The genomes of Hercules beetles reveal putative adaptive loci and distinct demographic histories in pristine North American forests.

Beetles, despite their remarkable biodiversity and a long history of research, remain lacking in reference genomes annotated with structural variations in loci of adaptive significance. We sequenced and assembled high-quality chromosome-level genomes of four Hercules beetles which exhibit divergence in male horn size and shape and body colouration. The four Hercules beetle genomes were assembled to 11 pseudo-chromosomes, where the three genomes assembled using Nanopore data (Dynastes grantii, D. hyllus and D. tityus) were mapped to the genome assembled using PacBio + Hi-C data (D. maya). We demonstrated a striking similarity in genome structure among the four species. This conservative genome structure may be attributed to our use of the D. maya assembly as the reference; however, it is worth noting that such a conservative genome structure is a recurring phenomenon among scarab beetles. We further identified homologues of nine and three candidate-gene families that may be associated with the evolution of horn structure and body colouration respectively. Structural variations in Scr and Ebony2 were detected and discussed for their putative impacts on generating morphological diversity in beetles. We also reconstructed the demographic histories of the four Hercules beetles using heterozygosity information from the diploid genomes. We found that the demographic histories of the beetles closely recapitulated historical changes in suitable forest habitats driven by climate shifts.

Analysis of a Needs Assessment Survey to Develop an Online Resource Repository Supporting Nurse Anesthesia Educators.

BACKGROUND: Without highly qualified nurse anesthesia educators and administrators, the health care system will be threatened by the inadequate supply of certified registered nurse anesthetists (CRNAs). PURPOSE: American Association of Nurse Anesthesiologists' Faculty Stabilization Task Force (FSTF) analyzed reasons for high faculty turnover and developed recommendations to support nurse anesthesia faculty and administrators. METHODS: A survey evaluated participants' current role, leadership development opportunities, mentorship experiences, and resource needs. RESULTS: Of 109 respondents, 87 (80%) were program administrators or assistant administrators with less than 5 years of experience in their role. Despite academic experience, 51% felt adequately prepared for their role. CONCLUSIONS: The FSTF provided 2 recommendations: to create a robust faculty development program for all faculty at all levels of CRNA education and a repository of information needed for program administrators and faculty to oversee and educate students in a high-quality CRNA program.

Long-read Sequencing Data Reveals Dynamic Evolution of Mitochondrial Genome Size and the Phylogenetic Utility of Mitochondrial DNA in Hercules Beetles (Dynastes; Scarabaeidae).

The evolutionary dynamics and phylogenetic utility of mitochondrial genomes (mitogenomes) have been of particular interest to systematists and evolutionary biologists. However, certain mitochondrial features, such as the molecular evolution of the control region in insects, remain poorly explored due to technological constraints. Using a combination of long- and short-read sequencing data, we assembled ten complete mitogenomes from ten Hercules beetles. We found large-sized mitogenomes (from 24 to 28 kb), which are among the largest in insects. The variation in genome size can be attributed to copy-number evolution of tandem repeats in the control region. Furthermore, one type of tandem repeat was found flanking the conserved sequence block in the control region. Importantly, such variation, which made up around 30% of the size of the mitogenome, may only become detectable should long-read sequencing technology be applied. We also found that, although different mitochondrial loci often inferred different phylogenetic histories, none of the mitochondrial loci statistically reject a concatenated mitochondrial phylogeny, supporting the hypothesis that all mitochondrial loci share a single genealogical history. We on the other hand reported statistical support for mito-nuclear phylogenetic discordance in 50% of mitochondrial loci. We argue that long-read DNA sequencing should become a standard application in the rapidly growing field of mitogenome sequencing. Furthermore, mitochondrial gene trees may differ even though they share a common genealogical history, and ND loci could be better candidates for phylogenetics than the commonly used COX1.

Methacholine challenges: comparison of different tidal breathing challenge methods.

Tidal-breathing methacholine challenges are now recommended by guidelines, to avoid the bronchoprotective effects of deep inhalation. This study compared different tidal breathing methacholine challenge methods; assessed the agreement between tidal dosimetric and continuous output challenges; and assessed challenge repeatability with different methods. 15 asthma patients performed dosimetric challenges and a continuous-output breath-actuated challenge, all ≥3 days apart. All subjects had a pre-bronchodilator forced expiratory volume in 1 s (FEV1) ≥65% predicted, and a cumulative dose causing a 20% reduction in FEV1 (PD20) <1.2 mg. Of the dosimetric challenges, one method increased methacholine concentration (standard dosimetric challenge), and one adjusted nebuliser output time to increase dose (adjusted dosimetric challenge). The adjusted dosimetric and continuous output challenges were performed twice on separate days to assess for repeatability. All challenges were matched for dose at each dose step. The mean PD20 ratio of the standard dosimetric challenge to the adjusted dosimetric challenge was 0.90 (95% CI 0.66-1.23, p=0.49) and intraclass correlation coefficient (ICC) was 0.82. Repeated adjusted dosimetric challenges had an ICC 0.62 for PD20. Repeated continuous output challenges had an ICC 0.74 for PD20. The adjusted dosimetric and continuous output challenges correlated (r=0.69, p=0.0043; ICC 0.65), but PD20 was higher for the adjusted dosimetric challenge (mean PD20 ratio 2.31, 95% CI 1.57-3.40; p=0.0004). Tidal dosimetric methacholine challenge using adjustment of nebuliser output produces results with good repeatability. The results of this adjusted dosimetric method differed from the continuous output method, underscoring that the results of different methacholine challenge methodologies may not be directly comparable.

Creating a Cognitive Aid for Use During Intraoperative Power Failures.

An intraoperative power failure (IOPF) is a complete or partial absence of the electrical power supply with or without the availability of a backup generator system during an operative or other invasive procedure. An IOPF can be stressful for the OR team and puts surgical patients at risk for adverse outcomes. To prepare providers for an IOPF, a CRNA piloted a project to create an evidence-based, facility-specific cognitive aid (CA) to guide decision making and enhance patient management and outcomes during an IOPF. The project team tested the battery-power capabilities of essential anesthesia equipment, including anesthesia gas machines, IV pumps, and vital sign monitors, and included the results in the CA. A needs assessment survey was sent to the anesthesia professionals at the facility to promote clinician buy-in and solicit feedback for creating the CA.

Basic Airway Management for the Professional Nurse.

The registered nurse (RN) on a medical-surgical nursing unit may be the first health care professional to encounter a patient with the signs of impending respiratory failure. Importantly, the RN must recognize the signs of respiratory compromise and possess the competence and confidence to intervene without delay. Signs of respiratory deterioration, physical assessment, and respiratory laboratory studies are reviewed. Modes of oxygen therapy, basic airway management techniques, including bag mask ventilation, and use of oropharyngeal and nasopharyngeal airways are discussed. The assembly of equipment and medications frequently used for intubation are also outlined.

Evolution of adult male horn developmental phenotypes and character displacement in Xylotrupes beetles (Scarabaeidae).

Character displacement that leads to divergent phenotypes between sympatric species has been hypothesized to facilitate coexistence and promote the accumulation of biodiversity. However, there are alternative evolutionary mechanisms that may also lead to the evolution of phenotypic divergence between sympatric species; one of the mechanisms is evolutionary contingency. We studied the evolution of the presence and absence of a major male horn phenotype, which may have ecological implications for promoting coexistence between sympatric beetles, across geographic populations from different Xylotrupes beetles. By using a previously published phylogeny with 80 Xylotrupes taxa, we estimated the transition rates between the two phenotypic states (i.e., presence vs. absence of a major male phenotype). Based on the estimated transition rates, we then simulated possible phenotypic outcomes between sympatric species. We found that sympatric species were equally likely to evolve the same versus distinct phenotypic states based on the estimated transition rates given the phylogeny. The empirically observed number of sympatric species showing different phenotypic states can be explained by evolutionary contingency alone. We discussed the importance of applying phylogenetic comparative methods when studying phenotypic evolution and more generally to investigate the effect of stochastic processes before making deterministic inferences.

Faculty development workshop on gender-associated incivility in nursing education.

BACKGROUND: Men comprise the minority of entry-level baccalaureate nursing students and are at increased risk of experiencing gender-associated incivility. PROBLEM: Uncivil peer-to-peer behavior can negatively affect students' mental and physical well-being, and learning experience. Nursing faculty must be able to identify and address gender-associated incivility among students. AIM: The purpose of this quality improvement program was to train nursing faculty to prevent, identify, and manage gender-associated incivility in the educational environment. METHODS: A day-long interactive workshop utilizing trigger films, small group discussions, and interactive theater was developed to train nursing faculty to implement proactive and reactive techniques to address uncivil behavior which will enhance the learning environment for all students. Utilizing Kirkpatrick's Model of Evaluation, participants were surveyed at the conclusion of the workshop and four months postworkshop to evaluate their learning and its implementation. RESULTS: Participants gained greater understanding of the impact of gender-associated incivility and felt both empowered and better prepared to manage gender-associated conflict. CONCLUSION: Similar approaches may be useful for schools of nursing that wish to empower their nursing faculty to support an equitable nursing education environment free of gender-associated incivility.

Improving Emergency Cricothyroidotomies: Simulation-Based Training for Critical Care Providers.

This article discusses skill proficiency of providers related to emergency cricothyroidotomies. Various techniques to improve procedural skills were studied. Accurate identification of the cricothyroid membrane via palpation remained consistently inadequate. High-fidelity simulation including the use of human cadavers may be the preferred method of skill training for crisis management. The authors emphasize that additional research is needed regarding a method for rapid cricothyroid membrane identification as well as needle cricothyroidotomy versus surgical airway on cadavers. More consistent training will enable emergency care providers to perform this rare but lifesaving skill.

Using a Retrospective Secondary Data Analysis to Identify Risk Factors for Pulmonary Complications in Trauma Patients in Pietermaritzburg, South Africa.

BACKGROUND: The trauma burden in South Africa is significant. The objective of this project was to investigate the incidence of posttrauma pulmonary complications (PPCs) and to identify patient, health risks, and hospital factors, which predispose trauma patients to develop PPCs hospital in Pietermaritzburg, South Africa. METHODS: The design was a retrospective secondary data analysis of patients who presented as a trauma admission via the health systems' Hybrid Electronic Medical Registry. The final data set included 6382 trauma admissions. RESULTS: The PPC rate was 9.4% for patients with a surgical intervention versus 1.9% for those without a surgical intervention. Of the total 289 PPCs reported, the most common included pneumonia or atelectasis (46.4%) and prolonged ventilation (36.0%). The risk of developing a PPC was statistically significantly (P < 0.0001) associated with surgical intervention and the number of surgeries. CONCLUSIONS: The trauma burden in South Africa requires complex medical and surgical interventions. The incidence of PPCs is significantly associated with surgical intervention. With the increasing demand to harness data and improve patient care, the Hybrid Electronic Medical Registry proves to be a driver for quality improvement.

Point-of-Care Ultrasound in Anesthesia Care: New AANA Practice Document Adopted by AANA Board of Directors.

The American Association of Nurse Anesthetists recently released a practice considerations document titled, "Point-of-Care Ultrasound in Anesthesia Care," that clinicians, administrators, and other stakeholders are encouraged to download and read in their entirety, available at aana.com/PracticeManual.

Increasing Medication Access by Promoting Appropriate Use of Multi-dose Vials.

Medication shortage is a problem that affects patients, providers, and institutions of all sizes and scope across the United States. The objective of this quality improvement project was to promote the appropriate use of multi-dose vials (MDVs) by anesthesia providers at an independent plastic surgery office. Multi-dose vials can be used to decrease waste and potentially cost, thus increasing access to necessary medications for the patients at this practice. A focus group was used to obtain an understanding of barriers to the use of MDVs at this practice. A focused E-learning module on safe use based on established guidelines was then created, and a simplified flow sheet was implemented and placed in medication preparation areas as a cognitive aid. The education and flow sheet focused on identification and preparation of the medication area, proper identification of MDVs versus single-use vials, hand hygiene, proper beyond-use labeling, septum cleaning, use of a new sterile syringe and needle, and administration time frames. Provider feedback included high levels of satisfaction with the E-learning module. Our comparison of the use of ketamine from MDVs during the pre- and postimplementation phases showed a 14% increase in the number of doses used per vial. This finding suggests that were similar practices implemented at a larger site with MDVs of medications other than ketamine, resources could be impacted to manage shortages and increase access to medications.

Maximizing Use of Social Media to Improve Member Engagement in a Professional Organization.

The North Carolina Association of Nurse Anesthetists recognized concerns surrounding decreased member engagement and communication. Member engagement and communication is the lifeblood of an organization and is directly related to the success of an organization's outcomes and goals. Revamping of social media is a cost-effective method to help increase membership engagement and communication. The purpose of this project was to identify Certified Registered Nurse Anesthestist membership preferences for social media-based communication and engagement through the measurement of activity levels based on Facebook posting content, feature, and time. Therefore, a literature review and retrospective analysis was conducted. Results revealed that posting content of public relations/advocacy, the feature of tagging, and the time of week was influential on audience engagement on the association's Facebook account. The aims of the project were met. Social media allows organizations to employ various features and techniques to increase member engagement and communication. To successfully use social media to engage and communicate with members, organizations will need to continuously analyze and adjust their social media posts.

Considerations for an aging nurse anesthetists workforce.

The Certified Registered Nurse Anesthetists (CRNA) workforce is aging. It is estimated that nearly half (49.7%) of the CRNA workforce is age 50 or greater, with those practicing in management positions and as educators having the oldest mean ages. Older CRNAs face workplace challenges that can lead to decreased productivity and overall job satisfaction. Common injuries to older practitioners result from repetitive motion, slips and falls, needle sticks, fatigue, and emotional or mental health related illness. Because of the high acuity environment in which CRNAs practice they are at an elevated risk for these injuries. Creating a healthy and supportive work environment has been shown to improve the retention of aging healthcare workers, and succession planning is essential in preparing for their retirement.

A historical look at men's involvement in nursing and leadership in GAPNA.

The role of men in nursing is not always evident. Men have been care takers in early societies, military health care, and the religious sector. The perception of men in nursing, however, took a shift from one of honor to one of deviance and failure from medical school. As the contributions of historical men in nursing, such as Walt Whitman, are brought to light, so are the contributions of select men within the Gerontological Advanced Practice Nurses Association (GAPNA). Dr. George Peraza-Smith provides an exclusive interview, shares his dedication and contributions to the care of the aging adult, and provides words of wisdom to those wanting to impact the care of geriatric nursing.

Use of Near-Infrared Spectroscopy to Measure Tissue Oxygen Saturation During Total Knee Arthroplasty With Use of a Tourniquet.

The primary purpose of this proof-of-concept quality improvement effort was to evaluate the practicality of using near-infrared spectroscopy (NIRS) to measure tissue oxygen saturation (Sto2) during total knee arthroplasty (TKA) with use of a tourniquet. NIRS sensors were applied to the biceps femoris (BF) and gastrocnemius (GS) muscles of both lower extremities of patients undergoing TKA procedures. For a convenience sample of 15 patients, measurement of Sto2 was attempted at baseline, following subarachnoid block administration, and after tourniquet inflation and deflation. Mean baseline Sto2 (SD) was 71% (6%) in the BF muscle and 66% (7%) in the GS muscle. Significant changes in Sto2 values were observed following subarachnoid block, tourniquet inflation, and tourniquet deflation. The Sto2 returned to or above baseline in the BF muscle but did not return to baseline in the GS muscle following tourniquet deflation. Changes in tissue oxygen saturation resulting from use of a tourniquet can be continuously monitored with the use of an NIRS device. Further evaluation of the use of NIRS should be undertaken to determine if it could be used to guide safe duration and pressure limits for tourniquet inflation.

The importance of the STOP- BANG questionnaire as a preoperative assessment tool for the elderly population.

Undiagnosed obstructive sleep apnea (OSA) may adversely impact surgical patients and can lead to increased morbidity and mortality during the perioperative period, especially among the geriatric patient population (Chung et al. 2008, 2012, 2014; McDonald et al., 2018; Zietlow et al., 2018; Singh et al., 2012). The setting of this quality improvement project was a preoperative anesthesia and geriatric evaluation clinic housed within a 957-bed tertiary academic affiliated hospital. The sample included 45 patients who met the criteria established for surgery and OSA screening preoperatively. Nine patients (20.0%) were assessed as low risk (Stop-bang [SB] score /= 3 indicative of high-risk for OSA. The retrospective utilization of a modified SB screening on charts that did not receive a clinical OSA evaluation (n = 52) detected 23 (44.2%) patients who were considered high-risk for OSA but were not identified prior to surgery. The SB questionnaire is underutilized, and patients' OSA is often unidentified prior to surgery.

Relationship of Patient Self-Administered COPD Assessment Test to Physician Standard Assessment of Chronic Obstructive Pulmonary Disease in a Family Medicine Residency Training Program.

Assessing the global impact of chronic obstructive pulmonary disease (COPD) on a patient's life can be difficult to perform in the clinical setting due to time constraints and workflow challenges. The primary objective of this study was to compare disease impact ratings between patient self-administered COPD Assessment Test (CAT) and physician standard office assessment. This prospective study was conducted at a family medicine residency clinic in northeast Tennessee. The study included two study groups: 1) adult patients seen at the clinic during the 3-month study period with an active diagnosis of COPD, and 2) their physicians. Physicians' assessment of the impact of COPD on their patients' daily lives was compared to patients' self-administered CAT assessments. Physician assessment of COPD impact and patient assessment of CAT categories significantly differed (χ2=11.0, P=0.012). There was very poor agreement between patient and physician ratings (κ=0.003), with 42.9% of physician ratings underestimating the impact, 28.6% overestimating the impact, and 28.6% correctly estimating the impact COPD had on their patients' lives. These findings support the use of validated assessment tools to help providers understand the symptom burden for patients with COPD.

Improving Emergency Airway Knowledge and Self-Efficacy Levels of Outpatient Gastroenterology Staff via Implementation of Online Education and In Situ Simulation.

Twenty percent of all ambulatory surgery cases utilizing monitored anesthesia care and sedation report at least one perioperative respiratory complication such as bronchospasm, hypoxia, laryngospasm, or aspiration (). However, the national Standards of Practice for both surgical technicians and ambulatory care nurses do not mandate emergency airway education beyond cardiopulmonary resuscitation and Basic Life Support training. A local outpatient gastroenterology clinic noticed the gap in education, and the anesthesia team decided to implement an evidence-based dual-factorial quality improvement project utilizing online education and in situ simulation. First, registered nurses and procedural technologists completed a test to assess their baseline knowledge and airway emergency performance self-efficacy levels. Then an online module was distributed that included information on the 3 most common anesthesia airway emergencies in the outpatient setting: laryngospasm, aspiration, and obstruction with resultant hypoxemia. Next, participants completed an in situ simulation of the 3 airway emergencies using low-fidelity mannequins. A post-education assessment was distributed after completion of the simulation training and again at 6 weeks and 3 months post-implementation. The data collected showed a statistically significant increase in both knowledge scores and levels of self-efficacy at 6 weeks and 3 months posteducation (p < .001).

A Quality Improvement Project to Increase Adherence to a Pain, Agitation, and Delirium Protocol in the Intensive Care Unit.

BACKGROUND: In recent years, the incidence of delirium has grown to epidemic proportions in the intensive care setting with up to 80% of mechanically ventilated patients being affected. This can lead to adverse patient outcomes such as increased lengths of hospital stay, increased mortality rates, and increased long-term cognitive impairment. OBJECTIVES: The objective of this project is to determine whether a quality improvement project can increase adherence to an existing pain, agitation, and delirium (PAD) protocol for enhanced patient outcomes. METHODS: Chart audits were conducted to determine baseline compliance, use of the PAD protocol was measured, and the type of medications administered to each mechanically ventilated patient was assessed. Using the Knowledge-to-Action framework, a multidisciplinary, multidimensional educational module was then developed and implemented that included an online tutorial, point-of-care reminders, written materials, and verbal coaching. A 3-month postimplementation chart audit was conducted to determine whether increased protocol competence was achieved. RESULTS: Protocol use unexpectedly decreased from 74% to 41% (P < .01);however, compliance with medication recommendations did increase despite the decrease in use. Intravenous opioid use increased from 12% to 40% (P ≤ .001), whereas sedative propofol infusions decreased from 82% to 35% (P ≤ .001). CONCLUSIONS: The implementation of a multidimensional, multidisciplinary project was successful in increasing compliance to the clinical practice guidelines for the management of PAD in adult intensive care unit patients, despite a decrease in protocol use. This unanticipated decrease in protocol use indicates the need for additional research in this area. Future recommendations also include a review of the existing PAD protocol to determine whether revisions could be made to better suit the needs of the staff while also improving patient outcomes in the arena of delirium experienced during critical care stays.