Screen-Based Patient Simulation: An Exemplar for Developing and Assessing Competency.

BACKGROUND: Nursing education is moving toward competency-based education and assessment. Nurse educators will need to adopt strategies to develop and measure competence. PURPOSE: The purpose of this study was to determine if screen-based virtual patient simulation is an effective strategy to assist learners in developing competencies and subcompetencies required in nursing practice. METHODS: Thirteen questions (6 assessment and clinical reasoning focused, 4 clinical judgment focused, 3 attitude and socialization to nursing focused), aligned with the competencies of the American Association of Colleges of Nursing Essentials, were developed for a pre-/posttest design to evaluate student competency development. RESULTS: Senior nursing students (n = 52) participated; 1-tailed paired t test identified 12 of 13 items as statistically significant. Posttest scores were greater than pretest scores. CONCLUSIONS: The change in mean scores from pre- to posttest suggests screen-based virtual patient simulation scenarios improve learners' competence in addressing the patient's physical and psychological comfort and decreased caregiver biases.

Impact of a Virtual Patient Simulation on Nursing Students' Attitudes of Transgender Care.

BACKGROUND: Transgender individuals experience considerable prejudice and bias, creating barriers to health care. PURPOSE: The purpose of this study was to determine the effect of a virtual patient simulation scenario of caring for a transgender adult on nursing students' attitudes and beliefs about transgender people. METHODS: A validated 29-item instrument developed to assess an individual's view of transgender identity was administered in a pre-/posttest nonequivalent-groups design to junior- and senior-level nursing students. RESULTS: Statistically significant differences were found between the control and treatment groups for the subscale human value. CONCLUSIONS: Findings support experiential learning in nursing as an effective tool in teaching cultural competence and sensitivity when caring for transgender patients. Attitudes and beliefs of senior nursing students and junior nursing students toward transgender individuals differed, with senior students being more receptive.

Fabrication and characterization of 3-dimensional electrospun poly(vinyl alcohol)/keratin/chitosan nanofibrous scaffold.

Layer-by-layer three-dimensional nanofibrous scaffolds (3DENS) were produced using the electrospinning technique. Interest in using biopolymers and application of electrospinning fabrication techniques to construct nanofibers for biomedical application has led to the development of scaffolds composed of PVA, keratin, and chitosan. To date, PVA/keratin blended nanofibers and PVA/chitosan blended nanofibers have been fabricated and studied for biomedical applications. Electrospun scaffolds comprised of keratin and chitosan have not yet been reported in published literature, thus a novel nanofibrous PVA/keratin/chitosan scaffold was fabricated by electrospinning. The resulting 3DENS were characterized using fourier transform infrared (FT-IR) spectroscopy, scanning electron microscopy (SEM), differential scanning colorimetry (DSC), and thermogravimetric analysis (TGA). Physiochemical properties of the polymer solutions such as viscosity (rheology) and conductivity were also investigated. The 3DENS possess a relatively uniform fibrous structure, suitable porosity, swelling properties, and degradation which are affected by the mass ratio of keratin, and chitosan to PVA. These results demonstrate that PVA/keratin/chitosan 3DENS have the potential for biomedical applications.

Prediction of applied pressure on model lower limb exerted by an air pneumatic device.

Air pneumatic compression is a concept used for management of venous disease, including oedema. A typical air pneumatic compression device (PCD) consists of an inflatable sleeve composed of either single or multiple pressure chambers that encircle a limb. The aim of this research was to develop a mathematical model to predict the pressure applied by an air pneumatic device to an irregular cross-sectional lower limb manikin. The radius of curvature at any cross-section of the lower limb (i.e. calf (gastrocnemius), tibial crest (anterior edge of the tibia bone)) is irregular, and differs amongst individuals and populations. The effectiveness of air pneumatic devices is difficult to predict with these irregular cross sections. A theoretical model was developed to calculate pressure applied by compression sleeves on a lower leg manikin and results compared against experimental pressure exerted on the manikin by a silicone-based PCD. This prediction was made at each of three positions. The theoretical model developed based on elliptical shaped forms predicted the pressure more accurately for the ankle to above ankle position, whereas the model based on circular shaped forms predicted the pressure more accurately for below the calf to below the knee position. Refinements to the theoretical model to predict the pressure applied by PCD are recommended.

Understanding Stress-Strain Behavioral Change in Fabrics for Compression Bandaging.

Bandages are common in many health-related treatments, including management of edema of the lower limb where they may remain in place for several days. The behavior of 2 bandage fabrics was investigated after exposure for up to 5 days to a multiaxial extension laboratory setup on a tensile tester in compression mode. The fabrics were extended 20% and remained under that machine setting. Stress-relaxation over time was determined by analyzing the rate of change over 24 hours and over 5 days. Most change, a rapid drop in force, occurred during the first 15 minutes; thereafter, for the next 12-hour period, a slower rate of decrease was observed. Both fabrics continued to relax gradually during the next 12 hours and continued to do so for up to 5 days. Little further change was evident during the last 12 hours or so. This phenomenon suggests that rewrapping may be appropriate (albeit not practical) after 12 hours of compression therapy to optimize the compression given to the lower leg. Relaxation behavior of these 2 fabrics can be explained using the generalized Maxwell-Wiechert model.

Textile-based compression therapy in managing chronic oedema: Complex interactions.

BACKGROUND: Compression is a common therapy for management of chronic disease, including oedema of the lower limb. Modern compression interventions exert pressure on the lower limb through use of one or more materials which exert pressure against the limb over time. Where these materials are textiles, they range from elastic to inelastic, and are produced using knitting, weaving, or other textile technologies which can be manipulated to control performance properties. Thus, understanding of both the materials/textiles and the human body is needed if the most appropriate compression device and treatment strategy is to be used. Neither is independent of the other. This review aims to enhance understanding of critical textile performance properties and how selection of textiles may affect treatment efficacy when managing chronic oedema of the lower limb. METHOD: Relevant papers for review were identified via PubMed Central® library, and Google Scholar using keywords associated with textile-based treatments of the oedematous lower limb and wider interdisciplinary factors. RESULTS: Assessment of the disorder, the severity of oedema, and location of fluid accumulation are required to inform treatment of chronic oedema. While the need to understand the patient is well established (e.g. age, sex, body mass index, skin thickness and colour, patient compliance with treatment), information about preferred compression systems and material structures, and inherent properties of these, is generally lacking. CONCLUSION: Greater detail about materials used (e.g. fabric structure, number and order of layers, fibre content) and patient diagnosis (e.g. underlying cause, severity, location of oedema; patient age and sex; evidence of compliance with treatment; pressure exerted; lower leg shape, size, and properties of the tissue) is needed to facilitate advances in efficacy of compression treatment. Reduced limb swelling with a textile-based treatment occurs simultaneously with changes to the textile itself. Textiles cannot be considered inert.

Encapsulation of Electrically Conductive Apparel Fabrics: Effects on Performance.

Electrically conductive fabrics are achieved by functionalizing with treatments such as graphene; however, these change conventional fabric properties and the treatments are typically not durable. Encapsulation may provide a solution for this, and the present work aims to address these challenges. Next-to-skin wool and cotton knit fabrics functionalized using graphene ink were encapsulated with three poly(dimethylsiloxane)-based products. Properties known to be critical in a next-to-skin application were investigated (fabric structure, moisture transfer, electrical conductivity, exposure to transient ambient conditions, wash, abrasion, and storage). Wool and cotton fabrics performed similarly. Electrical conductivity was conferred with the graphene treatment but decreased with encapsulation. Wetting and high humidity/low temperature resulted in an increase in electrical conductivity, while decreases in electrical conductivity were evident with wash, abrasion, and storage. Each encapsulant mitigated effects of exposures but these effects differed slightly. Moisture transfer changed with graphene and encapsulants. As key performance properties of the wool and cotton fabrics following treatment with graphene and an encapsulant differed from their initial state, use as a patch integrated as part of an upper body apparel item would be acceptable.

Application of Curriculum Mapping Concepts to Integrate Multidisciplinary Competencies in the Care of Older Adults in Graduate Nurse Practitioner Curricula.

The number of Americans ages 65 and older is projected to more than double over the next four decades and to equal nearly one-fourth of the entire population by 2060. Recognizing that the health care workforce in the United States is not sufficiently prepared to meet the care needs of this growing population, the National Academy of Medicine has recommended curricular enhancements for health professional educational programs. To meet this challenge, the University of South Florida College of Nursing applied curriculum mapping principles and concepts to examine and align Family Nurse Practitioner and Adult-Gerontology Primary Care Nurse Practitioner program curricula for congruence with Partnership for Health in Aging multidisciplinary geriatric competencies. Through this process, we developed a geriatric-specific curriculum map and threaded geriatric-specific content, learning experiences, and learning assessment strategies to promote attainment of all 23 competencies. Given the growing role that nurse practitioners are projected to play in the delivery of primary care for older adults in the future, it is imperative that colleges and schools of nursing provide students with learning experiences to support attainment of the knowledge and skills graduates will need to care for older adults in practice. The techniques and strategies described here represent our approach.

Medical Faculty Beliefs: Self-Rated Importance and Confidence in Teaching Geriatrics Primary Care.

OBJECTIVES: To evaluate and contrast 25 content areas essential to the primary care of older adults by medical faculty, thus identifying faculty beliefs and areas of possible improvement. DESIGN: Using measures from the Healthcare Effectiveness Data and Information Set, the Consumer Assessment of Healthcare Providers and Systems, and Healthy People 2020, nine practicing clinical faculty identified 25 content areas essential to the primary care of older adults. SETTING: A large academic health center in southeastern United States. PARTICIPANTS: Eighty-two university medical faculty. MEASUREMENTS: Faculty rated importance, knowledge, and confidence in teaching the 25 content areas on a scale from 1 (low) to 10 (high). Gap scores reflecting the difference in ratings for importance and confidence in teaching were calculated and assessed. The survey had high internal consistency within each of the three domains-Cronbach's α > .94. RESULTS: The most important content areas were being able to explain details about patient's condition and taking medication clearly, followed by taking age-appropriate history. The three largest gaps were: "evaluating sensory impairment," "identifying and counseling at-risk drivers," and "evaluating cognition." The three smallest gaps were: "explaining prescribed medications," "explaining health conditions in easy-to-understand language," and "taking an age-appropriate patient history and performing a physical assessment." CONCLUSION: Medical faculty were comfortable with topics reflecting primary care expertise but expressed less confidence with more specialized topics, such as sensory or cognitive impairment and driving. This may represent key areas for geriatrics training applicable to all those involved in education and training of future healthcare professionals. Integration of specialists (eg, neurologists, psychiatrists) may improve the geriatrics curricula. J Am Geriatr Soc 67:576-580, 2019.

Copy number signatures and mutational processes in ovarian carcinoma.

The genomic complexity of profound copy number aberrations has prevented effective molecular stratification of ovarian cancers. Here, to decode this complexity, we derived copy number signatures from shallow whole-genome sequencing of 117 high-grade serous ovarian cancer (HGSOC) cases, which were validated on 527 independent cases. We show that HGSOC comprises a continuum of genomes shaped by multiple mutational processes that result in known patterns of genomic aberration. Copy number signature exposures at diagnosis predict both overall survival and the probability of platinum-resistant relapse. Measurement of signature exposures provides a rational framework to choose combination treatments that target multiple mutational processes.

Layering garments during rest and exercise in the cold (8°C): wearer responses and comparability with selected fabric properties.

How garments contribute to performance of the clothing system during wear is of interest, as is understanding the value of using fabric properties to inform end-use characteristics. To investigate the influences of layering upper-body garments, four fabrics were used to construct two first-layer garments (wool and polyester) and two outer-layer garments (wool and membrane laminate). Over six sessions, 10 moderately trained males wore each first-layer garment as a single layer and in combination with each outer-layer garment while resting, running and walking in cold environmental conditions (8 ± 1°C, 81 ± 4% RH). Here, the type of garment arrangement worn (fabric type or number of layers) had little influence on heart rate, core body temperature and change in body mass. Weighted mean covered skin temperature was warmer and weighted mean next-to-skin vapour pressure was typically higher (following the onset of exercise) with two layers versus one. Differences among fabrics for individual properties were typically overstated compared to differences among corresponding garments for physiological and psychophysical variables under the conditions of this study. These findings inform the interpretation of particular fabric properties and highlight issues to be acknowledged during development/refinement of fabric test methods. PRACTITIONER SUMMARY: We examined the way in which selected fibre, fabric and garment (layering) characteristics contribute to performance of the clothing system during wear under cold conditions. Selected properties of the constituent fabrics were found to provide limited insight into how garments perform during wear under the conditions of this study.

Mice overexpressing BAFF develop a commensal flora-dependent, IgA-associated nephropathy.

B cell activation factor of the TNF family (BAFF) is a potent B cell survival factor. BAFF overexpressing transgenic mice (BAFF-Tg mice) exhibit features of autoimmune disease, including B cell hyperplasia and hypergammaglobulinemia, and develop fatal nephritis with age. However, basal serum IgA levels are also elevated, suggesting that the pathology in these mice may be more complex than initially appreciated. Consistent with this, we demonstrate here that BAFF-Tg mice have mesangial deposits of IgA along with high circulating levels of polymeric IgA that is aberrantly glycosylated. Renal disease in BAFF-Tg mice was associated with IgA, because serum IgA was highly elevated in nephritic mice and BAFF-Tg mice with genetic deletion of IgA exhibited less renal pathology. The presence of commensal flora was essential for the elevated serum IgA phenotype, and, unexpectedly, commensal bacteria-reactive IgA antibodies were found in the blood. These data illustrate how excess B cell survival signaling perturbs the normal balance with the microbiota, leading to a breach in the normal mucosal-peripheral compartmentalization. Such breaches may predispose the nonmucosal system to certain immune diseases. Indeed, we found that a subset of patients with IgA nephropathy had elevated serum levels of a proliferation inducing ligand (APRIL), a cytokine related to BAFF. These parallels between BAFF-Tg mice and human IgA nephropathy may provide a new framework to explore connections between mucosal environments and renal pathology.

Recent changes in a remote Arctic lake are unique within the past 200,000 years.

The Arctic is currently undergoing dramatic environmental transformations, but it remains largely unknown how these changes compare with long-term natural variability. Here we present a lake sediment sequence from the Canadian Arctic that records warm periods of the past 200,000 years, including the 20th century. This record provides a perspective on recent changes in the Arctic and predates by approximately 80,000 years the oldest stratigraphically intact ice core recovered from the Greenland Ice Sheet. The early Holocene and the warmest part of the Last Interglacial (Marine Isotope Stage or MIS 5e) were the only periods of the past 200,000 years with summer temperatures comparable to or exceeding today's at this site. Paleoecological and geochemical data indicate that the past three interglacial periods were characterized by similar trajectories in temperature, lake biology, and lakewater pH, all of which tracked orbitally-driven solar insolation. In recent decades, however, the study site has deviated from this recurring natural pattern and has entered an environmental regime that is unique within the past 200 millennia.

Extending residential care through telephone counseling: initial results from the Betty Ford Center Focused Continuing Care protocol.

There is increasing evidence that a chronic care model may be effective when treating substance use disorders. In 1996, the Betty Ford Center (BFC) began implementing a telephone-based continuing care intervention now called Focused Continuing Care (FCC) to assist and support patients in their transition from residential treatment to longer-term recovery in the "real world". This article reports on patient utilization and outcomes of FCC. FCC staff placed clinically directed telephone calls to patients (N=4094) throughout the first year after discharge. During each call, a short survey was administered to gauge patient recovery and guide the session. Patients completed an average of 5.5 (40%) of 14 scheduled calls, 58% completed 5 or more calls, and 85% were participating in FCC two months post-discharge or later. There was preliminary evidence that greater participation in FCC yielded more positive outcomes and that early post-discharge behaviors predict subsequent outcomes. FCC appears to be a feasible therapeutic option. Efforts to revise FCC to enhance its clinical and administrative value are described.

Targeting the lymphotoxin-beta receptor with agonist antibodies as a potential cancer therapy.

The lymphotoxin-beta receptor (LT beta R) is a tumor necrosis factor receptor family member critical for the development and maintenance of various lymphoid microenvironments. Herein, we show that agonistic anti-LT beta R monoclonal antibody (mAb) CBE11 inhibited tumor growth in xenograft models and potentiated tumor responses to chemotherapeutic agents. In a syngeneic colon carcinoma tumor model, treatment of the tumor-bearing mice with an agonistic antibody against murine LT beta R caused increased lymphocyte infiltration and necrosis of the tumor. A pattern of differential gene expression predictive of cellular and xenograft response to LT beta R activation was identified in a panel of colon carcinoma cell lines and when applied to a panel of clinical colorectal tumor samples indicated 35% likelihood a tumor response to CBE11. Consistent with this estimate, CBE11 decreased tumor size and/or improved long-term animal survival with two of six independent orthotopic xenografts prepared from surgical colorectal carcinoma samples. Targeting of LT beta R with agonistic mAbs offers a novel approach to the treatment of colorectal and potentially other types of cancers.

Are personal digital assistants an acceptable incentive for rural community-based preceptors?

BACKGROUND AND OBJECTIVES: This study's objective was to evaluate the acceptability, effect, and use of handheld computers (also known as personal digital assistants or PDAs) as a reward for undergraduate rural community-based family medicine preceptors. METHODS: All rural, undergraduate family physician teachers who accepted an undergraduate student for a 1-month placement were offered the choice between a PDA that carried medical software or a monetary payment of an equivalent value. Approximately 1 year later, different surveys were sent to both groups of preceptors to collect data on their use of PDAs and computer technology. RESULTS: The most commonly reported reason for choosing a PDA in lieu of payment was that it provided a good opportunity to learn about PDA technology. Of those who accepted a PDA, however, 10% had not yet used it, and another 44% of recipients had difficulty in getting started using the PDA. There were more reported problems with the software than the hardware. When surveyed 1 year later, those who received a PDA and were still using it reported satisfaction with the medical software, ranging from 31% for Epocrates qid to 71% for the 5-Minute Medical Consult. More than 90% of those using their PDA 1 year later reported that they used it in clinical settings, with 68% feeling their PDA had some or a significant effect on patient care. CONCLUSIONS: Rural family physicians appeared to find PDAs an acceptable reward for teaching, based on the reported use and utility of their PDA, but many had technical difficulties. Recipients of the PDA reported using their PDA primarily in the clinical setting, with the feeling that the PDA had a positive effect on their patient care. Many users had difficulty with technical aspects of PDA use. To support PDA recipients, technical assistance should be provided.

Variation in the ordered structure of complexes between CD154 and anti-CD154 monoclonal antibodies.

The cell surface co-stimulatory protein CD154 (CD40L) is a target for monoclonal antibody (mAb) inhibitors of T-cell mediated immune diseases. This protein, like most other members of the TNF ligand family, forms homotrimeric complexes on the cell surface and in solution, with a three-fold axis of symmetry. We find that several different anti-CD154 monoclonal antibodies form distinctive complexes with soluble CD154. These soluble complexes have been analyzed using size exclusion chromatography, static and dynamic light scattering, and electron microscopy and shown to consist of caged structures of various geometries. The cell surface complexes have been analyzed by confocal microscopy and, depending on the mAb, remain as small, separate complexes or form large aggregates. The formation of these complexes in solution is likely to have an impact on measures of affinity, while the cell surface complexes could affect binding potency and provoke other biological effects.

Pretibial injury in patients aged 50 years and over.

AIMS: To establish the rate of, and identify circumstances surrounding, pretibial injury in patients aged 50 years and over. METHODS: The rate of pretibial injury was estimated from national hospital discharge data from the New Zealand Health Information Service (NZHIS) National Minimum Dataset (1986-1999), and estimates of New Zealand s resident population. Cases accepted by the Accident Rehabilitation and Compensation Insurance Corporation (ACC) (1999) were used to estimate a difference in the number of accepted cases (ie, those that were and were not treated in hospital), and the number of cases resulting in hospital admission. Events surrounding pretibial injuries were identified by surveying 75 patients treated at the Wellington Regional Plastic, Maxillofacial and Burns Unit at Hutt Hospital (January 1999 - November 2000). RESULTS: Estimates of pretibial injury in New Zealand were: annual incidence between 420 and 30 500; standardised rate 0.4-0.7 per 1000 population per year (females 0.6-1.0, males 0.07-0.3); crude rate 33 per 1000 population. About 60% of patients remained hospitalised for 2-14 days. Most of the injured were females (85-90% of NZHIS, 74% of ACC), were aged 70-89 years (68% females/males of NZHIS), and of New Zealand European/Pakeha ethnic origin (90%). Over half of the injury events occurred in the home (eg, caused by household items and furniture). CONCLUSIONS: Pretibial injury is a potential problem for older women in New Zealand. As the result of an ageing population, the annual number of cases is expected to increase.