoff) are both drivers of contaminant mixtures in aquatic habitats. The objectives of this study were to identify the contaminant mixtures present in surface waters impacted by both point and nonpoint sources, to determine if aquatic biota (amphibian and fish) health effects (testicular oocytes and parasites) occurred at these sites, and to understand if differences in biological and chemical measures existed between point (on-stream) and nonpoint sources (off-stream). To accomplish this, water chemistry, fishes, and frogs were collected from 21 sites in the New Jersey Pinelands, United States. Off-stream sites consisted of 3 reference and 10 degraded wetlands. On-stream sites consisted of two reference lakes and six degraded streams/lakes (four sites above and two sites below wastewater outfalls). Surface water was collected four times at each site and analyzed for 133 organic and inorganic contaminants. One native and five non-native fish species were collected from streams/lakes and native green frogs from wetlands (ponds and stormwater basins). Limited differences in contaminant concentrations were observed in reference and degraded wetlands but for streams/lakes, results indicated that landscape alteration, (upland agricultural and developed land) was the primary driver of contaminant concentrations rather than municipal wastewater. Incidence of estrogenic endocrine disruption (intersex) was species dependent with the highest prevalence observed in largemouth bass and black crappie and the lowest prevalence observed in green frogs and tessellated darters. Parasite prevalence was site and species dependent. Prevalence of eye parasites increased with increasing concentrations of industrial, mycotoxin, and cumulative inorganic contaminants. These findings are critical to support the conservation, protection, and management of a wide range of aquatic species in the Pinelands and elsewhere as habitat loss, alteration, and fragmentation increase with increasing development.

Innovative Hospital-Based Pediatric Virtual Learning for Nursing Students.

BACKGROUND/PROBLEM: Specialty clinical sites, including pediatrics, are historically scarce in prelicensure nursing education. APPROACH: Simulation educators developed the Pediatric Virtual Clinical Learning Series (PVCLS) containing 4 virtual learning modules designed to enhance knowledge and skills of prelicensure nursing students in clinical pediatric care. Topics included documentation, rapid response, code blue, and a pediatric case. The learning sessions were initially offered as synchronous virtual classes and were then posted on our e-learning platform to serve as enduring asynchronous material. The target audience was nursing students and faculty from regional and nationally affiliated nursing schools with the pediatric hospital. OUTCOMES: Faculty and 185 nursing students participated in the synchronous or asynchronous learning sessions. Students' ratings that the virtual classes met their personal expectations were 4.02 to 4.56 of 5 for the synchronous sessions and 3.41 to 3.58 of 4 for the asynchronous sessions. CONCLUSIONS: The PVCLS provided both synchronous and asynchronous learning experiences to fill a widening knowledge gap in pediatrics.

Development of a Multiplex Fluorescence in Situ Hybridization Assay to Identify Coinfections in Young-of-the-Year Smallmouth Bass.

Histopathological assessments of young-of-the-year (age-0) Smallmouth Bass Micropterus dolomieu in the Susquehanna River drainage identified a high prevalence of the myxozoan Myxobolus inornatus. This myxozoan infects the connective tissue of the muscle below the skin but is sometimes observed in the esophagus and buccal cavity. In some instances, shallow infections cause breaks in the skin, which could increase the chance of opportunistic bacterial infections. Several microbial pathogens, including Flavobacterium columnare, Aeromonas spp., and Largemouth Bass virus, have also been cultured from clinically diseased young of year. A multiplex fluorescence in situ hybridization (FISH) assay was developed to determine potential colocalization of M. inornatus, Flavobacterium spp., and Aeromonas spp. infections. With FISH, 75% of age-0 Smallmouth Bass exhibited M. inornatus infections, 10% had Aeromonas spp. infections, and 5% had Flavobacterium spp. infections, while 3% had coinfections with both bacterial species and M. inornatus. The results of the multiplex FISH assay revealed a low occurrence of coinfections of Flavobacterium spp. and/or Aeromonas spp. with M. inornatus in randomly sampled individuals.

Evaluation of Communication and Safety Behaviors During Hospital-Wide Code Response Simulation.

INTRODUCTION: To understand the baseline quality of team communication behaviors at our organization, we implemented institution-wide simulation training and measured the performance of safety behaviors of ad hoc teams in emergent situations. METHODS: Clinicians participated in 2 interprofessional video-recorded simulation scenarios, each followed by debriefing. Using a standardized evaluation instrument, 2 reviewers independently evaluated the presence or absence of desired team safety behaviors, including escalating care, sharing a mental model, establishing leadership, thinking out loud, and identifying roles and responsibilities. We also scored the quality of sharing the mental model, closed-loop communication, and overall team performance on a 7-point scale. Discordant reviews were resolved with scoring by an additional reviewer. RESULTS: A total of 1404 clinicians participated in 398 simulation scenarios, resulting in 257 usable videos. Overall, teams exhibited desired behaviors at the following frequencies: escalating care, 85%; sharing mental models, 66%; verbally establishing leadership, 6%; thinking out loud, 87%; and identifying roles and responsibilities, 27%. Across all reviews, the quality of the graded behaviors (of 7 points) was 2.8 for shared mental models, 3.3 for closed-loop communication, and 3.2 for overall team performance. CONCLUSIONS: In a simulation setting with ad hoc teams, there was variable performance on completing safety behaviors and only a fair quality of graded communication behaviors. These results establish a baseline assessment of communication and teamwork behaviors and will guide future quality improvement interventions.

Simulation for Neonatal Endotracheal Intubation Training: How Different Is It From Clinical Practice?

INTRODUCTION: Neonatal endotracheal intubation is a critical skill that is difficult for learners to acquire even with simulation-based training (SBT). Trainees prefer clinical experiences over SBT. The objective of the study was to explore the differences between SBT and clinical practice in acquiring neonatal intubation skills to inform mannequin design and to improve fidelity. METHODS: A basic qualitative study using semistructured interviews was conducted to determine the experience of newly competent trainees (second- and third-year neonatal-perinatal medicine fellows) and their instructors in developing intubation skills. Participants were asked to compare learning through SBT with clinical practice in terms of context, equipment, and environment. Their responses were analyzed using an inductive approach. RESULTS: Thirty-two participants (20 fellows and 12 faculty) indicated that SBT does not equal the real experience. Specifically, the look, feel, and function of the simulators differ enough from the real patient and the clinical environmental that they do not elicit the desired learning responses. The clinical environment prompted heightened emotions and had a chaotic atmosphere that was not fully captured by SBT. Participants suggested that programs use SBT in the initial phases of training only to gain basic skills and they provided several solutions for mannequin and SBT session design. CONCLUSIONS: Simulation-based training does not fully prepare neonatal-perinatal medicine fellows for neonatal intubation. Mannequins with unique active features, such as multiple airway configurations, slipperiness, secretions, and softer textures should be developed. Realistic environments that replicate the interprofessional nature and stressors of the clinical environment might better prepare learners for the complexity of clinical practice.

Reproductive health and endocrine disruption in smallmouth bass (Micropterus dolomieu) from the Lake Erie drainage, Pennsylvania, USA.

Smallmouth bass Micropterus dolomieu were sampled from three sites within the Lake Erie drainage (Elk Creek, Twentymile Creek, and Misery Bay, an embayment in Presque Isle Bay). Plasma, tissues for histopathological analyses, and liver and testes preserved in RNALater® were sampled from 30 smallmouth bass (of both sexes) at each site. Liver and testes samples were analyzed for transcript abundance with Nanostring nCounter® technology. Evidence of estrogenic endocrine disruption was assessed by the presence and severity of intersex (testicular oocytes; TO) and concentrations of plasma vitellogenin in male fish. Abundance of 17 liver transcripts associated with reproductive function, endocrine activity, and contaminant detoxification pathways and 40 testes transcripts associated with male and female reproductive function, germ cell development, and steroid biosynthesis were also measured. Males with a high rate of TO (87-100%) and plasma vitellogenin were noted at all sites; however, TO severity was greatest at the site with the highest agricultural land cover. Numerous transcripts were differentially regulated among the sites and patterns of transcript abundance were used to better understand potential risk factors for estrogenic endocrine disruption. The results of this study suggest endocrine disruption is prevalent in this region and further research would benefit to identify the types of contaminants that may be associated with the observed biological effects.

Use of Virtual Reality for Pediatric Cardiac Critical Care Simulation.

Simulation is a key component of training in the pediatric cardiac intensive care unit (CICU), a complex environment that lends itself to virtual reality (VR)-based simulations. However, VR has not been previously described for this purpose. Two simulations were developed to test the use of VR in simulating pediatric CICU clinical scenarios, one simulating junctional ectopic tachycardia and low cardiac output syndrome, and the other simulating acute respiratory failure in a patient with suspected coronavirus disease 2019. Six attending pediatric cardiac critical care physicians were recruited to participate in the simulations as a pilot test of VR's feasibility for educational and practice improvement efforts in this highly specialized clinical environment. All participants successfully navigated the VR environment and met the critical endpoints of the two clinical scenarios. Qualitative feedback was overall positive with some specific critiques regarding limited realism in some mechanical aspects of the simulation. This is the first described use of VR in pediatric cardiac critical care simulation.

Code Response Training: Improving Interprofessional Communication.

Introduction: Using simulation to improve team performance in emergencies is commonplace. Decreasing codes hospital-wide can be challenging. To address these needs, hospital leaders requested a simulation program to provide team training across an institution focused on patient safety and communication techniques. Methods: We developed a multimodal approach pairing three online modules on communication techniques with a simulation-based learning session. The three modules required 1 hour, followed by a 1-hour, in-person, simulation-based, interprofessional, small-group session of clinical staff. In ad hoc teams, participants managed two cases: a toddler with airway obstruction and a child developing septic shock. A focused debriefing included discussion of mental models, team formation and expertise, and communication techniques to create a common language to use in ad hoc team formation and patient care. Results: Through more than 200 training sessions reaching over 1,400 staff members, we executed code response training. A nurse and physician facilitated each session, emphasizing the interprofessional nature needed for patient care. Participants rated the learning experience highly on a 5-point Likert scale (1 = low/poor, 5 = high/excellent), with an average rating of 4.3 for achieving objectives and an average rating of 4.8 for facilitator effectiveness. Discussion: Through engaging leadership and frontline clinicians, the simulation program provided code response training hospital-wide, emphasizing the importance of teamwork and communication in critical situations. Such hospital-wide training can emphasize a shared language to empower clinicians at all levels to deliver safe, quality patient care.

Perfluoroalkyl Substances in Plasma of Smallmouth Bass from the Chesapeake Bay Watershed.

Smallmouth bass Micropterus dolomieu is an economically important sportfish and within the Chesapeake Bay watershed has experienced a high prevalence of external lesions, infectious disease, mortality events, reproductive endocrine disruption and population declines. To date, no clear or consistent associations with contaminants measured in fish tissue or surface water have been found. Therefore, plasma samples from two sites in the Potomac River and two in the Susquehanna River drainage basins, differing in land-use characteristics, were utilized to determine if perfluoroalkyl substances were present. Four compounds, perfluorooctane sulphonic acid (PFOS), perfluoroundecanoic acid (PFUnA), perfluorodecanoic acid (PFDA) and perfluorododecanoic acid (PFDoA), were detected in every fish. Two additional compounds, perfluorooctane sulphonamide (PFOSA) and perfluorononanoic acid (PFNA), were less commonly detected at lower concentrations, depending on the site. Concentrations of PFOS (up to 574 ng/mL) were the highest detected and varied significantly among sites. No seasonal differences (spring versus fall) in plasma concentrations were observed. Concentrations of PFOS were not significantly different between the sexes. However, PFUnA and PFDoA concentrations were higher in males than females. Both agricultural and developed land-use appeared to be associated with exposure. Further research is needed to determine if these compounds could be affecting the health of smallmouth bass and identify sources.

Creation of a "Patient" Hospital Escape Room Experience to Reduce Harm and Improve Quality of Care.

BACKGROUND: Increases in nursing documentation requirements, adherence to regulatory standards, and workforce diversity add to the complexity of delivering safe patient care. PURPOSE: The aim was to reinforce elements of quality and safety in patient care delivery. APPROACH: In an effort to deliver necessary, though often dull, regulatory information to nursing staff, a team of nurse educators and nursing quality leaders used the concepts of a popular social game to develop an escape room. OUTCOMES: The escape room was conducted with nearly 100 learners with both a regulatory focus and a patient safety focus with success. Participants stated that teamwork, communication, and problem-solving were necessary to escape the room; nearly 60% indicated the escape room experience would contribute to changes in their nursing practice. CONCLUSIONS: The escape room template can be easily modified to target a myriad of learning objectives and learners of varying levels of experience.