Examining Student Preparation for Advancing Care in a Diverse Society.

BACKGROUND: Although many nursing programs include health equity in their curriculum, research investigating the efficacy of such curricula often is lacking. METHOD: Using criterion sampling, school of nursing alumni who could speak about their graduate preparation and current experiences working with diverse patient populations were recruited for this study. Semistructured interviews were conducted with 22 alumni regarding their curricular, clinical, and co-curricular experiences as graduate students to better understand the strengths and gaps in their preparation as health professionals. RESULTS: Four major themes emerged from the analysis of interview transcripts (n = 22). These themes included: (1) diversity and representation; (2) implicit bias and microaggressions; (3) skills and knowledge areas; and (4) supplemental learning through co-curricular experiences. CONCLUSION: Implications for policy, curriculum innovation, and clinical practice can better prepare students to advance care for a diverse society. [J Nurs Educ. 2024;63(4):228-232.].

Justice, Equity, and Inclusion in a School of Nursing: A Quality Improvement Program.

BACKGROUND: Despite the increased racial and ethnic diversity in the general population of the United States, the nursing workforce remains mostly White. Schools of nursing (SON) have increased recruitment and enrollment; however, students who represent racial and ethnic minoritized groups experience microaggressions, injustice, and social exclusion. This quality improvement program sought to equip faculty with skills to create a just and inclusive SON. The program was guided by the Institute for Healthcare's Model for Improvement. METHOD: Five workshops were developed and implemented during two semesters. Workshops were led and moderated by a diversity, equity, and inclusion consultant. RESULTS: After the workshops, participants committed to create an inclusive environment, intervene when microaggressions occurred, implement curricular changes, and recognize themselves as members of a privileged group. Postworkshop discussions and reflections led to new initiatives in the SON. CONCLUSION: This faculty development program demonstrates programs to enhance justice, equity, and inclusion can be implemented successfully within SON. [J Nurs Educ. 2023;62(1):20-27.].

Orthogonal CRISPR-Cas tools for genome editing, inhibition, and CRISPR recording in zebrafish embryos.

The clustered regularly interspaced short palindromic repeats (CRISPR)-Cas universe continues to expand. The type II CRISPR-Cas system from Streptococcus pyogenes (SpyCas9) is the most widely used for genome editing due to its high efficiency in cells and organisms. However, concentrating on a single CRISPR-Cas system imposes limits on target selection and multiplexed genome engineering. We hypothesized that CRISPR-Cas systems originating from different bacterial species could operate simultaneously and independently due to their distinct single-guide RNAs (sgRNAs) or CRISPR-RNAs (crRNAs), and protospacer adjacent motifs (PAMs). Additionally, we hypothesized that CRISPR-Cas activity in zebrafish could be regulated through the expression of inhibitory anti-CRISPR (Acr) proteins. Here, we use a simple mutagenesis approach to demonstrate that CRISPR-Cas systems from S. pyogenes (SpyCas9), Streptococcus aureus (SauCas9), Lachnospiraceae bacterium (LbaCas12a, previously known as LbCpf1) are orthogonal systems capable of operating simultaneously in zebrafish. CRISPR systems from Acidaminococcus sp. (AspCas12a, previously known as AsCpf1) and Neisseria meningitidis (Nme2Cas9) were also active in embryos. We implemented multichannel CRISPR recording using three CRISPR systems and show that LbaCas12a may provide superior information density compared with previous methods. We also demonstrate that type II Acrs (anti-CRISPRs) are effective inhibitors of SpyCas9 in zebrafish. Our results indicate that at least five CRISPR-Cas systems and two anti-CRISPR proteins are functional in zebrafish embryos. These orthogonal CRISPR-Cas systems and Acr proteins will enable combinatorial and intersectional strategies for spatiotemporal control of genome editing and genetic recording in animals.

Disrupting Bias Without Trainings: The Effect of Equity Advocates on Faculty Search Committees.

Many institutions of higher education have implemented workshops for hiring committee members to familiarize them with the pernicious effects of implicit bias and how to counteract them. Unfortunately, the enthusiasm for implicit bias trainings is not matched by the evidence for their effectiveness. Recognizing the difficulty of removing entrenched biases and the potential for trainings to backfire, we introduced the role of equity advocate (EA) at one institution. EAs are trained volunteer faculty and staff members who serve on search committees outside their home departments to identify behaviors and judgments that might have a disparate racial effect in hiring. We conducted focus groups to document the perspectives of both EAs and non-EA search committee members who completed a cycle of academic hiring. Search committee members credited EAs with helping to mitigate bias by questioning their assumptions and introducing standardized tools for evaluating candidates. By contrast, EAs reported a more contentious relationship with the rest of the search committee and expressed less confidence that the process was free from bias. Both groups agreed that the EAs added valuable race-conscious equitable practices, and untrained committee members identified ways they could apply the lessons of bias reduction in other parts of their professional roles. Our study provides evidence for how to engage all faculty and staff members in sustainable, equity-minded efforts.

Transvenous Phrenic Nerve Stimulation for Central Sleep Apnea: Clinical and Billing Review.

Central sleep apnea (CSA) frequently coexists with heart failure and atrial fibrillation and contributes to cardiovascular disease progression and mortality. A transvenous phrenic nerve stimulation (TPNS) system has been approved for the first time by the Food and Drug Administration for the treatment of CSA. This system, remede System (Zoll Medical, Inc.), is implanted during a minimally invasive outpatient procedure and has shown a favorable safety and efficacy profile. Currently, patient access to this therapy remains limited by the small number of specialized centers in the United States and the absence of a standard coverage process by insurers. Although a period of evaluation by insurers is expected for new therapies in their early stages, the impact on patients is particularly severe given the already limited treatment options for CSA. Implantation and management of this novel therapy require the establishment of a specialized multidisciplinary program as part of a sleep medicine practice and support from health care systems and hospitals. Several centers in the United States have been successful in building sustainable TPNS programs offering this novel therapy to their patients by navigating the current reimbursement environment. In this article, we review the background and efficacy data of TPNS and briefly address relevant aspects of the clinical activities involved in a TPNS program. The article presents the status of coverage and reimbursement for this novel therapy. We also discuss the current approach to obtaining reimbursement from third-party payors during this transitional period of evaluation by Medicare and other insurers.

Nonadherence to CPAP Associated With Increased 30-Day Hospital Readmissions.

STUDY OBJECTIVES: The primary objective of this study was to determine if nonadherence to continuous positive airway pressure (CPAP) is associated with increased 30-day all-cause, cardiovascular-cause, and pulmonary-cause hospital readmissions. METHODS: Retrospective cohort study at a Veterans Affairs hospital of patients with obstructive sleep apnea (OSA) who were hospitalized from January 1, 2007 to December 31, 2015. Odds ratio of 30-day readmission was calculated for all-cause, cardiovascular-cause, and pulmonary-cause readmissions. Logistic regression model was used to evaluate odds of nonadherent versus adherent group while adjusting for age, sex, body mass index, living situation, race, comorbidities, and medication adherence. RESULTS: Out of 2,077 records reviewed, 345 patients (183 adherent and 162 nonadherent) met our inclusion criteria. The adherent group had a total of 215 initial admissions, and the nonadherent group had a total of 268 index admissions. Thirty-day all-cause readmission rate was significantly higher in the nonadherent group, with an adjusted odds ratio (OR) of 3.52 (95% confidence interval [CI], 2.04-6.08, P < .001). Thirty-day cardiovascular-cause readmission rate was significantly higher in the nonadherent group, with an adjusted OR of 2.31 (95% CI, 1.11-4.78, P = .024). Difference in 30-day pulmonary-cause readmissions was not statistically significant, with an adjusted OR of 3.66 (95% CI, 0.41-32.76, P = .25). CONCLUSIONS: Nonadherence to CPAP is associated with increased 30-day all-cause and cardiovascular-cause readmission in patients with OSA. Ensuring CPAP adherence is crucial in addressing general and cardiovascular-related healthcare utilization and morbidity in patients with OSA. COMMENTARY: A commentary on this article appears in this issue on page 161.

Sleep disordered breathing in pregnant women: maternal and fetal risk, treatment considerations, and future perspectives.

INTRODUCTION: Numerous physiologic and anatomic changes during pregnancy exacerbate or unmask obstructive sleep apnea in women. Left untreated, upper airway flow limitation during pregnancy may lead to dire maternal and fetal health consequences. Areas covered: This review outlines the relationship between sleep disordered breathing (SDB) and gestational hypertension, preeclampsia, and gestational diabetes. It also discusses the implications of SDB on fetal and maternal health and concludes with a review of the emerging literature of treatment options for SDB in pregnancy and its benefit. Expert commentary: Providers should screen, recognize, and treat SDB in pregnant women given its implicated risk on maternal and fetal health. This is particularly true in preeclampsia, a leading cause of maternal and fetal morbidity and mortality where SDB has been shown to add risk and severity. It is important to note that repetitive upper airway flow limitations in pregnancy are associated with surges in nocturnal blood pressure and poor maternal and fetal outcomes, and may be just as detrimental as frank apneas/hypopneas. Future large, prospective, randomized controlled studies on the effects of CPAP are still needed. The epidemiology of SDB in pregnant women needs to be further studied, as well as highlighting the need for systematic, long-term follow ups on mother and infant health post-delivery.

Timing Matters: Circadian Rhythm in Sepsis, Obstructive Lung Disease, Obstructive Sleep Apnea, and Cancer.

Physiological and cellular functions operate in a 24-hour cyclical pattern orchestrated by an endogenous process known as the circadian rhythm. Circadian rhythms represent intrinsic oscillations of biological functions that allow for adaptation to cyclic environmental changes. Key clock genes that affect the persistence and periodicity of circadian rhythms include BMAL1/CLOCK, Period 1, Period 2, and Cryptochrome. Remarkable progress has been made in our understanding of circadian rhythms and their role in common medical conditions. A critical review of the literature supports the association between circadian misalignment and adverse health consequences in sepsis, obstructive lung disease, obstructive sleep apnea, and malignancy. Circadian misalignment plays an important role in these disease processes and can affect disease severity, treatment response, and survivorship. Normal inflammatory response to acute infections, airway resistance, upper airway collapsibility, and mitosis regulation follows a robust circadian pattern. Disruption of normal circadian rhythm at the molecular level affects severity of inflammation in sepsis, contributes to inflammatory responses in obstructive lung diseases, affects apnea length in obstructive sleep apnea, and increases risk for cancer. Chronotherapy is an underused practice of delivering therapy at optimal times to maximize efficacy and minimize toxicity. This approach has been shown to be advantageous in asthma and cancer management. In asthma, appropriate timing of medication administration improves treatment effectiveness. Properly timed chemotherapy may reduce treatment toxicities and maximize efficacy. Future research should focus on circadian rhythm disorders, role of circadian rhythm in other diseases, and modalities to restore and prevent circadian disruption.

Case of a lung mass due to melioidosis in Mexico.

BACKGROUND: Melioidosis, an infection caused by the gram-negative bacterium Burkholderia pseudomallei, is an important cause of pneumonia, skin infection, sepsis, and death in Southeast Asia and Australia, but is exceedingly rare in North America. Pulmonary melioidosis typically presents as acute bacterial pneumonia or cavitary lung lesions resembling tuberculosis. CASE REPORT: We report melioidosis in a 70-year-old active smoker from Mexico with no history of travel to disease-endemic areas. The patient presented with a left supraclavicular abscess and a non-cavitary, left lung mass encasing a pulmonary vein. Incision and drainage of the patient's subcutaneous abscess isolated B. pseudomallei, and fine-needle aspiration of enlarged mediastinal lymph nodes revealed the presence of intracellular gram-negative bacilli with no evidence of malignancy. Biochemical tests determined that the strain the patient acquired from Mexico is identical to only 1 other isolate from Thailand. CONCLUSIONS: This report highlights the blurring epidemiological borders of this organism, its rare presentation mimicking lung malignancy, and an aggressive antimicrobial treatment that resulted in resolution of the patient's symptoms.

Visualizing biofilm formation in endotracheal tubes using endoscopic three-dimensional optical coherence tomography.

Biofilm formation has been linked to ventilator-associated pneumonia, which is a prevalent infection in hospital intensive care units. Currently, there is no rapid diagnostic tool to assess the degree of biofilm formation or cellular biofilm composition. Optical coherence tomography (OCT) is a minimally invasive, nonionizing imaging modality that can be used to provide high-resolution cross-sectional images. Biofilm deposited in critical care patients' endotracheal tubes was analyzed in vitro. This study demonstrates that OCT could potentially be used as a diagnostic tool to analyze and assess the degree of biofilm formation and extent of airway obstruction caused by biofilm in endotracheal tubes.

Species-specific features of DARC, the primate receptor for Plasmodium vivax and Plasmodium knowlesi.

The DARC (Duffy antigen/receptor for chemokines) gene, also called Duffy or FY, encodes a membrane-bound chemokine receptor. Two malaria parasites, Plasmodium vivax and Plasmodium knowlesi, use DARC to trigger internalization into red blood cells. Although much has been reported on the evolution of DARC null alleles, little is known about the evolution of the coding portion of this gene or the role that protein sequence divergence in this receptor may play in disease susceptibility or zoonosis. Here, we show that the Plasmodium interaction domain of DARC is nearly invariant in the human population, suggesting that coding polymorphism there is unlikely to play a role in differential susceptibility to infection. However, an analysis of DARC orthologs from 35 simian primate species reveals high levels of sequence divergence in the Plasmodium interaction domain. Signatures of positive selection in this domain indicate that species-specific mutations in the protein sequence of DARC could serve as barriers to the transmission of Plasmodium between primate species.

Efferent projections of prokineticin 2 expressing neurons in the mouse suprachiasmatic nucleus.

The suprachiasmatic nucleus (SCN) in the hypothalamus is the predominant circadian clock in mammals. To function as a pacemaker, the intrinsic timing signal from the SCN must be transmitted to different brain regions. Prokineticin 2 (PK2) is one of the candidate output molecules from the SCN. In this study, we investigated the efferent projections of PK2-expressing neurons in the SCN through a transgenic reporter approach. Using a bacterial artificial chromosome (BAC) transgenic mouse line, in which the enhanced green fluorescence protein (EGFP) reporter gene expression was driven by the PK2 promoter, we were able to obtain an efferent projections map from the EGFP-expressing neurons in the SCN. Our data revealed that EGFP-expressing neurons in the SCN, hence representing some of the PK2-expressing neurons, projected to many known SCN target areas, including the ventral lateral septum, medial preoptic area, subparaventricular zone, paraventricular nucleus, dorsomedial hypothalamic nucleus, lateral hypothalamic area and paraventricular thalamic nucleus. The efferent projections of PK2-expressing neurons supported the role of PK2 as an output molecule of the SCN.