Trainee district nurses' understanding and perceptions of the palliative care key worker role: a qualitative study.

BACKGROUND: The district nurse is identified as a keyworker in community based palliative care. However, a dearth of research exists on trainees' views and understanding of adopting the role upon qualification. AIMS: The aim of this study was to explore the understanding and perceptions of district nurse trainees in relation to the palliative care key worker role. METHODS: Data was gathered via online semi-structured interviews (n=10) and the results were analysed using a thematic model. FINDINGS: The four evolving themes included: understanding of the palliative care key worker role scope and function; the level of preparation for the role; a juggling act and embedding the role in practice. CONCLUSION: The themes highlighted various drivers and barriers that reflect a degree of incongruence with policy and practice. Recommendations to standardise the palliative care key worker role, underpinned by formal preparation and clearly defined responsibilities may enhance future development and implementation of the role.

An Interview with Lisa McDonald, Metagenics Senior Director of Marketing and Medical Education.

No Abstract Available.

Philanthropic donor perspectives about providing harm reduction services for people living with HIV/AIDS in a hospital setting.

BACKGROUND: Hospital-based harm reduction services are needed to reduce drug-related harms, facilitate retention in care, and increase medical treatment adherence for people who use drugs. Philanthropic donor support plays a key role in delivering such innovative services which might fall outside current funding streams. However, little is known about how the principles, implementation, and practice of harm reduction services, which are often highly stigmatized, may impact donor behaviours. We explored this issue within Casey House, a speciality hospital in Toronto, Canada. METHODS: Our mixed methods study utilized an explanatory sequential design. A convenience sample of n = 106 philanthropic individual donors, recruited via email, completed an anonymous web-based survey, between July and October 2020, which assessed their knowledge of harm reduction services and the potential impact of implementing new hospital-based harm reduction services on donors' future support. Following this, we conducted semi-structured qualitative interviews with n = 12 of the donors who completed a survey and volunteered to be interviewed. Interviews examined donors' perspectives about harm reduction and their hopes/concerns for such programming at Casey House. Data were analysed using descriptive statistics and participatory-based thematic analysis. RESULTS: Survey data show a high level of support for hospital-based harm reduction services, with participants reporting that they "strongly agree/agree" with providing harm reduction equipment (85%), supervised consumption services (82%), and prescription opioid treatment (76%) at Casey House. A majority of participants (66%) claimed that implementing new harm reduction services at the hospital would not impact their future donation, while 6% said they would be less inclined to donate. Interview participants were supportive of harm reduction services at Casey House, recognizing the benefits of providing such services for hospital clients and the wider community. However, some spoke of the potential impact that implementing hospital-based harm reduction services may have on "other" donors who might be opposed. Although some believed harm reduction services should be fully funded by the government, most saw a role for donors in supporting such services. CONCLUSIONS: Our findings show support of hospital-based harm reduction services among philanthropic donors and provide insight into how donor support may be affected when such services are introduced.

Bone Metabolism in Charcot.

Bone metabolism in the healthy, young adult is identified as a relatively stable process. Normal bone turnover is a dynamic state, which is conferred through intracellular signaling and complex cellular pathways. It has been well described in the literature that Charcot neuro-osteoarthropathy is a disease state, which is marked by intense bone turnover leading to structural collapse and dissolution of skeletal features of the foot and ankle. Within the last two decades, extensive interest has been placed in characterizing the metabolic pathogenesis of Charcot bone metabolism. Despite this work, there remains an incomplete understanding of this devastating disorder. In this article, we review bone histology, physiologic bone metabolism, biomarkers of bone metabolism, pathologic bone metabolism in Charcot diabetics, and potential avenues for intervention.

Beaming the Charcot Foot.

The Charcot diabetic foot presents unique challenges to the podiatric surgeon in the quest to salvage the limb. This disorder is an intersection of prototypical metabolic diseases and neurodegenerative disorder. Furthermore, it can be considered a disease of bone and ligaments that is often complicated by peripheral vascular disease and serious deep infection. Presently, simplistic ablative surgical procedures and the brace-makers art, still have a valid place in treating this disorder. Newer methods of surgical reconstruction are rapidly evolving to address distorted and nonfunctional limb. This article seeks to evidence the principles and practice of beaming the Charcot midfoot. As will be presented, the beam is a load-sharing device, which can be surgically introduced in an intramedullary method to restore architecture and strength to the Charcot foot. Problems with beam failure and migration have resulted in unsatisfactory outcomes as will be discussed. New Charcot-specific beams are currently reaching the podiatric surgeon with hopes of improving durability. In this article, we aim to address the surgical art of the beam, the engineering principles of beaming, and the novel introduction of a truss/tie rod configuration of beaming.

Effects of gender harassment on science popularization behaviors.

In this pilot study, we used a mixed methods online survey to ask science popularizers how gender harassment influences the way they communicate science to the public. Popularizers reported that gender harassment caused the science popularization field to increasingly strive for gender inclusivity in the creation of content. However, harassment made female popularizers feel they must emphasize their legitimacy, quite conscious of their clothing choices, and wary of engaging the public through mediums or topics that provoke more severe harassment. Implications for science communication and public engagement are discussed.

Preoperative Anemia in Hindfoot and Ankle Arthrodesis.

This is a retrospective study (n = 39) evaluating the postoperative outcomes of patients with mild to moderate preoperative anemia who underwent a hindfoot and/or ankle arthrodesis. In the study, 32 patients did not have preoperative anemia, and 7 had preoperative anemia. Mortality, length of hospital stay, blood transfusions, deep-vein thrombosis, infection, time to union, malunion, delayed union, nonunion, and ulceration were of particular interest. Comparative analyses between patients with preoperative anemia and those without were performed utilizing the independent samples t-test or by the nonparametric Mann-Whitney U-test. The Fisher exact test was used to analyze categorical data. The Shapiro-Wilk test was utilized to check normality. Statistical significance was defined at a 2-sided level of P <.05. Delayed union, nonunion, and malunion were all significantly increased in patients with preoperative anemia (P = .032, P = .004, and P = .028, respectively). Accordingly, the median total number of noninfectious complications (delayed union + nonunion + malunion) in patients with preoperative anemia (0.86 ± 0.38) was significantly higher than in patients without preoperative anemia (0.063 ± 0.25; P < .001). Patients with preoperative anemia had a significantly longer length of hospital stay in days (4.14 ± 2.61). Total infection was also significantly associated with preoperative anemia (P = .001). This study clearly demonstrated that infectious complications, noninfectious complications, and length of hospital stay in hindfoot and/or ankle arthrodesis was significantly affected by preoperative anemia. Thus, consideration should be given to addressing preoperative anemia prior to hindfoot and/or ankle arthrodesis. LEVELS OF EVIDENCE: Level II Study.

Pain Management After Total Joint Arthroplasty.

Controlling pain after total joint arthroplasty (TJA) is critical to minimizing complications, decreasing costs, and expediting patients' return to function. We implemented a TJA multimodal pain management protocol at a Level III trauma center in a small, rural community in New York. We retrospectively reviewed 266 patient charts and collected patient demographics, pain management information, and discharge data. Our primary goals were to quantify the total number of narcotic medication doses used and length of hospital stay. The multimodal pain management protocol significantly reduced the number of narcotic doses used (P < .01). Hospital length of stay decreased slightly; although not statistically significant (P = .25), this may be clinically significant. Gender, age, and type of arthroplasty (ie, knee, hip) were not significant factors. A multimodal approach to pain management after TJA can reduce narcotic use and hospital length of stay, thereby also reducing the incidence of side effects from narcotics.

Winning the war on surgical site infection: evidence-based preoperative interventions for total joint arthroplasty.

Postoperative surgical site infections (SSIs) are the most common cause of expensive and debilitating revision surgeries. The Institute for Healthcare Improvement has introduced a three-intervention package, titled Project JOINTS, which attempts to control preoperative and perioperative factors contributing to postoperative SSI in patients undergoing total joint arthroplasty (TJA). The three interventions are preoperative screening for Staphylococcus aureus, decolonizing the skin and nares, and intraoperative administration of combined antimicrobial and alcohol agents to the skin. Canton-Potsdam Hospital was an early adopter of the Project JOINTS protocol, and this quality improvement project has demonstrated a reduced SSI rate throughout the two years of implementation. Before implementation, 596 TJAs were performed with an S aureus SSI rate of 1.8%. During Project JOINTS, 305 TJAs were conducted with a significantly (P = .050) lower S aureus SSI rate of 0.66%. Thus, Project JOINTS is effective at reducing the postoperative incidence of S aureus SSIs in patients undergoing TJA.

Undergraduate research involving human subjects should not be granted ethical approval unless it is likely to be of publishable quality.

Small-scale research projects involving human subjects have been identified as being effective in developing critical appraisal skills in undergraduate students. In deciding whether to grant ethical approval to such projects, university research ethics committees must weigh the benefits of the research against the risk of harm or discomfort to the participants. As the learning objectives associated with student research can be met without the need for human subjects, the benefit associated with training new healthcare professionals cannot, in itself, justify such risks. The outputs of research must be shared with the wider scientific community if it is to influence future practice. Our survey of 19 UK universities indicates that undergraduate dissertations associated with the disciplines of medicine, dentistry and pharmacy are not routinely retained in their library catalogues, thus closing a major avenue to the dissemination of their findings. If such research is unlikely to be published in a peer-reviewed journal, presented at a conference, or otherwise made available to other researchers, then the risks of harm, discomfort or inconvenience to participants are unlikely to be offset by societal benefits. Ethics committees should be satisfied that undergraduate research will be funnelled into further research that is likely to inform clinical practice before granting ethical approval.

The fox and the grapes: an Anglo-Irish perspective on conscientious objection to the supply of emergency hormonal contraception without prescription.

Emergency hormonal contraception (EHC) has been available from pharmacies in the UK without prescription for 11 years. In the Republic of Ireland this service was made available in 2011. In both jurisdictions the respective regulators have included 'conscience clauses', which allow pharmacists to opt out of providing EHC on religious or moral grounds providing certain criteria are met. In effect, conscientious objectors must refer patients to other providers who are willing to supply these medicines. Inclusion of such clauses leads to a cycle of cognitive dissonance on behalf of both parties. Objectors convince themselves of the existence of a moral difference between supply of EHC and referral to another supplier, while the regulators must feign satisfaction that a form of regulation lacking universality will not lead to adverse consequences in the long term. We contend that whichever of these two parties truly believes in that which they purport to must act to end this unsatisfactory status quo. Either the regulators must compel all pharmacists to dispense emergency contraception to all suitable patients who request it, or a pharmacist must refuse either to supply EHC or to refer the patient to an alternative supplier and challenge any subsequent sanctions imposed by their regulator.

Development of an evidence-based clinical guideline for age-appropriate screening, prevention, and management of bone abnormalities in children post-hematopoietic stem cell transplant.

Musculoskeletal complaints, pain, and weakness are common among children post-hematopoietic stem cell transplant (HSCT). Bone abnormalities include decreased bone mineral density and avascular necrosis, both affecting ambulation and quality of life for survivors. Several risk factors for both disorders among adults have been described along with suggested interventions. However, similar recommendations for screening and management of bone abnormalities among children and adolescents post-HSCT are not clearly defined. A review of the literature using PubMed, CINAHL, National Guideline Clearinghouse, and Cochrane Collection databases identified a paucity of reports specific to the management of bone abnormalities in children and adolescents post-HSCT. Although guidelines for evaluation of bone health in pediatric patients with cancer exist, none specifically address early screening and prevention. The purpose of this article is to provide a review of the literature on current evidence for age appropriate screening, prevention, and management of bone abnormalities in children post-HSCT and to present a clinical guideline for bone abnormalities in children post-HSCT used in a hospital-based outpatient center.

Clinical practice implications of immunizations after pediatric bone marrow transplant: a literature review.

The number of pediatric bone marrow transplants is increasing for malignant and nonmalignant diseases. The number of survivors is also increasing, and their long-term health and protection from infection is increasingly important. To prevent infections, it is standard practice to re-immunize pediatric patients after bone marrow transplant (BMT) using the Centers for Disease Control and Prevention immunization guidelines; however, surveys in the United States and other parts of the world indicate that many BMT patients do not receive all the recommended immunizations. A literature review was conducted to identify research based on evidence for immunization following BMT and to recognize barriers to the process. Also, the immunization clinical guidelines from 2000 and 2011 for patients following BMT were compared and an updated clinical protocol and immunization schedule was developed to reflect the current evidence, encourage a change in practice, and discourage fragmented care.

Clonal cytogenetic abnormalities after tyrosine kinase inhibitor therapy in Ph+ ALL resolution after decitabine therapy.

Mixed chimerism and presence of minimal residual disease after stem cell transplantation (SCT) usually predict leukemia recurrence. In Philadelphia chromosome positive (Ph+) leukemia tyrosine kinase inhibitors can restore remission. These agents can induce clonal cytogenetic abnormalities in the Philadelphia negative cell population (CCA/Ph-), which may rarely progress to acute myeloid leukemia. A child with Ph+ acute lymphoblastic leukemia showed mixed donor chimerism and persistent bcr-abl transcripts after a matched sibling SCT. There was no response to tyrosine kinase inhibitor (TKI) therapy, but she has remained hematologically normal for more than 5 years. CCA/Ph- was detected but resolved with hypomethylating therapy.

Growth patterns and gastrointestinal symptoms in pediatric patients after hematopoietic stem cell transplantation.

PURPOSE/OBJECTIVES: To identify growth patterns and gastrointestinal (GI) symptoms in pediatric patients during the first four months after hematopoietic stem cell transplantation (HSCT) and to assess whether an association exists between acute graft-versus-host disease (GVHD) and growth pattern changes or GI symptoms. DESIGN: A prospective, longitudinal cohort design. SETTING: A tertiary children's hospital in a metropolitan area in the southern United States. SAMPLE: A convenience sample of 35 pediatric patients receiving allogeneic HSCT. METHODS: Anthropometric measurements were obtained and GI symptoms were surveyed in pediatric patients before HSCT and two and four months after HSCT. MAIN RESEARCH VARIABLES: GI symptoms, anthropometric measurements, and presence or absence of acute GVHD. FINDINGS: All anthropometric measurements showed a significant change over time; height showed an increase, and weight, skinfold triceps, and mid-arm circumference showed a decrease over the fourmonth measurement period. Eight GI symptoms were prevalent over the four months, and the mean severity and distress scores fluctuated minimally during that time. No statistically significant differences were noted in any of the anthropometric measurements or GI symptoms between pediatric patients with and without GVHD. CONCLUSIONS: Pediatric patients in the study exhibited poor growth patterns during the four months after HSCT and experienced multiple GI symptoms before and after HSCT. IMPLICATIONS FOR NURSING: Nurses should be aware of the importance of evaluating growth and symptom experience in all pediatric patients during HSCT recovery and assist in defining treatment plans that will optimize patient health.

Nursing considerations for clofarabine in the treatment of acute lymphoblastic leukemia in children.

Each year, almost 3500 children are diagnosed with leukemia, representing approximately 30% of pediatric cancer cases. Acute lymphoblastic leukemia is the most common form of pediatric leukemia, accounting for approximately 80% of cases. A significant number of children fail to respond to existing chemotherapies or are unable to maintain remission. Their prognosis is poor, with little hope for long-term survival.

Clofarabine, a novel nucleoside analog, is active in pediatric patients with advanced leukemia.

Despite progress in leukemia therapy, most children who experience relapse have a dismal prognosis. New, effective approaches are needed. We conducted a phase 1 study of a novel nucleoside analog, clofarabine, in pediatric patients with refractory and relapsed leukemia. Clofarabine was infused intravenously over 1 hour each day for 5 days. Six dose levels, between 11.25 and 70 mg/m(2) per day for 5 days, were studied in 25 patients. A modified 3 + 3 phase 1 design was followed with 30% dose escalation until the dose-limiting toxicity (DLT) was defined. The maximum tolerated dose (MTD) was 52 mg/m(2) per day for 5 days. At the end of infusion at MTD, clofarabine triphosphate levels in leukemia blasts varied between 6 microM and 19 microM, which resulted in complete and sustained inhibition of DNA synthesis. The DLT was reversible hepatotoxicity and skin rash at 70 mg/m(2) per day for 5 days. Twenty-five patients were treated. Five patients achieved complete remission (CR), and 3 achieved partial remission (PR), for an overall response rate of 32%. Clofarabine is well tolerated and shows significant antileukemic activity in heavily pretreated children. Multicenter phase 2 trials in pediatric acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) are ongoing.

Genome sequence of the dissimilatory metal ion-reducing bacterium Shewanella oneidensis.

Shewanella oneidensis is an important model organism for bioremediation studies because of its diverse respiratory capabilities, conferred in part by multicomponent, branched electron transport systems. Here we report the sequencing of the S. oneidensis genome, which consists of a 4,969,803-base pair circular chromosome with 4,758 predicted protein-encoding open reading frames (CDS) and a 161,613-base pair plasmid with 173 CDSs. We identified the first Shewanella lambda-like phage, providing a potential tool for further genome engineering. Genome analysis revealed 39 c-type cytochromes, including 32 previously unidentified in S. oneidensis, and a novel periplasmic [Fe] hydrogenase, which are integral members of the electron transport system. This genome sequence represents a critical step in the elucidation of the pathways for reduction (and bioremediation) of pollutants such as uranium (U) and chromium (Cr), and offers a starting point for defining this organism's complex electron transport systems and metal ion-reducing capabilities.