The Doctor-Patient Relationship, Partnership Theory, and the Patient as Partner: Finding a Balance Between Domination and Partnership.

It is perhaps most useful to approach the Doctor-Patient relationship (DPR) by admitting that it's complicated. We review some of the strategies that have been employed to mitigate this complexity, zeroing in on one that promises to capture the main features of the DPR without eliminating some of its more important, existential components; pieces of the puzzle that must be retained if we are to avoid oversimplification and the errors that can arise by ignoring important foundational properties. We believe that a useful way to look at the DPR and to capture essential features that must be balanced in the process is provided by Partnership Theory and its definition in terms of the so-called domination and partnership systems. We apply this theory to the DPR and investigate the implications of this application to health care. We see that in the absence of mitigating circumstances, adoption of the patient-as-partner model serves healthcare well and is flexible enough to accommodate circumstances that dictate modifications.

Directed Evolution of 2'-Fluoro-Modified, RNA-Supported Carbohydrate Clusters That Bind Tightly to HIV Antibody 2G12.

Carbohydrate binding proteins (CBPs) are attractive targets in medicine and biology. Multivalency, with several glycans binding to several binding pockets in the CBP, is important for high-affinity interactions. Herein, we describe a novel platform for design of multivalent carbohydrate cluster ligands by directed evolution, in which serum-stable 2'-fluoro modified RNA (F-RNA) backbones evolve to present the glycan in optimal clusters. We have validated this method by the selection of oligomannose (Man9) glycan clusters from a sequence pool of ∼1013 that bind to broadly neutralizing HIV antibody 2G12 with 13 to 36 nM affinities.

Predictors of Turnover Among Asian Foreign-Educated Nurses in Their 1st Year of US Employment.

OBJECTIVE: The aim of this study was to investigate factors affecting turnover of Asian foreign-educated nurses (FENs), which may lead to improvements in retention strategies. BACKGROUND: Asian FENs working in the United States have considerable rates of turnover. Little is known about which factors are related. METHODS: A cross-sectional design was used. A convenience sample (n = 201) of Asian FENs completed surveys by regular mail and through a website. Backward multivariable logistic regression was performed to identify factors associated with turnover in their 1st year of employment. RESULTS: Most participants were from the Philippines and Korea. Perceived quality of orientation predicted organizational-level turnover and trended toward predicting unit-level turnover. CONCLUSIONS: Healthcare institutions may benefit from developing organizational programs for FENs that are sensitive to their unique needs, in the interest of reducing rapid or early turnover and accompanying negative effects on hospital finances and patient care.

Improving Nursing Communication Skills in an Intensive Care Unit Using Simulation and Nursing Crew Resource Management Strategies: An Implementation Project.

Effective interprofessional communication is critical to patient safety. This pre-/postimplementation project used a multifaceted educational strategy with high-fidelity simulation to introduce evidence-based communication tools, adapted from Nursing Crew Resource Management, to intensive care unit nurses. Results indicated that participants were satisfied with the education, and their perceptions of interprofessional communication and knowledge improved. Teams (n = 16) that used the communication tools during simulation were more likely to identify the problem, initiate key interventions, and have positive outcomes.

Communication Between Acute Care Hospitals and Skilled Nursing Facilities During Care Transitions: A Retrospective Chart Review.

HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE INSTRUCTIONS 1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must: 1. Read the article, "Communication Between Acute Care Hospitals and Skilled Nursing Facilities During Care Transitions: A Retrospective Chart Review" found on pages 19-28, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until February 29, 2020. CONTACT HOURS This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. ACTIVITY OBJECTIVES 1. Discuss problematic barriers during care transitions. 2. Describe the significance of interprofessional collaboration in the delivery of quality health care. DISCLOSURE STATEMENT Neither the planners nor the author have any conflicts of interest to disclose. The purpose of the current project was to (a) examine the type of information accompanying patients on transfer from acute care to skilled nursing facilities (SNFs), (b) discuss how these findings meet existing standards, and (c) make recommendations to improve transfer of essential information. The study was a retrospective convenience sample chart audit in one SNF. All patients admitted from an acute care hospital to the SNF were examined. The audit checklist was developed based on recommendations by local and national standards. One hundred fifty-five charts were reviewed. Transferring of physician contact information was missing in 65% of charts. The following information was also missing from charts: medication lists (1%), steroid tapering instructions (42%), antiarrhythmic instructions (38%), duration/indication of anticoagulant medications (25%), and antibiotic medications (22%). Findings support the need for improved transitional care models and better communication of information between care settings. Recommendations include designating accountability and chart audits comparing timeliness, completeness, and accuracy. [Journal of Gerontological Nursing, 43(3), 19-28.].

Turnover and Associated Factors in Asian Foreign-Educated Nurses.

OBJECTIVES: The purposes of this study are to (1) describe the gap between expected and perceived organizational experiences among Asian foreign-educated nurses (FENs) in the United States and (2) to examine factors associated with turnover in their 1st year of employment. BACKGROUND: Little is known about factors associated with turnover among Asian FENs. METHODS: A cross-sectional design with a convenience sampling was conducted. Subjects (n = 201) responded either via Web-based or mail survey. A series of simple and multivariable logistic regressions were used. RESULTS: Expectations of FENs before organizational entry were significantly higher than their experiences. The FENs who reported less organizational responsibility than expected were more likely to leave their 1st employment to move to another organization or unit. CONCLUSION: This study may contribute to our understanding of the potential factors that assist or interfere with the organization's administrative retention plan for Asian FENs.

Gender differences in use of hearing protection devices among farm operators.

PURPOSE: Although farm operators have frequent exposure to hazardous noise and high rates of noise-induced hearing loss, they have low use of hearing protection devices (HPDs). Women represent about one-third of farm operators, and their numbers are climbing. However, among published studies examining use of HPDs in this worker group, none have examined gender-related differences. The purpose of this study was to examine gender-related differences in use of hearing protection and related predictors among farm operators. MATERIALS AND METHODS: Data previously collected at farm shows and by telephone were analyzed using t-tests and generalized linear model with zero inflated negative binomial (ZINB) distribution. FINDINGS: The difference in rate of hearing protector use between men and women farm operators was not significant. There was no difference between men and women in most hearing protector-related attitudes and beliefs. CONCLUSION: Although men and women farm operators had similar rates of use of hearing protectors when working in high-noise environments, attitudes about HPD use differed. Specifically, interpersonal role modeling was a predictor of HPD use among women, but not for men. This difference suggests that while farm operators of both genders may benefit from interventions designed to reduce barriers to HPD use (e.g., difficulty communicating with co-workers and hearing warning sounds), farm women have unique needs in relation to cognitive-perceptual factors that predict HPD use. Women farm operators may lack role models for use of HPDs (e.g., in peers and advertising), contributing to their less frequent use of protection.

Perception of Jordanian nurses regarding involvement in decision-making.

BACKGROUND: Nurses in any organizational context are members of a team and cannot work independently. Teamwork requires making decisions frequently, and these decisions affect team performance on a regular basis. Ultimately, the team shapes the quality of patient care. AIM: This study examines nurse decision-making related to patient care, self-management and the work environment. METHOD: Qualitative descriptive design was used to collect data. Eighteen staff nurses participated in semi-structured interviews to explore the perception of Jordanian staff nurses regarding their participation in decision-making. RESULTS: Variation in decision-making involvement was found to exist across unit types and from hospital to hospital. In general, the participants were not satisfied with their level of decision-making involvement and believed that they could participate more. CONCLUSION: The results have implications for nurse managers in facilitating the engagement of staff nurses in decision-making and creating an organizational culture to facilitate this engagement.

Understanding the Effects of Mental Health on Reproductive Health Service Use: A Mixed Methods Approach.

Appropriate and woman-led health care for displaced women is essential to respecting basic human rights. In this article, we describe the results of an analysis of the association between mental health and reproductive health service use from a sample of Congolese refugee women residing in short- and long-term camps in Rwanda, with a post-hoc qualitative potion added to expand upon the data-based results. Our findings suggest that structural factors including health policy initiatives affect or even inhibit individual care choices.

A mechanistic study of thioester hydrolysis with heavy atom kinetic isotope effects.

The carbonyl-C, carbonyl-O, and leaving-S kinetic isotope effects (KIEs) were determined for the hydrolysis of formylthiocholine. Under acidic conditions, (13)k(obs) = 1.0312, (18)k(obs) = 0.997, and (34)k(obs) = 0.995; for neutral conditions, (13)k(obs) = 1.022, (18)k(obs) = 1.010, and (34)k(obs) = 0.996; and for alkaline conditions, (13)k(obs) = 1.0263, (18)k(obs) = 0.992, and (34)k(obs) = 1.000. The observed KIEs provided helpful insights into a qualitative description of the bond orders in the transition state structure.

Nurses in the United States with a practice doctorate: implications for leading in the current context of health care.

The Institute of Medicine has recommended doubling the number of nurses with doctorates by 2020. The National Research Council has recommended a clearer distinction between doctoral preparation for a practice profession and that for the preparation of scientists. To support the central premise that both the research-oriented doctorate (PhD) and the practice-oriented doctorate, the doctor of nursing practice (DNP), are critical to achieve and expand doctoral education, we present current information regarding the impact of DNP programs, including enrollments, scholarly productivity of DNP graduates, and the employment setting of DNP scholars. Scholarly productivity was estimated by searching publication databases between 2005 and 2012 using three strategies to estimate the publication record of nurses who had earned a DNP degree. The large numbers of nurses receiving the DNP are helping to fulfill the Institute of Medicine's recommendation and are increasingly contributing to the scholarly output in the field, especially related to clinical practice.

A kinetic isotope effect and isotope exchange study of the nonenzymatic and the equine serum butyrylcholinesterase-catalyzed thioester hydrolysis.

Formylthiocholine (FTC) was synthesized and found to be a substrate for nonenzymatic and butyrylcholinesterase (BChE)-catalyzed hydrolysis. Solvent (D2O) and secondary formyl-H kinetic isotope effects (KIEs) were measured by an NMR spectroscopic method. The solvent (D2O) KIEs are (D2O)k = 0.20 in 200 mM HCl, (D2O)k = 0.81 in 50 mM HCl, and (D2O)k = 4.2 in pure water. The formyl-H KIEs are (D)k = 0.80 in 200 mM HCl, (D)k = 0.77 in 50 mM HCl, (D)k = 0.75 in pure water, (D)k = 0.88 in 50 mM NaOH, and (D)(V/K) = 0.89 in the BChE-catalyzed hydrolysis in MES buffer at pH 6.8. Positional isotope exchange experiments showed no detectable exchange of (18)O into the carbonyl oxygen of FTC or the product, formate, under any of the above conditions. Solvent nucleophile-O KIEs were determined to be (18)k = 0.9917 under neutral conditions, (18)k = 1.0290 (water nucleophile) or (18)k = 0.989 (hydroxide nucleophile) under alkaline conditions, and (18)(V/K) = 0.9925 for BChE catalysis. The acidic, neutral, and BChE-catalyzed reactions are explained in terms of a stepwise mechanism with tetrahedral intermediates. Evidence for a change to a direct displacement mechanism under alkaline conditions is presented.

Factors associated with sleep quality among operating engineers.

Blue collar workers generally report high job stress and are exposed to loud noises at work and engage in many of risky health behavioral factors, all of which have been associated with poor sleep quality. However, sleep quality of blue collar workers has not been studied extensively, and no studies have focused Operating Engineers (heavy equipment operators) among whom daytime fatigue would place them at high risk for accidents. Therefore, the purpose of this study was to determine variables associated with sleep quality among Operating Engineers. This was a cross-sectional survey design with a dependent variable of sleep quality and independent variables of personal and related health behavioral factors. A convenience sample of 498 Operating Engineers was recruited from approximately 16,000 Operating Engineers from entire State of Michigan in 2008. Linear regression was used to determine personal and related health behavior factors associated with sleep quality. Multivariate analyses showed that personal factors related to poor sleep quality were younger age, female sex, higher pain, more medical comorbidities and depressive symptoms and behavioral factors related to poor sleep quality were nicotine dependence. While sleep scores were similar to population norms, approximately 34 % (n = 143) showed interest in health services for sleep problems. While many personal factors are not changeable, interventions to improve sleep hygiene as well as interventions to treat pain, depression and smoking may improve sleep quality resulting in less absenteeism, fatal work accidents, use of sick leave, work disability, medical comorbidities, as well as subsequent mortality.

Factors influencing functional recovery in patients with acute ischemic stroke.

AIM: This study examined factors influencing functional recovery, including neurological and psychological function and activity of daily Living (ADL), in individuals hospitalized with acute ischemic stroke. METHODS: A prospective observational study was undertaken in a sample of 141 hospitalized adults with acute ischemic stroke in three hospitals in metropolitan Bangkok and one in regional Thailand. Sociodemographic and clinical data were collected using a standardized questionnaire. Co-morbidity burden was assessed using the Charlson Co-morbidity Index-Modified-Thai version (CCI-T) and acute stroke care services usage using the Measurement of Acute Stroke Care Services Received form. Recovery of neurological function was measured by the National Institutes of Health Stroke Scale-Thai (NIHSS-T), and ADL function was measured by the Modified Barthel Index Measurement-Thai Version (BI-T). Psychological function was assessed using the Center for Epidemiologic Studies Depression Scale-Thai version (CES-D-T). Multivariate Logistic regression was used to analyze the predictive ability of pre-specified variables. RESULTS: Receiving thrombolytic therapy was a significant predictor of functional recovery in terms of neurological (OR=4.714; P=.004) and ADL functions on the day of discharge (OR= 5.408; P=.002). Accessing acute stroke care service was the only factor predicting improved psychological function on hospital discharge (OR=1.312; P=.049).

Synthesis of Mannosidase-Stable Man3 and Man4 Glycans Containing S-linked Manα1→2Man Termini.

Oligomannose glycans are of interest as HIV vaccine components, but they are subject to mannosidase degradation in vivo. Herein, we report the synthesis of oligosaccharides containing a thio linkage at the nonreducing end. A thio-linked dimannose donor participates in highly stereoselective glycosylations to afford trimannose and tetramannose fragments. Saturation transfer difference nuclear magnetic resonance (STD NMR) studies show that these glycans are recognized by HIV antibody 2G12, and we confirm that the reducing terminal S-linkage confers complete stability against x. manihotis mannosidase.

The transition from inquiry to evidence to actionable clinical knowledge: A proposed roadmap.

RATIONALE, AIMS, AND OBJECTIVES: We consider the question "What should we do?" in the context of clinical research/practice. There are several steps along the way to providing a satisfactory answer, many of which have received considerable attention in the literature. We aim to provide a unified summary and explication of these "steps along the way". The result will be an increased appreciation for the meaning and structure of "actionable clinical knowledge". METHODS: We review the literature to identify pertinent works dealing with evidence production and translation into actionable clinical knowledge. We draw from insights in this literature about various aspects of reasoning relevant to clinical questions and integrate these into a unified approach to the processes that lead to actionable clinical knowledge. RESULTS: We collect, collate, and integrate some of the work by Bauer, Carper, Goldman, Haack, McHugh and Walker, and Upshur and colleagues and obtain guidelines to aid in the evidence-to-actionable-clinical- knowledge transition. CONCLUSIONS: Clinical decision-making is not infallible, and the steps we can take to minimize error are context dependent. Medical evidence, produced as it is by human effort, can never be perfect. We will be doing well by assuring that the evidence we use has been produced by a reliable process and is relevant to the question posed.

Scientism recognizes evidence only of the quantitative/general variety.

RATIONALE, AIMS AND OBJECTIVES: McHugh and Walker introduced a model of knowledge to demonstrate that EBM is a form of scientism that ignores important sources of knowledge thereby impairing the practice of medicine. We study the development of this model and explore additional applications. METHODS: Review of the relevant literature and identification of possible areas for fruitful application. RESULTS: We show that the McHugh and Walker model is closely related to the model of evidence considered earlier by Upshur et al. We also indicate that the utility of this model is not limited to showing scientism distorts clinical practice. Several representative applications are identified, including psychotherapy, the Salk polio vaccine trial, and the placebo effect. CONCLUSIONS: Priority should be given to Upshur et al for the development of a model that has far-reaching application to medical epistemology. It is shown that all four of the types of evidence considered-qualitative/personal, qualitative/general, quantitative/general, and quantitative/personal-are required to adequately characterize epistemology in medical research and practice.

The Impact of Sustained Immunization Regimens on the Antibody Response to Oligomannose Glycans.

The high mannose patch (HMP) of the HIV envelope protein (Env) is the structure most frequently targeted by broadly neutralizing antibodies; therefore, many researchers have attempted to use mimics of this region as a vaccine immunogen. In our previous efforts, vaccinating rabbits with evolved HMP mimic glycopeptides containing Man9 resulted in an overall antibody response targeting the glycan core and linker rather than the full glycan or Manα1→2Man tips of Man9 glycans. A possible reason could be processing of our immunogen by host serum mannosidases. We sought to test whether more prolonged dosing could increase the antibody response to intact glycans, possibly by increasing the availability of intact Man9 to germinal centers. Here, we describe a study investigating the impact of immunization regimen on antibody response by testing immunogen delivery through bolus, an exponential series of mini doses, or a continuously infusing mini-osmotic pump. Our results indicate that, with our glycopeptide immunogens, standard bolus immunization elicited the strongest HIV Env-binding antibody response, even though higher overall titers to the glycopeptide were elicited by the exponential and pump regimens. Antibody selectivity for intact glycan was, if anything, slightly better in the bolus-immunized animals.

Human resources in nursing education: a worldwide crisis.

The global shortage of nurses is escalating. A key contributing factor to the production of new nurses is the growing shortage of qualified faculty. This paper explores the forces influencing the global faculty shortage, including those that increase demand and those that limit the supply of nursing faculty. The authors discuss potential solutions to the shortage, placing particular emphasis on leveraging the strengths of the profession to accelerate the progression of nurses to graduate school, the enhancement of funding for graduate education, changing the paradigm of clinical education, and the expansion of the science base for practice.

Gene expression signatures, clinicopathological features, and individualized therapy in breast cancer.

CONTEXT: Gene expression profiling may be useful for prognostic and therapeutic strategies in breast carcinoma. OBJECTIVES: To demonstrate the value in integrating genomic information with clinical and pathological risk factors, to refine prognosis, and to improve therapeutic strategies for early stage breast cancer. DESIGN, SETTING, AND PATIENTS: Retrospective study of patients with early stage breast carcinoma who were candidates for adjuvant chemotherapy; 964 clinically annotated breast tumor samples (573 in the initial discovery set and 391 in the validation cohort) with corresponding microarray data were used. All patients were assigned relapse risk scores based on their respective clinicopathological features. Signatures representing oncogenic pathway activation and tumor biology/microenvironment status were applied to these samples to obtain patterns of deregulation that correspond with relapse risk scores to refine prognosis with the clinicopathological prognostic model alone. Predictors of chemotherapeutic response were also applied to further characterize clinically relevant heterogeneity in early stage breast cancer. MAIN OUTCOME MEASURES: Gene expression signatures and clinicopathological variables in early stage breast cancer to determine a refined estimation of relapse-free survival and sensitivity to chemotherapy. RESULTS: In the initial data set of 573 patients, prognostically significant clusters representing patterns of oncogenic pathway activation and tumor biology/microenvironment states were identified within the low-risk (log-rank P = .004), intermediate-risk (log-rank P = .01), and high-risk (log-rank P = .003) model cohorts, representing clinically important genomic subphenotypes of breast cancer. As an example, in the low-risk cohort, of 6 prognostically significant clusters, patients in cluster 4 had an inferior relapse-free survival vs patients in cluster 1 (log-rank P = .004) and cluster 5 (log-rank P = .03). Median relapse-free survival for patients in cluster 4 was 16 months less than for patients in cluster 1 (95% CI, 7.5-24.5 months) and 19 months less than for patients in cluster 5 (95% CI, 10.5-27.5 months). Multivariate analyses confirmed the independent prognostic value of the genomic clusters (low risk, P = .05; high risk, P = .02). The reproducibility and validity of these patterns of pathway deregulation in predicting relapse risk was established using related but not identical clusters in the independent validation cohort. The prognostic clinicogenomic clusters also have unique sensitivity patterns to commonly used cytotoxic therapies. CONCLUSIONS: These results provide preliminary evidence that incorporation of gene expression signatures into clinical risk stratification can refine prognosis. Prospective studies are needed to determine the value of this approach for individualizing therapeutic strategies.