Frailty Interdisciplinary Pathway: Compliance and Sustainability in a Level I Trauma Center.

BACKGROUND: Frailty is a state of physiological vulnerability that predisposes many older adult trauma patients to poor health outcomes. Specialized care pathways for frail trauma patients have been shown to improve outcomes, but the compliance and sustainability of these pathways have not been reported (Bryant et al., 2019; Engelhardt et al., 2018). METHODS: We retrospectively measured compliance and sustainability during the first 2 years of a frailty pathway for patients 65 years or older at an urban Level I trauma center. Compliance to 19 pathway elements was collected for 279 pathway patients between October 1, 2016, and September 30, 2018. Compliance was analyzed and reported as a percentage of the total possible times each element could have been completed per pathway guidelines. Benchmark compliance was 75% or more. RESULTS: Retrospective 2-year mean overall compliance to all pathway elements was 68.2% and improved from Year 1 (65.0%) to Year 2 (71.4%). Seven elements achieved a mean 75% or more compliance over the 2-year period: frailty screening on admission (92.8%), consultation requests for physical therapy (97.9%), geriatrics (96.2%), and nutrition (92.3%), consultant care within 72 hr of admission (78.0%), delirium screening 3 times daily (76.3%), and daily senna administration (76.0%). Compliance to 10 elements significantly improved from Year 1 to Year 2 and significantly worsened in 2 elements. CONCLUSION: Many standardized geriatric care processes for frail older adult trauma patients can be successfully integrated into routine daily inpatient practice and sustained over time. Multicenter studies are needed to demonstrate how to improve compliance and to understand better which pathway elements are most effective.

Nursing Students' Academic Success Factors: A Quantitative Cross-sectional Study.

BACKGROUND: Attrition from nursing programs is an ongoing concern. Capitalizing on nursing students' strengths and supporting areas for remediation will maximize student success. PURPOSE: This study explored undergraduate nursing student strengths and areas for remediation at program entry and across all years of nursing education study. METHODS: We used a cross-sectional design and collected data via the Academic Success Inventory for College Students survey tool. Baseline data were collected on first-year students after program start, and data were collected for all years of study at the end of the academic terms. RESULTS: Compared with other undergraduate students, nursing students exhibited strengths in study skills, in self-organization strategies, in their certainty of progress toward career goals, in recognizing the importance of their studies, and in levels of socializing that did not hinder academic performance. At some data collection points, they had strengths in motivation, confidence, and concentration. Nursing students indicated areas for remediation in studying or test-taking anxiety and their perception of the educator's ability to organize, teach, and assess student progress. CONCLUSION: Nurse educators' pedagogical approaches should augment nursing student strengths. Remediation is required to support student success relative to anxiety, and students need orientation to the process of learning.

Exacerbation of Physical Intimate Partner Violence during COVID-19 Pandemic.

Background Intimate partner violence (IPV) is a global social and public health problem, but published literature regarding the exacerbation of physical IPV during the coronavirus disease 2019 (COVID-19) pandemic is lacking. Purpose To assess the incidence, patterns, and severity of injuries in IPV victims during the COVID-19 pandemic in 2020 compared with the prior 3 years. Materials and Methods The demographics, clinical presentation, injuries, and radiologic findings of patients reporting physical abuse arising from IPV during the statewide COVID-19 pandemic between March 11 and May 3, 2020, were compared with data from the same period for the past 3 years. Pearson χ2 and Fisher exact tests were used for analysis. Results A total of 26 victims of physical IPV from 2020 (mean age, 37 years ± 13 [standard deviation]; 25 women) were evaluated and compared with 42 victims of physical IPV (mean age, 41 years ± 15; 40 women) from 2017 to 2019. Although the overall number of patients who reported IPV decreased during the pandemic, the incidence of physical IPV was 1.8 times greater (95% CI: 1.1, 3.0; P = .01). The total number of deep injuries was 28 during 2020 versus 16 from 2017 to 2019; the number of deep injuries per victim was 1.1 during 2020 compared with 0.4 from 2017 to 2019 (P < .001). The incidence of high-risk abuse defined by mechanism was two times greater in 2020 (95% CI: 1.2, 4.7; P = .01). Patients who experienced IPV during the COVID-19 pandemic were more likely to be White; 17 (65%) victims in 2020 were White compared with 11 (26%) in the prior years (P = .007). Conclusion There was a higher incidence and severity of physical intimate partner violence (IPV) during the coronavirus disease 2019 (COVID-19) pandemic compared with the prior 3 years. These results suggest that victims of IPV delayed reaching out to health care services until the late stages of the abuse cycle during the COVID-19 pandemic. © RSNA, 2020.

Anxiety, mental illness, learning disabilities, and learning accommodation use: A cross-sectional study.

BACKGROUND: Nurse educators require a robust understanding of nursing students' attributes to meet their learning needs and support their success. PURPOSE: This research seeks to understand the proportion of nursing students with self-reported medically diagnosed anxiety, mental illnesses (MI), learning disabilities (LD), and utilized learning accommodations (LA), and determine how these students compared to a normative sample regarding studying and test-taking anxiety. METHOD: A secondary analysis of quantitative cross-sectional data that included the Academic Success Inventory for College Students (ASICS) tool. First-year students were surveyed (4-6 weeks after program start, and students in years 1 through 4 were surveyed at the end of both academic terms. RESULTS: At program start, 21% were diagnosed with anxiety, 16% with MI, 2% with a LD, and 6% accessed LA. By fourth-year these proportions were 23%, 22%, 8% and 13% respectively. Alarming proportions of respondents exhibited anxiety related to test-taking compared to the ASICS normative sample with large effect sizes (Anxiety h = 0.884; MI h = 0.601; LD: h = 2.094; LA h = 0.725). CONCLUSION: To support students, we highlight a need for early identification and tailored support, enriched faculty knowledge, faculty introspection and willingness to adapt, and time for relational and individual pedagogy.

Building patient capacity to participate in care during hospitalisation: a scoping review.

OBJECTIVES: To map the existing literature and describe interventions aimed at building the capacity of patients to participate in care during hospitalisation by: (1) describing and categorising the aspects of care targeted by these interventions and (2) identifying the behaviour change techniques (BCTs) used in these interventions. A patient representative participated in all aspects of this project. DESIGN: Scoping review. DATA SOURCES: MEDLINE, Embase and CINAHL (Inception -2017). STUDY SELECTION: Studies reporting primary research studies on building the capacity of hospitalised adult patients to participate in care which described or included one or more structured or systematic interventions and described the outcomes for at least the key stakeholder group were included. DATA EXTRACTION: Title and abstract screening and full text screening were conducted by pairs of trained reviewers. One reviewer extracted data, which were verified by a second reviewer. Interventions were classified according to seven aspects of care relevant to hospital settings. BCTs identified in the articles were assigned through consensus of three reviewers. RESULTS: Database searches yielded a total 9899 articles, resulting in 87 articles that met the inclusion criteria. Interventions directed at building patient capacity to participate in care while hospitalised were categorised as those related to improving: patient safety (20.9%); care coordination (5.7%); effective treatment (5.7%) and/or patient-centred care using: bedside nursing handovers (5.7%); communication (29.1%); care planning (14%) or the care environment (19.8%). The majority of studies reported one or more positive outcomes from the defined intervention. Adding new elements (objects) to the environment and restructuring the social and/or physical environment were the most frequently identified BCTs. CONCLUSIONS: The majority of studies to build capacity for participation in care report one or more positive outcomes, although a more comprehensive analysis is warranted.

Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients.

BACKGROUND: Frailty is a well-established marker of poor outcomes in geriatric trauma patients. There are few interventions to improve outcomes in this growing population. Our goal was to determine if an interdisciplinary care pathway for frail trauma patients improved in-hospital mortality, complications, and 30-day readmissions. STUDY DESIGN: This was a retrospective cohort study of frail patients ≥65 years old, admitted to the trauma service at an academic, urban level I trauma center between 2015 and 2017. Patients transferred to other services and those who died within the first 24 hours were excluded. An interdisciplinary protocol for frail trauma patients, including early ambulation, bowel/pain regimens, nonpharmacologic delirium prevention, nutrition/physical therapy consults, and geriatrics assessments, was implemented in 2016. Our main outcomes were delirium, complications, in-hospital mortality, and 30-day readmission, which were compared with these outcomes in patients treated the year before the pathway was implemented. Multivariate logistic regression was used to determine the association of being on the pathway with outcomes. RESULTS: There were 125 and 144 frail patients in the pre- and post-intervention cohorts, respectively. There were no significant demographic differences between the 2 groups. Among both groups, the mean age was 83.51 years (SD 7.11 years), 60.59% were female, and median Injury Severity Score was 10 (interquartile range 9 to 14). In univariate analysis, there were no significant differences in complications (28.0% vs 28.5%, respectively, p = 0.93); however, there was a significant decrease in delirium (21.6% to 12.5%, respectively, p = 0.04) and 30-day readmission (9.6% to 2.7%, respectively, p = 0.01). After adjusting for patient characteristics, patients on the pathway had lower delirium (odds ratio [OR] 0.44, 95% CI 0.22 to 0.88, p = 0.02) and 30-day readmission rates (OR 0.25, 95% CI 0.07 to 0.84, p = 0.02), than pre-pathway patients. CONCLUSIONS: An interdisciplinary care protocol for frail geriatric trauma patients significantly decreases their delirium and 30-day readmission risk. Implementing pathways standardizing care for these vulnerable patients could improve their outcomes after trauma.

Effectiveness of Instructional Interventions for Hemorrhage Control Readiness for Laypersons in the Public Access and Tourniquet Training Study (PATTS): A Randomized Clinical Trial.

Importance: Several national initiatives have emerged to empower laypersons to act as immediate responders to reduce preventable deaths from uncontrolled bleeding. Point-of-care instructional interventions have been developed in response to the scalability challenges associated with in-person training. However, to our knowledge, their effectiveness for hemorrhage control has not been established. Objective: To evaluate the effectiveness of different instructional point-of-care interventions and in-person training for hemorrhage control compared with no intervention and assess skill retention 3 to 9 months after hemorrhage control training. Design, Setting, and Participants: This randomized clinical trial of 465 laypersons was conducted at a professional sports stadium in Massachusetts with capacity for 66 000 people and assessed correct tourniquet application by using different point-of-care interventions (audio kits and flashcards) and a Bleeding Control Basic (B-Con) course. Non-B-Con arms received B-Con training after initial testing (conducted from April 2017 to August 2017). Retesting for 303 participants (65%) was performed 3 to 9 months after training (October 2017 to January 2018) to evaluate B-Con retention. A logistic regression for demographic associations was performed for retention testing. Interventions: Participants were randomized into 4 arms: instructional flashcards, audio kits with embedded flashcards, B-Con, and control. All participants received B-Con training to later assess retention. Main Outcomes and Measures: Correct tourniquet application in a simulated scenario. Results: Of the 465 participants, 189 (40.7%) were women and the mean (SD) age was 46.3 (16.1) years. For correct tourniquet application, B-Con (88% correct application [n = 122]; P < .001) was superior to control (n = 104 [16%]) while instructional flashcards (n = 117 [19.6%]) and audio kit (n = 122 [23%]) groups were not. More than half of participants in point-of-care arms did not use the educational prompts as intended. Of 303 participants (65%) who were assessed 3 to 9 months after undergoing B-Con training, 165 (54.5%) could correctly apply a tourniquet. Over this period, there was no further skill decay in the adjusted model that treated time as either linear (odds ratio [OR], 0.98; 95% CI, 0.95-1.03) or quadratic (OR, 1.00; 95% CI, 1.00-1.00). The only demographic that was associated with correct application at retention was age; adults aged 18 to 35 years (n = 58; OR, 2.39; 95% CI, 1.21-4.72) and aged 35 to 55 years (n = 107; OR, 1.77; 95% CI, 1.04-3.02) were more likely to be efficacious than those older than 55 years (n = 138). Conclusions and Relevance: In-person hemorrhage control training for laypersons is currently the most efficacious means of enabling bystanders to act to control hemorrhage. Laypersons can successfully perform tourniquet application after undergoing a 1-hour course. However, only 54.5% retain this skill after 3 to 9 months, suggesting that investigating refresher training or improved point-of-care instructions is critical. Trial Registration: ClinicalTrials.gov Identifier: NCT03479112.

Student perception of initial transition into a nursing program: A mixed methods research study.

BACKGROUND: Transition into undergraduate education programs is stressful and impacts students' well-being and academic achievement. Previous research indicates nursing students experience stress, depression, anxiety, and poor lifestyle habits which interfere with learning. However, nursing students' experience of transition into nursing programs has not been well studied. Incongruence exists between this lack of research and the desire to foster student success. OBJECTIVES: This study analyzed students' experiences of initial transition into a nursing program. DESIGN: An embedded mixed method design. SETTING: A single site of a direct-entry, four year baccalaureate Canadian nursing program. PARTICIPANTS: All first year nursing students enrolled in the fall term of 2016. METHODS: This study combined the Student Adaptation to College Questionnaire (SACQ) with a subset of participants participating in qualitative focus groups. Quantitative data was analyzed using descriptive statistics to identify statistically significant differences in full-scale and subscale scores. Qualitative data was analyzed utilizing thematic analysis. RESULTS: Significant differences were seen between those who moved to attend university and those who did not, with those who moved scoring lower on the Academic Adjustment subscale. Focus group thematic analysis highlighted how students experienced initial transition into a baccalaureate nursing program. Identified themes included reframing supports, splitting focus/finding focus, negotiating own expectations, negotiating others' expectations, and forming identity. These findings form the Undergraduate Nursing Initial Transition (UNIT) Framework. CONCLUSION: Significance of this research includes applications in faculty development and program supports to increase student success in the first year of nursing and to provide foundational success for ongoing nursing practice.

Structured approaches to promote patient and family engagement in treatment in acute care hospital settings: protocol for a systematic scoping review.

BACKGROUND: While effective engagement of patients and families in treatment is increasingly viewed as a priority for many healthcare systems, much remains to be learned about the nature and outcomes of approaches that seek to accomplish this goal in the acute care hospital setting. Wide variability in the implementation of practices designed to promote patient and family engagement in hospitals has been noted. Approaches aimed at promoting patient and family engagement in treatment share the over-arching goal of changing behaviors of patients, families, and healthcare providers and possibly administrators. Behavior change techniques (BCTs) can be a key element of patient and family engagement approaches. This scoping review will contribute to the development of an evidence base detailing that the BCTs have potential to be effective in patient and family engagement interventions. The specific objectives of this review are to (a) identify and classify approaches used in acute care hospitals to engage patient and families in treatment according to the behavior change technique taxonomy; and (b) evaluate and synthesize the outcomes for these approaches for patients and families, healthcare providers, and health administrators/funders. METHODS: This systematic scoping review will allow us to determine the extent, range, and nature of research activity related to initiatives designed to promote patient and family engagement in care. A comprehensive electronic literature search will be conducted in MEDLINE, EMBASE, and CINAHL. Studies will be included if they report on outcomes of a structured or systematic approach to the promotion of adult inpatient and family engagement in treatment in acute care settings. Studies will be selected in a two-stage screening process (title and abstract; full text) and quality will be assessed using the mixed methods assessment tool. Data extraction will include narrative descriptions of the intervention and classification of the behavior change techniques employed. DISCUSSION: This review aims to identify and classify the specific behavior change techniques underpinning patient and family engagement interventions used in acute care hospital settings. By identifying the "active ingredients" in these interventions, our findings will be transferable to a wide range of acute care hospital contexts and populations.

Myocardin-related transcription factor A regulates conversion of progenitors to beige adipocytes.

Adipose tissue is an essential regulator of metabolic homeostasis. In contrast with white adipose tissue, which stores excess energy in the form of triglycerides, brown adipose tissue is thermogenic, dissipating energy as heat via the unique expression of the mitochondrial uncoupling protein UCP1. A subset of UCP1+ adipocytes develops within white adipose tissue in response to physiological stimuli; however, the developmental origin of these "brite" or "beige" adipocytes is unclear. Here, we report the identification of a BMP7-ROCK signaling axis regulating beige adipocyte formation via control of the G-actin-regulated transcriptional coactivator myocardin-related transcription factor A, MRTFA. White adipose tissue from MRTFA(-/-) mice contains more multilocular adipocytes and expresses enhanced levels of brown-selective proteins, including UCP1. MRTFA(-/-) mice also show improved metabolic profiles and protection from diet-induced obesity and insulin resistance. Our study hence unravels a central pathway driving the development of physiologically functional beige adipocytes.

Roles for peroxisome proliferator-activated receptor γ (PPARγ) and PPARγ coactivators 1α and 1ß in regulating response of white and brown adipocytes to hypoxia.

Obese white adipose tissue is hypoxic but is incapable of inducing compensatory angiogenesis. Brown adipose tissue is highly vascularized, facilitating delivery of nutrients to brown adipocytes for heat production. In this study, we investigated the mechanisms by which white and brown adipocytes respond to hypoxia. Brown adipocytes produced lower amounts of hypoxia-inducible factor 1α (HIF-1α) than white adipocytes in response to low O(2) but induced higher levels of hypoxia-associated genes. The response of white adipocytes to hypoxia required HIF-1α, but its presence alone was incapable of inducing target gene expression under normoxic conditions. In addition to the HIF-1α targets, hypoxia also induced many inflammatory genes. Exposure of white adipocytes to a peroxisome proliferator-activated receptor γ (PPARγ) ligand (troglitazone) attenuated induction of these genes but enhanced expression of the HIF-1α targets. Knockdown of PPARγ in mature white adipocytes prevented the usual robust induction of HIF-1α targets in response to hypoxia. Similarly, knockdown of PPARγ coactivator (PGC) 1ß in PGC-1α-deficient brown adipocytes eliminated their response to hypoxia. These data demonstrate that the response of white adipocytes requires HIF-1α but also depends on PPARγ in white cells and the PPARγ cofactors PGC-1α and PGC-1ß in brown cells.

Brown adipose tissue: a promising target to combat obesity.

Obesity has now reached pandemic proportions leading to a collection of morbidities referred to as metabolic syndrome including insulin resistance, type 2 diabetes and cardiovascular disease. The expansion of adipose tissue is a direct cause of these comorbidities due to excessive accumulation of triglycerides within adipocytes, causing disruption of normal adipose function. There are two major types of adipose tissue, white and brown. The former stores energy as triglycerides within large droplets, whereas the latter catabolizes lipids to produce heat. A strategy to combat obesity-associated disorders, therefore, includes enhancement of brown adipose tissue activity by targeting the recently identified regulators of brown adipocyte development and function, including its master regulator, PRDM16.

C/EBPalpha and the corepressors CtBP1 and CtBP2 regulate repression of select visceral white adipose genes during induction of the brown phenotype in white adipocytes by peroxisome proliferator-activated receptor gamma agonists.

White adipose tissue (WAT) stores energy in the form of triglycerides, whereas brown tissue (BAT) expends energy, primarily by oxidizing lipids. WAT also secretes many cytokines and acute-phase proteins that contribute to insulin resistance in obese subjects. In this study, we have investigated the mechanisms by which activation of peroxisome proliferator-activated receptor gamma (PPARgamma) with synthetic agonists induces a brown phenotype in white adipocytes in vivo and in vitro. We demonstrate that this phenotypic conversion is characterized by repression of a set of white fat genes ("visceral white"), including the resistin, angiotensinogen, and chemerin genes, in addition to induction of brown-specific genes, such as Ucp-1. Importantly, the level of expression of the "visceral white" genes is high in mesenteric and gonadal WAT depots but low in the subcutaneous WAT depot and in BAT. Mutation of critical amino acids within helix 7 of the ligand-binding domain of PPARgamma prevents inhibition of visceral white gene expression by the synthetic agonists and therefore shows a direct role for PPARgamma in the repression process. Inhibition of the white adipocyte genes also depends on the expression of C/EBPalpha and the corepressors, carboxy-terminal binding proteins 1 and 2 (CtBP1/2). The data further show that repression of resistin and angiotensinogen expression involves recruitment of CtBP1/2, directed by C/EBPalpha, to the minimal promoter of the corresponding genes in response to the PPARgamma ligand. Developing strategies to enhance the brown phenotype in white adipocytes while reducing secretion of stress-related cytokines from visceral WAT is a means to combat obesity-associated disorders.

Binding of proprotein convertase subtilisin/kexin type 9 to epidermal growth factor-like repeat A of low density lipoprotein receptor decreases receptor recycling and increases degradation.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) promotes degradation of hepatic low density lipoprotein receptors (LDLR), the major route of clearance of circulating cholesterol. Gain-of-function mutations in PCSK9 cause hypercholesterolemia and premature atherosclerosis, whereas loss-of-function mutations result in hypocholesterolemia and protection from heart disease. Recombinant human PCSK9 binds the LDLR on the surface of cultured hepatocytes and promotes degradation of the receptor after internalization. Here we localized the site of binding of PCSK9 within the extracellular domain of the LDLR and determined the fate of the receptor after PCSK9 binding. Recombinant human PCSK9 interacted in a sequence-specific manner with the first epidermal growth factor-like repeat (EGF-A) in the EGF homology domain of the human LDLR. Similar binding specificity was observed between PCSK9 and purified EGF-A. Binding to EGF-A was calcium-dependent and increased dramatically with reduction in pH from 7 to 5.2. The addition of PCSK9, but not heat-inactivated PCSK9, to the medium of cultured hepatocytes resulted in redistribution of the receptor from the plasma membrane to lysosomes. These data are consistent with a model in which PCSK9 binding to EGF-A interferes with an acid-dependent conformational change required for receptor recycling. As a consequence, the LDLR is rerouted from the endosome to the lysosome where it is degraded.