The Process of Professional Ethics Development in Midwifery Students: A Grounded Theory Study.

Background: Midwives are faced with important ethical issues in their professional lives; therefore, becoming a midwife is not only the acquisition of knowledge and skills but also includes acquiring moral values that cause fundamental changes in their attitudes toward their professional responsibilities. The aim of this study was to explore the process of professional ethics development in midwifery students. Materials and Methods: This grounded theory study was conducted from 2020 to 2022 at Mashhad University of Medical Sciences, Mashhad, Iran. The participants included 17 midwifery students and 14 key informants. They were selected through purposeful and theoretical sampling. Data were collected using semi-structured in-depth interviews, field notes, and theoretical notes until theoretical saturation was achieved. Data collection and data analysis were performed simultaneously. Data were analyzed based on the grounded theory presented by Corbin and Strauss (2014) using MAXQDA Analytics Pro 2020. Results: The core category was "interactive-cognitive learning in a two-way reasoning path" which addressed the participants' main issue of moral numbness. Moral distress, interactive-cognitive learning, moral reasoning, and moral hopelessness were the midwifery students' strategies that led to a spectrum of moral internalization to moral burnout. The improper context of moral development was the context theme of this study. Conclusions: The theory of "interactive-cognitive learning in the two-way path of reasoning" creates a deep understanding of the process of formation of professional ethics in midwifery students and it can be used in the effective training of students with the aim of promoting professional ethics in midwifery.

Information Architecture for Data Disclosure.

Preserving confidentiality of individuals in data disclosure is a prime concern for public and private organizations. The main challenge in the data disclosure problem is to release data such that misuse by intruders is avoided while providing useful information to legitimate users for analysis. We propose an information theoretic architecture for the data disclosure problem. The proposed framework consists of developing a maximum entropy (ME) model based on statistical information of the actual data, testing the adequacy of the ME model, producing disclosure data from the ME model and quantifying the discrepancy between the actual and the disclosure data. The architecture can be used both for univariate and multivariate data disclosure. We illustrate the implementation of our approach using financial data.

Development and efficacy testing of a portable negative pressure enclosure for airborne infection containment.

OBJECTIVES: To overcome the shortage of personal protective equipment and airborne infection isolation rooms (AIIRs) in the COVID-19 pandemic, a collaborative team of research engineers and clinical physicians worked to build a novel negative pressure environment in the hopes of improving healthcare worker and patient safety. The team then sought to test the device's efficacy in generating and maintaining negative pressure. The goal proved prescient as the US Food and Drug Administration (FDA) later recommended that all barrier devices use negative pressure. METHODS: Initially, engineers observed simulations of various aerosol- and droplet-generating procedures using hospital beds and stretchers to determine the optimal working dimensions of the containment device. Several prototypes were made based on these dimensions which were combined with filters and various flow-generating devices. Then, the airflow generated and the pressure differential within the device during simulated patient care were measured, specifically assessing its ability to create a negative pressure environment consistent with standards published by the Centers for Disease Control and Prevention (CDC). RESULTS: The portable fans were unable to generate any airflow and were dropped from further testing. The vacuums tested were all able to generate a negative pressure environment with the magnitude of pressure differential increasing with the vacuum horsepower. Only the 3.5-horsepower Shop-Vac, however, generated a -3.0 pascal (Pa) pressure gradient, exceeding the CDC-recommended minimum of -2.5 Pa for AIIRs. CONCLUSION: A collaborative team of physicians and engineers demonstrated the efficacy of a prototype portable negative pressure environment, surpassing the negative pressure differential recommended by the CDC.

Elaboration Models with Symmetric Information Divergence.

Various statistical methodologies embed a probability distribution in a more flexible family of distributions. The latter is called elaboration model, which is constructed by choice or a formal procedure and evaluated by asymmetric measures such as the likelihood ratio and Kullback-Leibler information. The use of asymmetric measures can be problematic for this purpose. This paper introduces two formal procedures, referred to as link functions, that embed any baseline distribution with a continuous density on the real line into model elaborations. Conditions are given for the link functions to render symmetric Kullback-Leibler divergence, Rényi divergence, and phi-divergence family. The first link function elaborates quantiles of the baseline probability distribution. This approach produces continuous counterparts of the binary probability models. Examples include the Cauchy, probit, logit, Laplace, and Student-t links. The second link function elaborates the baseline survival function. Examples include the proportional odds and change point links. The logistic distribution is characterized as the one that satisfies the conditions for both links. An application demonstrates advantages of symmetric divergence measures for assessing the efficacy of covariates.

Design and in-vitro testing of a portable patient isolation chamber for bedside aerosol containment and filtration.

The emergence of the SARS-CoV-2 pandemic has imposed a multitude of complications on healthcare facilities. Healthcare professionals had to develop creative solutions to deal with resource shortages and isolation spaces when caring for COVID positive patients. Among many other solutions, facilities have utilized engineering strategies to mitigate the spread of viral contamination within the hospital environment. One of the standard solutions has been the use of whole room negative pressurization (WRNP) to turn a general patient room into an infection isolation space. However, this has not always been easy due to many limitations, such as direct access to the outdoors and the availability of WRNP units. In operating rooms where a patient is likely to go through aerosol-generating procedures, other solutions must be considered because most operating rooms use positive pressure ventilation to maintain sterility. The research team has designed, built, and tested a Covering for Operations during Viral Emergency Response (COVER), a low-cost, portable isolation chamber that fits over a patient's torso on a hospital bed to contain and remove the pathogenic agents at the source (i.e., patient's mouth and nose). This study tests the performance of the COVER system under various design and performance scenarios using particle tracing techniques and compares its efficiency with WRNP units. The results show that COVER can dramatically reduce the concentration of particles within the room, while WRNP is only effective in preventing the room-induced particles from migrating to adjacent spaces.

Maximum entropy distributions with quantile information.

Quantiles are available in various problems for developing probability distributions. In some problems quantiles are elicited from experts and used for fitting parametric models, which induce non-elicited information. In some other problems comparisons are made with a quantile of an assumed model which is noncommittal to the quantile information. The maximum entropy (ME) principle provides models that avoid these issues. However, the information theory literature has been mainly concerned about models based on moment information. This paper explores the ME models that are the minimum elaborations of the uniform and moment-based ME models by quantiles. This property provides diagnostics for the utility of elaboration in terms of the information value of each type of information over the other. The ME model with quantiles and moments is represented as the mixture of truncated distributions on consecutive intervals whose shapes and existence are determined by the moments. Elaborations of several ME distributions by quantiles are presented. The ME model based only on quantiles elicited by the fixed interval method possesses a useful property for pooling information elicited from multiple experts. The elaboration of Laplace distribution is an extension of the information theory connection with minimum risk under symmetric loss functions to the asymmetric linear loss. This extension produces a new Asymmetric Laplace distribution. Application examples compare ME priors with a parametric model fitted to elicited quantiles, illustrate measuring uncertainty and disagreement of economic forecasters based on elicited probabilities, and adjust ME models for a fundamental quantile in an inventory management problem.

Three-dimensional analysis of the effect of human movement on indoor airflow patterns.

Human activity is known to leave significant effects on indoor airflow patterns. These patterns are carefully designed for many facilities such as cleanrooms, pharmaceutical settings, and healthcare environments, where human-induced wakes contribute to the transport of contaminants. Therefore, the knowledge about these wakes as it relates to indoor air quality is critical. As a result, a series of experiments were conducted in a controlled chamber to study the three-dimensional effects of true human walking on airflow. Experiments were designed to capture the effect of human walking under three different flow conditions, and for two different walking schemes. The results show that the effect of walking on the airflow is not negligible and can sustain up to 10 seconds after the moving body has passed. Walking on a straight line creates significant change in the velocity normal to the walking path and vertical to the plane of walking movement. These changes were detectable till 1.0 m away from the walking track. Also, the similarity between airflow patterns of walking once and twice illustrated a promising opportunity of predicting the flow patterns of random walk from a set of base cases.

COVID-19 Outbreak and Hospital Air Quality: A Systematic Review of Evidence on Air Filtration and Recirculation.

The outbreak of SARS-CoV-2 has made us all think critically about hospital indoor air quality and the approaches to remove, dilute, and disinfect pathogenic organisms from the hospital environment. While specific aspects of the coronavirus infectivity, spread, and routes of transmission are still under rigorous investigation, it seems that a recollection of knowledge from the literature can provide useful lessons to cope with this new situation. As a result, a systematic literature review was conducted on the safety of air filtration and air recirculation in healthcare premises. This review targeted a wide range of evidence from codes and regulations, to peer-reviewed publications, and best practice standards. The literature search resulted in 394 publications, of which 109 documents were included in the final review. Overall, even though solid evidence to support current practice is very scarce, proper filtration remains one important approach to maintain the cleanliness of indoor air in hospitals. Given the rather large physical footprint of the filtration system, a range of short-term and long-term solutions from the literature are collected. Nonetheless, there is a need for a rigorous and feasible line of research in the area of air filtration and recirculation in healthcare facilities. Such efforts can enhance the performance of healthcare facilities under normal conditions or during a pandemic. Past innovations can be adopted for the new outbreak at low-to-minimal cost.

Performance analysis of portable HEPA filters and temporary plastic anterooms on the spread of surrogate coronavirus.

The outbreak of COVID-19, and its current resurgence in the United States has resulted in a shortage of isolation rooms within many U.S. hospitals admitting COVID-19-positive cases. As a result, hospital systems, especially those at an epicenter of this outbreak, have initiated task forces to identify and implement various approaches to increase their isolation capacities. This paper describes an innovative temporary anteroom in addition to a portable air purifier unit to turn a general patient room into an isolation space. Using an aerosolization system with a surrogate oil-based substance, we evaluated the effectiveness of the temporary plastic anteroom and the portable air purifier unit. Moreover, the optimal location of the portable unit, as well as the effect of negative pressurization and door opening on the containment of surrogate aerosols were assessed. Results suggested that the temporary anteroom alone could prevent the migration of nearly 98% of the surrogate aerosols into the adjacent corridor. Also, it was shown that the best location of a single portable air purifier unit is inside the isolation room and near the patient's bed. The outcome of this paper can be widely used by hospital facilities managers when attempting to retrofit a general patient room into an airborne infection isolation room.

Now you see, now you don't - A radiopaque neck mass?

Chest X-ray is valuable in the primary care setting in helping clinicians to confirm the underlying findings of the respiratory and cardiovascular systems. This view also includes the lower cervical vertebrae region which is helpful in elaborating the findings surrounding the neck. However, a single view of the film may sometimes cause confusion regarding the exact origin of the abnormal signs of the X-ray images. Thus, clinical correlation and application of 'rule of two' in X-ray imaging is definitely useful to clarify the findings and avoiding any misdiagnosis, medical errors and non-justifiable further investigations. Here we report a case of an 18-year-old female student with abnormal radiopaque neck mass seen from her chest the X-ray image. She was clinically well without any significant clinical findings. Surprisingly, the findings totally resolved after repeat the Xray at two different occasions within the same week. This strange abnormal finding was later confirmed to be her hair tier. She was saved from unnecessary investigations for tuberculosis and thyroid disorder by repeating the X-ray (rule of two occasions). Now you see, now you don't of X-ray findings is indeed illogical and technical error needs to be rule out.

Renovation in hospitals: Training construction crews to work in health care facilities.

BACKGROUND: Health care facilities require frequent renovations to maintain or enhance their service, and to meet the dynamic demands of their patients. Construction activities in active health care facilities are a significant contributor to various challenges that range from infection to death. It is therefore essential to minimize the adverse impacts of construction activities on health care units as well as their adjacent sites. METHODS: A questionnaire was developed to study current training modules to prepare construction crews to work in health care environments. The survey was disseminated among professionals of the top 15 health care contractors. A total of 129 individuals participated, and their responses were analyzed using descriptive and categorical statistics. RESULTS: This study investigates current training practices regarding (1) the level of training, (2) the frequency of training, and (3) the impact that the sensitivity of the project has on the training. To effectively prepare construction crews, special training must be provided to them. CONCLUSIONS: There are uncertainties about the sufficiency and impact of the existing training. Existing trainings are tailored for upper management positions, and the amount/frequency of training for construction crews are substantially low. Findings of this study contribute to characterizing the activities and conditions pertaining to training of construction crews.

Renovation in Hospitals: Pressurization Strategies by Healthcare Contractors in the United States.

OBJECTIVE: The objective of the study was to identify current practices utilized by contractors in healthcare renovation projects. BACKGROUND: Renovation in healthcare facilities comprises nearly half of all healthcare construction. Since a complete shutdown of the healthcare facility during renovation is typically not feasible, efforts must be taken to isolate ongoing functions of the hospital from activities in the construction zone. There are numerous documented cases of morbidity and mortality related to construction activities in the hospital. Hence, guidelines recommend negative pressurization of the construction zone to prevent the migration of dust and potential pathogenic agents into the functioning zone. METHOD: To accomplish the paper objective, a questionnaire was developed to address pressurization strategies, the use of backup systems and anterooms, and workforce training for healthcare projects. One hundred twenty-nine project managers and superintendents from top healthcare construction companies in the United States participated in the study. RESULTS: Results show that owners influence pressurization strategy, but contractors typically assume a primary role in establishing pressurization levels, monitoring conformance, and training construction personnel. However, without solid evidence of effectiveness, pressurization levels often vary from Center for Disease Control standards. CONCLUSION: Further research is needed to establish evidence-based practices and to develop training modules for construction crews to support these best practices. Promoting evidence-based training can improve patient safety and minimize adverse patient outcomes.

Concomitant dengue fever in Varicella zoster infection - A rare presentation.

Varicella zoster infection is one of the self-limiting viral infections during childhood and dengue fever is an endemic infection in Malaysia, which commonly occurs in the form of nonspecific febrile illness at the initial stage. It is rare for the two viral infections to occur simultaneously. A case of dengue fever without warning sign in a five-year old girl was reported, with early symptoms of fever and vesicular rashes. She was clinically diagnosed with varicella zoster infection during the first visit. Surprisingly, she remained febrile even on day six of illness despite no new vesicular lesions on her skin. Due to suspicion of another infection, follow-up investigation was done and revealed isolated thrombocytopenia. This finding was confirmed with positive NS1Ag. A case of rare dengue fever concomitant with varicella zoster infection was reported.

Detecting glaucomatous change in visual fields: Analysis with an optimization framework.

Detecting glaucomatous progression is an important aspect of glaucoma management. The assessment of longitudinal series of visual fields, measured using Standard Automated Perimetry (SAP), is considered the reference standard for this effort. We seek efficient techniques for determining progression from longitudinal visual fields by formulating the problem as an optimization framework, learned from a population of glaucoma data. The longitudinal data from each patient's eye were used in a convex optimization framework to find a vector that is representative of the progression direction of the sample population, as a whole. Post-hoc analysis of longitudinal visual fields across the derived vector led to optimal progression (change) detection. The proposed method was compared to recently described progression detection methods and to linear regression of instrument-defined global indices, and showed slightly higher sensitivities at the highest specificities than other methods (a clinically desirable result). The proposed approach is simpler, faster, and more efficient for detecting glaucomatous changes, compared to our previously proposed machine learning-based methods, although it provides somewhat less information. This approach has potential application in glaucoma clinics for patient monitoring and in research centers for classification of study participants.

Ventilation Rates and Airflow Pathways in Patient Rooms: A Case Study of Bioaerosol Containment and Removal.

Most studies on the transmission of infectious airborne disease have focused on patient room air changes per hour (ACH) and how ACH provides pathogen dilution and removal. The logical but mostly unproven premise is that greater air change rates reduce the concentration of infectious particles and thus, the probability of airborne disease transmission. Recently, a growing body of research suggests pathways between pathogenic source (patient) and control (exhaust) may be the dominant environmental factor. While increases in airborne disease transmission have been associated with ventilation rates below 2 ACH, comparatively less data are available to quantify the benefits of higher air change rates in clinical spaces. As a result, a series of tests were conducted in an actual hospital to observe the containment and removal of respirable aerosols (0.5-10 µm) with respect to ventilation rate and directional airflow in a general patient room, and, an airborne infectious isolation room. Higher ventilation rates were not found to be proportionately effective in reducing aerosol concentrations. Specifically, increasing mechanical ventilation from 2.5 to 5.5 ACH reduced aerosol concentrations only 30% on average. However, particle concentrations were more than 40% higher in pathways between the source and exhaust as was the suspension and migration of larger particles (3-10 µm) throughout the patient room(s). Computational analyses were used to validate the experimental results, and, to further quantify the effect of ventilation rate on exhaust and deposition removal in patient rooms as well as other particle transport phenomena.

Vessel Delineation in Retinal Images using Leung-Malik filters and Two Levels Hierarchical Learning.

Blood vessel segmentation is important for the analysis of ocular fundus images for diseases affecting vessel caliber, occlusion, leakage, inflammation, and proliferation. We introduce a novel supervised method to evaluate performance of Leung-Malik filters in delineating vessels. First, feature vectors are extracted for every pixel with respect to the response of Leung-Malik filters on green channel retinal images in different orientations and scales. A two level hierarchical learning framework is proposed to segment vessels in retinal images with confounding disease abnormalities. In the first level, three expert classifiers are trained to delineate 1) vessels, 2) background, and 3) retinal pathologies including abnormal pathologies such as lesions and anatomical structures such as optic disc. In the second level, a new classifier is trained to detect vessels and non-vessel pixels based on results of the expert classifiers. Qualitative evaluation shows the effectiveness of the proposed expert classifiers in modeling retinal pathologies. Quantitative results on two standard datasets STARE (AUC = 0.971, Acc=0.927) and DRIVE (AUC = 0.955, Acc =0.903) are comparable with other state-of-the-art vessel segmentation methods.

Directional Airflow and Ventilation in Hospitals: A Case Study of Secondary Airborne Infection.

Since the 1990s, improvements in ventilation techniques and isolation procedures have been widely credited with the decline in nosocomial transmission of tuberculosis and other airborne diseases. Little effort, however, has been made to study the risk of isolation patients acquiring secondary infections from contaminated air migrating into negatively pressurized isolation rooms from adjacent spaces. As a result, an actual hospital was used to observe the transport of aerosol from a nursing station and general patient room to a nearby airborne infectious isolation room (AIIR). Aerosols ≤3.0 µm (viruses and most airborne bacteria) were found to be capable of migrating 14.5m from a general patient room to an AIIR anteroom entrance in <14 minutes at concentrations 2-5 times greater than ambient (e.g. background). Concentrations of aerosols within the anteroom and isolation room, however, remained virtually unchanged from ambient levels, indicating the effectiveness of door position and (or) ventilation. In contrast, gravitational settling and surface deposition appeared to limit the migration of aerosols >3.0 µm to the entrance of the general patient room (4.5m).

De novo prediction of cis-regulatory elements and modules through integrative analysis of a large number of ChIP datasets.

BACKGROUND: In eukaryotes, transcriptional regulation is usually mediated by interactions of multiple transcription factors (TFs) with their respective specific cis-regulatory elements (CREs) in the so-called cis-regulatory modules (CRMs) in DNA. Although the knowledge of CREs and CRMs in a genome is crucial to elucidate gene regulatory networks and understand many important biological phenomena, little is known about the CREs and CRMs in most eukaryotic genomes due to the difficulty to characterize them by either computational or traditional experimental methods. However, the exponentially increasing number of TF binding location data produced by the recent wide adaptation of chromatin immunoprecipitation coupled with microarray hybridization (ChIP-chip) or high-throughput sequencing (ChIP-seq) technologies has provided an unprecedented opportunity to identify CRMs and CREs in genomes. Nonetheless, how to effectively mine these large volumes of ChIP data to identify CREs and CRMs at nucleotide resolution is a highly challenging task. RESULTS: We have developed a novel graph-theoretic based algorithm DePCRM for genome-wide de novo predictions of CREs and CRMs using a large number of ChIP datasets. DePCRM predicts CREs and CRMs by identifying overrepresented combinatorial CRE motif patterns in multiple ChIP datasets in an effective way. When applied to 168 ChIP datasets of 56 TFs from D. melanogaster, DePCRM identified 184 and 746 overrepresented CRE motifs and their combinatorial patterns, respectively, and predicted a total of 115,932 CRMs in the genome. The predictions recover 77.9% of known CRMs in the datasets and 89.3% of known CRMs containing at least one predicted CRE. We found that the putative CRMs as well as CREs as a whole in a CRM are more conserved than randomly selected sequences. CONCLUSION: Our results suggest that the CRMs predicted by DePCRM are highly likely to be functional. Our algorithm is the first of its kind for de novo genome-wide prediction of CREs and CRMs using larger number of transcription factor ChIP datasets. The algorithm and predictions will hopefully facilitate the elucidation of gene regulatory networks in eukaryotes. All the predicted CREs, CRMs, and their target genes are available at http://bioinfo.uncc.edu/mniu/pcrms/www/.

Disease specific biomarkers of abdominal aortic aneurysms detected by surface enhanced laser desorption ionization time of flight mass spectrometry.

INTRODUCTION: Biomarkers have the potential to improve the clinical management of patients with AAA. REPORT: A prospective, proteomics discovery study was undertaken to compare patients with AAA (n = 20) to matched screened controls (n = 19) for plasma protein expression. Surface-Enhanced-Laser-Desorption-Ionization Time of Flight Mass Spectrometry (SELDI ToF MS) coupled with Artificial Neural Networks (ANN) analysis identified six protein related diagnostic biomarker ions with a combined AUC of 0.89. DISCUSSION: This study discovered a signature plasma protein profile for patients with AAA and demonstrated that mass spectrometric based research for disease specific biomarker of AAA is feasible.