What's in This For You? What's in This For Me?: A Win-Win Perspective of Involving Study Advisory Committee Members in Palliative Care Research.

Study advisory committees (SACs) provide critical value to clinical trials by providing unique perspectives that pull from personal and professional experiences related to the trial's healthcare topic. The Emergency Medicine Palliative Care Access (EMPallA) study had the privilege of convening a 16-person SAC from the project's inception to completion. The study team wanted to understand the impact this project had on the SAC members. In this narrative, we use reflective dialogue to share SAC members' lived experiences and the impact the EMPallA study has had on members both personally and professionally. We detail the (1) benefits SAC members, specifically patients, and caregivers, have had through working on this project. (2) The importance of recruiting diverse SAC members with different lived experiences and leveraging their feedback in clinical research. (3) Value of community capacity building to ensure the common vision of the clinical trial is promoted.

Advancing patient-centered research practices in a pragmatic patient-level randomized clinical trial: A thematic analysis of stakeholder engagement in Emergency Medicine Palliative Care Access (EMPallA).

BACKGROUND: Involving patient and community stakeholders in clinical trials adds value by ensuring research prioritizes patient goals both in conduct of the study and application of the research. The use of stakeholder committees and their impact on the conduct of a multicenter clinical trial have been underreported clinically and academically. The aim of this study is to describe how Study Advisory Committee (SAC) recommendations were implemented throughout the Emergency Medicine Palliative Care Access (EMPallA) trial. EMPallA is a multi-center, pragmatic two-arm randomized controlled trial (RCT) comparing the effectiveness of nurse-led telephonic case management and specialty, outpatient palliative care of older adults with advanced illness. METHODS: A SAC consisting of 18 individuals, including patients with palliative care experience, members of healthcare organizations, and payers was convened for the EMPallA trial. The SAC engaged in community-based participatory research and assisted in all aspects from study design to dissemination. The SAC met with the research team quarterly and annually from project inception to dissemination. Using meeting notes and recordings we completed a qualitative thematic analysis using an iterative process to develop themes and subthemes to summarize SAC recommendations throughout the project's duration. RESULTS: The SAC convened 16 times between 2017 and 2020. Over the course of the project, the SAC provided 41 unique recommendations. Twenty-six of the 41 (63%) recommendations were adapted into formal Institutional Review Board (IRB) study modifications. Recommendations were coded into four major themes: Scientific, Pragmatic, Resource and Dissemination. A majority of the recommendations were related to either the Scientific (46%) or Pragmatic (29%) themes. Recommendations were not mutually exclusive across three study phases: Preparatory, execution and translational. A vast majority (94%) of the recommendations made were related to the execution phase. Major IRB study modifications were made based on their recommendations including data collection of novel dependent variables and expanding recruitment to Spanish-speaking patients. CONCLUSIONS: Our study provides an example of successful integration of a SAC in the conduct of a pragmatic, multi-center RCT. Future trials should engage with SACs in all study phases to ensure trials are relevant, inclusive, patient-focused, and attentive to gaps between health care and patient and family needs. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03325985, 10/30/2017.

Clinical research should involve patient and community stakeholder perspectives to make sure the study addresses questions important to the studied population. One way to do this is by creating a group of stakeholders who can advise on the conduct of a study. We assembled a Study Advisory Committee (SAC) for the Emergency Medicine Palliative Care Access (EMPallA) trial. The purpose of this clinical trial is to compare the effectiveness of nurse-led telephonic case management and specialty, outpatient palliative care of older adults with advanced illness. This paper describes how the SACs involvement translated into direct impacts on the EMPallA trial. The trial research team held regular meetings with the SAC throughout the trial process. Their involvement led to many significant changes in the trial, such as  expanding recruitment inclusion criteria (Spanish-speaking patients), and including survey instruments to measure lonelines and caregiver burden. The SAC also devised strategies to overcome patient and caregiver recruitment and retention challenges, including the creation of patient-friendly materials and training for research coordinators. This study provides a successful example of how actively engaging patient and community stakeholders, through committee engagement, can promote patient priorities in all phases of a trial while facilitating patient recruitment and retention.

Partial N-acetyl glutamate synthase deficiency presenting as postpartum hyperammonemia: Diagnosis and subsequent pregnancy management.

N-acetyl glutamate synthase (NAGS) deficiency (OMIM #: 237310) is a rare urea cycle disorder that usually presents early in life with hyperammonemia. NAGS catalyzes the synthesis of N-acetyl glutamate (NAG) which functions as an activator of the carbamoyl phosphate synthetase-1 mediated conversion of ammonia to carbamoyl phosphate. The absence of NAG results in a proximal urea cycle disorder which can result in severe neurologic sequelae secondary to hyperammonemia and even death. Unlike the other urea cycle disorders, a specific pharmacological treatment for NAGS deficiency exists in the form of carglumic acid, an analog of NAG. Here we present a 29-year-old previously healthy female who presented with hyperammonemia and obtundation just after the birth of her first child. Exome sequencing revealed two novel variants in the NAGS gene, and plasma metabolomics revealed extremely low levels of NAG. Carglumic acid treatment led to prompt resolution of her biochemical abnormalities and symptoms. She tolerated two subsequent pregnancies, 2 years and 6 years after her initial presentation, while taking carglumic acid, and breastfed her third child, all without complications in the mother or children. This case report emphasizes the importance of considering urea cycle disorders in previously-healthy adults presenting with neurological symptoms during periods of metabolic stress, including the postpartum period. It also highlights the efficacious and safe use of carglumic acid during pregnancy and while breastfeeding.

Novel pathogenic UQCRC2 variants in a female with normal neurodevelopment.

Electron transport chain (ETC) disorders are a group of rare, multisystem diseases caused by impaired oxidative phosphorylation and energy production. Deficiencies in complex III (CIII), also known as ubiquinol-cytochrome c reductase, are particularly rare in humans. Ubiquinol-cytochrome c reductase core protein 2 (UQCRC2) encodes a subunit of CIII that plays a crucial role in dimerization. Several pathogenic UQCRC2 variants have been identified in patients presenting with metabolic abnormalities that include lactic acidosis, hyperammonemia, hypoglycemia, and organic aciduria. Almost all previously reported UQCRC2-deficient patients exhibited neurodevelopmental involvement, including developmental delays and structural brain anomalies. Here, we describe a girl who presented at 3 yr of age with lactic acidosis, hyperammonemia, and hypoglycemia but has not shown any evidence of neurodevelopmental dysfunction by age 15. Whole-exome sequencing revealed compound heterozygosity for two novel variants in UQCRC2: c.1189G>A; p.Gly397Arg and c.437T>C; p.Phe146Ser. Here, we discuss the patient's clinical presentation and the likely pathogenicity of these two missense variants.

The role of relaxin in anterior cruciate ligament injuries: a systematic review.

OBJECTIVE: Anterior cruciate ligament (ACL) tears are exceedingly common among the athletic population and are seen with higher incidence in females. Observational studies have noted peak ACL tear rates in the luteal phase of the menstrual cycle, a time in which the hormone relaxin peaks in serum concentration. METHODS: A systematic review of the literature was performed. Inclusion criteria specified all prospective and retrospective studies which included the role of relaxin in the pathogenesis of ACL tears. RESULTS: Six studies met inclusion criteria yielding 189 subjects from clinical studies and 51 in vitro samples. Included studies found that ACL samples exhibit selective relaxin binding. When pre-treated with estrogen prior to relaxin exposure, female ACL tissue samples exhibit increased expression of collagen degrading receptors. CONCLUSION: Relaxin displays binding specificity to the female ACL and increased serum concentrations are correlated with increased ACL tear rates in female athletes. Further research is needed in this area. LEVEL OF EVIDENCE: V.

Safe and Effective Aspirations and Nerve Blocks for the On-Call Orthopaedic Surgeon.

The on-call orthopaedic surgeon is faced with a wide array of orthopaedic pathology for which intra-articular aspiration, injection, and/or nerve/hematoma block may be used. Efficient use of these diagnostic and therapeutic modalities affords better patient care and a more effective on-call period. Often, these interventions are the rate limiting factor in a reduction or diagnosis. In this review, we describe joint aspirations, saline load tests, hematoma blocks, and nerve blocks in detail to include their indications, techniques, related pharmacology, pearls, and pitfalls.

The Path Toward Fellow Designation in the Academy of Emergency Nursing: Understanding and Navigating the Process to Ensure Your Success.

The Academy of Emergency Nursing was established to honor emergency nurses who have made enduring and substantial contributions that have had significant impact and continue to advance the emergency nursing specialty. Nurses who have been recognized as having made enduring and substantial contributions to emergency nursing achieve fellow status in the Academy of Emergency Nursing and are conferred the credential, Fellow of the Academy of Emergency Nursing. Academy of Emergency Nursing Board Members want to dismantle any structural barriers, clarify any misunderstandings or mysteries, and support diverse candidates by providing clear and equitable resources about the path toward fellow designation and the application process. Therefore, the purpose of this article is to support interested persons in their path toward Academy of Emergency Nursing fellow designation and give explicit details of each section of the application to develop a shared understanding among potential applicants, sponsors, and Fellows of the Academy of Emergency Nursing.

Direct Determination of Fission-Barrier Heights Using Light-Ion Transfer in Inverse Kinematics.

We demonstrate a new technique for obtaining fission data for nuclei away from ß stability. These types of data are pertinent to the astrophysical r process, crucial to a complete understanding of the origin of the heavy elements, and for developing a predictive model of fission. These data are also important considerations for terrestrial applications related to power generation and safeguarding. Experimentally, such data are scarce due to the difficulties in producing the actinide targets of interest. The solenoidal-spectrometer technique, commonly used to study nucleon-transfer reactions in inverse kinematics, has been applied to the case of transfer-induced fission as a means to deduce the fission-barrier height, among other variables. The fission-barrier height of ^{239}U has been determined via the ^{238}U(d,pf) reaction in inverse kinematics, the results of which are consistent with existing neutron-induced fission data indicating the validity of the technique.

Quantification of institutional and professional impact of a professional advancement program for advanced practice registered nurses and physician assistants.

ABSTRACT: Professional advancement programs, also known as career or clinical ladders, have proliferated for advanced practice registered nurses (APRNs) and physician assistants (PAs) and recognize clinical and/or professional contributions within clinical agencies. Although the literature is rich in describing the benefits of these programs on job satisfaction and staff retention, there is a dearth of literature on the effect of these programs on clinical practice, institutions, and the respective professions. This article quantifies the impact on the institution and profession of APRNs and PAs who have been promoted through an institution's career ladder.

A mixed methods study of moral distress among frontline nurses during the COVID-19 pandemic.

OBJECTIVE: The study's purpose was to develop an understanding of factors affecting moral distress among nurses during the COVID-19 pandemic. METHOD: California-licensed, registered nurses who cared for COVID-19 patients for at least 3 months were recruited for an explanatory concurrent mixed methods study. Data are derived from the first of two surveys administered 3 months apart, including open-ended questions. RESULTS: Variables with significant bivariate correlations were included as simultaneous predictors in a linear regression model predicting moral distress. The overall model was significant, explaining a substantial portion of the variance in moral distress, but results showed only organizational support and institutional betrayal uniquely predicted moral distress. Three qualitative themes were identified: Ethical Violations in Care, Institutional Betrayal, and Traumatic Strain. The impacts of organizational support and institutional betrayal on nurses' moral distress are important findings in both datasets. CONCLUSIONS: Findings provide insights into how nurses' experiences affected their feelings about work. Participants indicated feeling disregarded by management and institutional structures, indicating potential means of slowing the rates at which nurses plan to leave bedside practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Do associated proximal fibula fractures help predict the severity of tibial plateau fractures?

PURPOSE: Proximal fibula fractures are often associated with tibial plateau fractures, but their relationship is poorly characterized. The purpose of this study was to better define the relationship between tibial plateau injury severity and presence of associated soft tissue injuries. METHODS: A retrospective review was performed on all operatively treated tibial plateau fractures at a Level 1 trauma center over a 5-year period. Patient demographics, injury radiographs, CT scans, operative reports and follow-up were reviewed. RESULTS: Queried tibial plateau fractures from 2014 to 2019 totaled 217 fractures in 215 patients. Fifty-two percent were classified as AO/OTA 41B and 48% were AO/OTA 41C. Thirty-nine percent had an associated proximal fibula fracture. The presence of a proximal fibula fracture had significant correlation with AO/OTA 41C fractures, as compared with AO/OTA 41B fractures (chi-square, p < 0.001). Of the patients with a lateral split depression type tibial plateau fracture, the presence of a proximal fibula fracture was associated with more articular comminution, measured by number of articular fragments (mean = 4.0 vs. 2.9 articular fragments, p = 0.004). There was also a higher rate of meniscal injury in patients with proximal fibula fractures (37% vs. 20%, p = 0.003). CONCLUSIONS: There was a significant relationship between the higher energy tibial plateau fracture type (AO/OTA 41C) and the presence of an associated proximal fibula fracture. The presence of a proximal fibula fracture with a tibial plateau fracture is an indicator of a higher energy injury and a higher likelihood of meniscal injury.

Current Practice and Practice Competencies of Clinical Nurse Specialists Working in US Emergency Care Settings: A Survey Study.

PURPOSE/AIMS: The aim of this study was to investigate the current practice of clinical nurse specialists working in US emergency care settings to (1) explicate the application of the Emergency Nurses Association core competencies and define the specialized clinical nurse specialist role in emergency care and (2) align current clinical nurse specialist practice in emergency settings with the National Association of Clinical Nurse Specialists core competencies and the identified substantive areas of clinical nurse specialist practice. DESIGN: This study used a quantitative exploratory descriptive approach using survey data. METHODS: A purposive convenience sample was recruited from the Emergency Nurses Association and the National Association of Clinical Nurse Specialists. Participants completed a 39-item survey based on a consensus process to develop competencies for emergency department (ED)-situated clinical nurse specialists. RESULTS: Respondents (n = 285) reported spending more than 50% of their work time in a primary clinical nurse specialist role. Significant differences in practice were found between geographic location, setting, educational preparation, title protection status, and type of institution. CONCLUSIONS: Our findings suggest that that the competencies ascribed to ED-situated clinical nurse specialists are valid in both frequency and importance. However, ED-situated clinical nurse specialists are not fully credentialed or practicing to the full extent of their education and licenses, because of professional, legislative, and environmental limitations.

An overview and policy implications of national nurse identifier systems: A call for unity and integration.

There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses' collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers- the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.

VaxForce: Mobilizing interprofessional licensees and students for community COVID-19 vaccination events.

During the early phases of the COVID-19 vaccine efforts, there was limited supply of the vaccine available to administer. However, as the vaccine supply improved, there was a lack of qualified personnel to administer the vaccine. VaxForce, a volunteer workforce management system to vet healthcare professionals and students and match them with existing vaccination events, was created. VaxForce activities were mainly focused on under-resourced communities. From March 2021 through July 2022, VaxForce mobilized 316 health professional volunteers in 72 vaccination events administering over 8451 vaccines in 7 counties in California. The racial and ethnic profile of vaccine recipients in VaxForce events were reported to be 49% Latinx, 26% Black, 4% Asian/Pacific Islander, 18% White, 3% Mixed Race.

Prediction and Prevention of Preterm Birth: A Prospective, Randomized Intervention Trial.

OBJECTIVE: The study aimed to determine if a program of mid-trimester serum proteomics screening of women at low risk for spontaneous preterm birth (sPTB) and the use of a PTB risk-reduction protocol in those whose results indicated an increased risk of sPTB would reduce the likelihood of sPTB and its sequelae. STUDY DESIGN: Prospective comparison of birth outcomes in singleton pregnancies with mid-trimester cervical length ≥2.5 cm and at otherwise low risk for sPTB randomized to undergo or not undergo mid-trimester serum proteomics screening for increased risk of sPTB (NCT03530332). Screen-positive women were offered a group of interventions aimed at reducing the risk of spontaneous PTB. The primary outcome was the rate of sPTB <37 weeks, and secondary outcomes were gestational age at delivery, total length of neonatal stay, and NICU length of stay (LOS). Unscreened and screen-negative women received standard care. The adaptive study design targeted a sample size of 3,000 to 10,000 women to detect a reduction in sPTB from 6.4 to 4.7%. Due to limited resources, the trial was stopped early prior to data unblinding. RESULTS: A total of 1,191 women were randomized. Screened and unscreened women were demographically similar. sPTB <37 weeks occurred in 2.7% of screened women and 3.5% of controls (p = 0.41). In the screened compared with the unscreened group, there were no between-group differences in the gestational age at delivery, total length of neonatal stay, and NICU LOS. However, the NICU LOS among infants admitted for sPTB was significantly shorter (median = 6.8 days, interquartile range [IQR]: 1.8-8.0 vs. 45.5 days, IQR: 34.6-79.0; p = 0.005). CONCLUSION: Mid-trimester serum proteomics screening of women at low risk for sPTB and the use of a sPTB risk-reduction protocol in screen-positive patients did not significantly reduce the rate of sPTB compared with women not screened, though the trial was underpowered thus limiting the interpretation of negative findings. Infants in the screened group had a significantly shorter NICU LOS, a difference likely due to a reduced number of infants in the screened group that delivered <35 weeks. KEY POINTS: · Mid-trimester serum proteomics screening of women at low risk for sPTB and the use of a sPTB risk-reduction protocol in screen-positive patients did not significantly reduce the rate of sPTB, though the trial was underpowered.. · NICU LOS following sPTB was significantly shortened among women who underwent screening and risk-reduction management.. · The use of serum biomarkers may contribute to a practical strategy to reduce sPTB sequelae..

An interactive web application for exploring human plasma and fibroblast metabolomics data from patients with inborn errors of metabolism.

Metabolomic profiling is instrumental in understanding the systemic and cellular impact of inborn errors of metabolism (IEMs), monogenic disorders caused by pathogenic genomic variants in genes involved in metabolism. This study encompasses untargeted metabolomics analysis of plasma from 474 individuals and fibroblasts from 67 subjects, incorporating healthy controls, patients with 65 different monogenic diseases, and numerous undiagnosed cases. We introduce a web application designed for the in-depth exploration of this extensive metabolomics database. The application offers a user-friendly interface for data review, download, and detailed analysis of metabolic deviations linked to IEMs at the level of individual patients or groups of patients with the same diagnosis. It also provides interactive tools for investigating metabolic relationships and offers comparative analyses of plasma and fibroblast profiles. This tool emphasizes the metabolic interplay within and across biological matrices, enriching our understanding of metabolic regulation in health and disease. As a resource, the application provides broad utility in research, offering novel insights into metabolic pathways and their alterations in various disorders.

Quenching of Single-Particle Strength in A=15 Nuclei.

Absolute cross sections for the addition of s- and d-wave neutrons to ^{14}C and ^{14}N have been determined simultaneously via the (d,p) reaction at 10 MeV/u. The difference between the neutron and proton separation energies, ΔS, is around -20 MeV for the ^{14}C+n system and +8 MeV for ^{14}N+n. The population of the 1s_{1/2} and 0d_{5/2} orbitals for both systems is reduced by a factor of approximately 0.5 compared with the independent single-particle model, or about 0.6 when compared with the shell model. This finding strongly contrasts with results deduced from intermediate-energy knockout reactions between similar nuclei on targets of ^{9}Be and ^{12}C. The simultaneous technique used removes many systematic uncertainties.

Analysis of an inverse weak-value tiltmeter in the kilohertz regime.

We present a follow-on experiment to the recent study from The University of Rochester [Opt. Lett.42, 2479 (2017)OPLEDP0146-959210.1364/OL.42.002479], which reported a new architecture for an inverse weak-value tiltmeter. We recreate the Rochester tiltmeter and specifically investigate mirror oscillations in the low-kilohertz frequency regime, which is relevant to certain potential applications, such as Coriolis vibratory gyroscopes. We find that the inverse weak-value amplification effect persists in this regime, although our measured noise floors are higher than those obtained in the Rochester experiment-approximately 2prad/Hz for mirror oscillation frequencies between 1 and 25 kHz.

The Impact of COVID-19 Pandemic on Spine Surgeons Worldwide: A One Year Prospective Comparative Study.

STUDY DESIGN: Survey. OBJECTIVE: In March of 2020, an original study by Louie et al investigated the impact of COVID-19 on 902 spine surgeons internationally. Since then, due to varying government responses and public health initiatives to the pandemic, individual countries and regions of the world have been affected differently. Therefore, this follow-up study aimed to assess how the COVID-19 impact on spine surgeons has changed 1 year later. METHODS: A repeat, multi-dimensional, 90-item survey written in English was distributed to spine surgeons worldwide via email to the AO Spine membership who agreed to receive surveys. Questions were categorized into the following domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions. RESULTS: Basic respondent demographics, such as gender, age, home demographics, medical comorbidities, practice type, and years since training completion, were similar to those of the original 2020 survey. Significant differences between groups included reasons for COVID testing, opinions of media coverage, hospital unemployment, likelihood to be performing elective surgery, percentage of cases cancelled, percentage of personal income, sick leave, personal time allocation, stress coping mechanisms, and the belief that future guidelines were needed (P<.05). CONCLUSION: Compared to baseline results collected at the beginning of the COVID-19 pandemic in 2020, significant differences in various domains related to COVID-19 perceptions, hospital preparedness, practice impact, personal impact, and future perceptions have developed. Follow-up assessment of spine surgeons has further indicated that telemedicine and virtual education are mainstays. Such findings may help to inform and manage expectations and responses to any future outbreaks.