Addressing Burnout in the Primary Care Setting: The Impact of an Evidence-Based Mindfulness Toolkit.

BACKGROUND: Burnout is insidious and manifests over prolonged, repeated exposure to occupational stressors. There is a growing crisis among health care workers (HCWs) due to high levels of burnout and associated adverse outcomes. Identifying and addressing burnout can be problematic due to extensive variances of perceived occupational stressors across HCWs. PURPOSE: Mindfulness-based training can enhance individual HCWs' abilities to perceive and constructively respond to stresses endemic in the health care environment. It can reduce the prevalence of burnout in the primary care setting. An evidence-based multimodal Mindfulness-Based Stress Reduction toolkit (MBSR TK) was designed, implemented, and evaluated for its impact on HCWs' self-reported stress levels (SRSL). IMPLEMENTATION STRATEGIES: A pre-post-program evaluation explored the impact of a multimodal toolkit program on HCW SRSL with the Mini-Z burnout survey (MZBS). The MBSR TK program, consisting of a 45 minute introduction and 4 biweekly 15 minute mindfulness sessions offering acupressure, meditation, journaling for gratitude, and self-compassion was designed, delivered, and evaluated with HCWs across 2 military primary care clinics in South Texas. RESULTS: All HCWs across 2 Air Force family practice clinics were invited to participate in all toolkit components. Seventy percent of all HCWs (N = 90) attended the introduction session. Thirty-seven (41%) HCWs completed pre and post MZBSs, and these responses are included in the data analysis section. The most represented HCWs were registered nurses, physician assistants, and technicians, respectively, at 24%, 21%, and 18%. The Wilcoxon Signed-Rank test examined changes in HCWs' SRSL after participation in the MBSR TK program. HCWs who attended the introduction plus one biweekly session showed statistically significant decreases in self-reported stress (P = 0.018) and burnout (P = 0.045) and a significant increase in electronic health record proficiency (P = 0.033). CONCLUSIONS: Multimodal mindfulness toolkits to address SRSL burnout are practical, accessible, easily implemented, adaptive to any environment, and can decrease burnout with participation with just one 15 minute session. This MBSR TK implementation effectively lowered self-reported stress in HCWs who are repeatedly challenged to adapt to various settings around the world during peacetime, wars, natural disasters, humanitarian crises, and now, pandemics.

Applying the RIME Framework to Level Nurse Practitioner Curriculum Competencies.

BACKGROUND: Nurse practitioner (NP) faculty assess student acquisition of knowledge through examinations, simulation, and clinical performance. PROBLEM: Developing appropriately leveled curriculum, assessments, and clinical expectations that accurately capture student maturation presents a challenge. APPROACH: The Reporter, Interpreter, Manager, Educator (RIME) provided the framework for doctor of nursing practice NP curriculum redesign to enhance student performance and content mastery. Faculty used a gap analysis approach, iteratively leveling specialty content, course competencies, examination questions, simulation cases, and clinical expectations using the building blocks of RIME. OUTCOMES: Objective scores on student evaluations for clinical courses exceeded the threshold established, including 83% of simulation encounters. Faculty implemented targeted methods to remediate areas of underperformance. CONCLUSIONS: Structuring the course competencies and preceptor feedback around RIME made it easier to pinpoint specific deficiencies and target remediation. It also helped guide discussions about the minimum acceptable standard for student performance.

Artificial light at night alters diurnal and nocturnal behavior and physiology in green anole lizards.

Artificial light at night (ALAN) disrupts biological rhythms across widely diverse organisms. To determine how energy is allocated by animals in different light environments, we investigated the impacts of ALAN on behavior and physiology of diurnal green anole lizards (Anolis carolinensis). Two groups of 24 adult lizards (half males, half females) were maintained in a controlled lab setting for six weeks. One group was exposed to a simulated natural summer light-dark cycle; the other was exposed to ALAN that simulated urban, nocturnal light exposure. After an acclimation period, we conducted four behavioral trials. One trial examined behavioral time allocation over two 24 h periods, and three others were conducted during mid-day and mid-night: open field tests, to examine exploratory behavior; foraging trials, to examine prey consumption; and social interaction trials, to examine same-sex interactions. We then measured each lizard's snout-vent length and mass of its body, abdominal fat pads, liver, and, for males, testes. Lizards exposed to ALAN were more likely to be awake at night, using nocturnal light to explore, forage, and display to conspecifics. However, during the day, ALAN lizards were less likely to be awake, slower to move, and females displayed less frequently. ALAN lizards had heavier fat pads and testes, but ALAN did not impact body mass, liver mass, or snout-vent length. In sum, ALAN appears to cause a broad shift towards increased nocturnal activity and may alter metabolic and reproductive processes. Future work should examine the fitness consequences of these behavioral and physiological changes.

Optimizing Detection of Lymphatic Invasion in Primary Cutaneous Melanoma With the Use of D2-40 and a Paired Melanocytic Marker.

ABSTRACT: Dual immunohistochemical (IHC) staining with D2-40 and S100 improves detection of lymphatic invasion (LI) in primary cutaneous melanoma. However, limited data exist evaluating this technique using other melanocytic markers, and thus, the optimal marker for detection of LI is unestablished. To address this knowledge gap, a case-control study was performed comparing melanoma specimens from 22 patients with known lymphatic spread (LS) with a control group of 11 patients without LS. Specimens underwent dual IHC staining with D2-40 and MART-1, SOX-10, and S100 to evaluate for LI. Receiver operating characteristic analysis was used to estimate each stain's accuracy for detection of LI. The LS group was more likely to be ≥65 years (P = 0.04), have a tumor thickness of ≥1 mm (P < 0.01), and have ulcerated tumors (P = 0.02). Detection of LI with D2-40/MART-1 significantly correlated with LS (P = 0.03), and the D2-40/MART-1 stain was most accurate for LI based on receiver operating characteristic curve analysis (area under the curve [AUC] 0.705) in comparison with D2-40/SOX-10 (AUC 0.575) and D2-40/S100 (AUC 0.633). These findings suggest that MART-1 may be the optimal melanocytic marker to combine with D2-40 for detection of LI in melanoma. Further studies are needed to determine the utility of routinely performing these stains for histopathologic analysis of melanoma.

Exploration Into Donor-Recipient Relationship After Living-Donor Liver Transplantation Using Gift-Exchange Theory.

AIM: This qualitative study aimed to explore the donor-recipient relationships following living-donor liver transplantation. METHOD: A 1-time cross-sectional qualitative interview was conducted with liver transplant recipients (n = 17) and living liver donors (n = 11) post-transplant. The interviews were transcribed verbatim and analyzed manually by using thematic content analysis. RESULTS: The mean age of the recipients and the donors was 54.41 ± 8.0 (range 39-71) and 36.6 ± 7.69 (range 28-57) years, respectively. Following the interviews, 2 overarching themes emerged: (1) Became care providers, and (2) differentiation in relationships after transplantation. A total of 3 sub-themes were explained under "differentiation in relationships after transplantation;" feeling guilty, becoming closer and more intense owing to a feeling of indebtedness, and putting some distance owing to a feeling of indebtedness. CONCLUSION: The study focused on the reciprocation stage according to gift-exchange theory. During reciprocation, although recipients expressed positive feelings such as gratitude, closer relationships, and special bonds; they also reported negative feelings like guilt and indebtedness resulting in a purposeful distancing from their donors. Most donors understood what the recipients felt, but they wanted their relationship to return to normal. Married female donors had worse experiences, such as divorce or a weakened marital relationship after donation.

Histopathologic synoptic reporting of invasive melanoma: How reliable are the data?

BACKGROUND: Synoptic reporting is recommended by many guideline committees to encourage the thorough histologic documentation necessary for optimal management of patients with melanoma. METHODS: One hundred fifty-one pathologists from 40 US states interpreted 41 invasive melanoma cases. For each synoptic reporting factor, the authors identified cases with "complete agreement" (all participants recorded the same value) versus any disagreement. Pairwise agreement was calculated for each case as the proportion of pairs of responses that agreed, where paired responses were generated by the comparison of each reviewer's response with all others. RESULTS: There was complete agreement among all reviewers for 22 of the 41 cases (54%) on Breslow thickness dichotomized at 0.8 mm, with pairwise agreement ranging from 49% to 100% across the 41 cases. There was complete agreement for "no ulceration" in 24 of the 41 cases (59%), with pairwise agreement ranging from 42% to 100%. Tumor transected at base had complete agreement for 26 of the 41 cases (63%), with pairwise agreement ranging from 31% to 100%. Mitotic rate, categorized as 0/mm2 , 1/mm2 , or 2/mm2 , had complete agreement for 17 of the 41 cases (41%), with pairwise agreement ranging from 36% to 100%. Regression saw complete agreement for 14 of 41 cases (34%), with pairwise agreement ranging from 40% to 100%. Lymphovascular invasion, perineural invasion, and microscopic satellites were rarely reported as present. Respectively, these prognostic factors had complete agreement for 32 (78%), 37 (90%), and 18 (44%) of the 41 cases, and the ranges of pairwise agreement were 47% to 100%, 70% to 100%, and 53% to 100%, respectively. CONCLUSIONS: These findings alert pathologists and clinicians to the problem of interobserver variability in recording critical prognostic factors. LAY SUMMARY: This study addresses variability in the assessment and reporting of critical characteristics of invasive melanomas that are used by clinicians to guide patient care. The authors characterize the diagnostic variability among pathologists and their reporting methods in light of recently updated national guidelines. Results demonstrate considerable variability in the diagnostic reporting of melanoma with regard to the following: Breslow thickness, mitotic rate, ulceration, regression, and microscopic satellites. This work serves to alert pathologists and clinicians to the existence of variability in reporting these prognostic factors.

Education Priorities and What Matters to Those Considering Living Kidney Donation.

INTRODUCTION: Although informed consent content elements are prescribed in detailed regulatory guidance, many live kidney donors describe feeling underprepared and under informed. The goal of this pilot study was to explore the educational components needed to support an informed decision-making process for living kidney donors. METHODS/APPROACH: A qualitative description design was conducted with thematic analysis of 5 focus groups with 2 cohorts: living kidney donor candidates (n = 11) and living kidney donors (n = 8). FINDINGS: The educational components needed to engage in an informed decision-making process were: 1) contingent upon, and motivated by, personal circumstances; 2) supported through explanation of risks and benefits; 3) enhanced by understanding the overall donation experience; and 4) personalized by talking to another donor. DISCUSSION: Tailoring education to meet the needs for fully informed decision-making is essential. Current education requirements, as defined by regulatory bodies, remain challenging to transplant teams attempting to ensure fully informed consent of living kidney donor candidates. Information on the emotional, financial, and overall life impact is needed, along with acknowledgement of relational ties driving donor motivations and the hoped-for recipient outcomes. Discussion of care practices, and access to peer mentoring may further strengthen the informed decision-making process.

Taking the leap from clinical practice to academic faculty: A beginner's guide.

ABSTRACT: Exploring new roles and responsibilities available to clinicians offers a path to renovate a nurse practitioner's career. The role of academician and nurse faculty broadens career horizons, presents a sense of autonomy, and offers unique opportunities to teach, participate in research, build leadership skills, and contribute to the health care delivery system at a higher level. Advance practice nurses often consider a shift to academia but are concerned about the unfamiliarity of the entire process. This article offers elements a clinician will likely encounter throughout the transition to a faculty role. These include expectations for the application and interview, negotiating for a position, and orientation to the role of an academic.

Interprofessional Healthcare Student Training in the Care of Sexual Assault Patients Utilizing Standardized Patient Methodology.

BACKGROUND: The medical assessment of sexual assault (SA) is challenging because SA patients are often hesitant to disclose their medical needs, which puts them at further physical and psychological risk, and because of provider unease in conducting SA examinations. This challenge is compounded by a lack of provider training. OBJECTIVES: The study goals were to develop an interprofessional simulation event that would foster SA interview skills, foster effective communication with SA patients, and increase learner confidence in assessing SA patients. METHODS: Participants were senior-year school of medicine (n = 165) and advanced practice registered nursing (n = 30) students (N = 195) who were enrolled in a mandatory Military Sexual Assault Assessment and Treatment course, along with data provided by trained standardized patients (SPs, n = 16) who participated in the simulation event and in assessments of learners. Measures included the Sexual Assault Interview Skills Checklist, the Essential Elements of Communication, and the Confidence in SA Assessment scale. Data were analyzed using analysis of variance and t tests at the P < 0.05 threshold. RESULTS: Postsimulation Sexual Assault Interview Skills Checklist and Essential Elements of Communication scores demonstrated an acceptable level of competence according to both students and SPs. Confidence in SA assessment rose significantly from presimulation to postsimulation. Before simulation, medical students were significantly lower than nursing students, but the simulation event closed the confidence in SA assessment gap. CONCLUSIONS: This interprofessional simulation event resulted in SA interview competence, communication skills competence, and improved confidence scores. Combined, these findings support the efficacy of simulation to train emerging healthcare providers to properly assess SA.

Mitigating Barriers to Doctoral Education for Nurses.

AIM: This article reports preliminary outcomes of the Guiding Initiative for Doctoral Education, which promotes success in doctoral study. BACKGROUND: Nurses face challenges as they move intentionally, effectively, and expediently toward earning the doctorate. Selecting the doctoral education best suited to individual career goals is essential for success. METHOD: An intensive, daylong program focused on setting goals, generating personal action plans, and mobilizing resources to promote success in application and return to the role of student. RESULTS: Based on 70 nurses who participated in seven programs, 22 (31 percent) were admitted to their doctoral program of choice (6 PhD, 15 DNP, 1 EdD). CONCLUSION: Nurses benefit from and value learning about the options for doctoral study, requirements for educational opportunities, the nature of the commitment required, challenges commonly encountered during the process, and the impact advanced education can be expected to have on immediate and long-term career opportunities.

Histological immune response patterns in sentinel lymph nodes involved by metastatic melanoma and prognostic significance.

BACKGROUND: To further characterize the micromorphometric immunological pattern to metastatic melanoma in sentinel lymph node (SLN) biopsies and completion lymph node (CLN) dissections and their relation to 5-year overall survival (OS). METHODS: Retrospective cohort of 49 patients from 1996 to 2005 with a positive SLN who underwent CLN dissection (CLD) was studied. Micromorphometric characteristics included follicular center count (FCC)/profile, sinus histiocytosis, metastatic size, tumor infiltrating lymphocytes (intranodal), paracortical dendritic cells, germinal center reaction and morphology. Comparison of Kaplan-Meier survival curves used the exact log-rank statistic. RESULTS: In the high-FCC (n = 5-51) vs the low-FCC (n < 5) lymph nodes, a delayed separation occurred at 3 years, with 5-year OS rates being 73% vs 54% in the high- and low-FCC groups, respectively. Improved survival up to 3 years was also noted in CLDs that showed a higher FCC when compared to the prior SLN. Patients with metastatic deposits >2 mm had significantly lower 5-year survival (both <.001). CONCLUSIONS: Nodal micromorphometric features (ie, FCC) are probably related to host immune response to metastasis. Quantitative evaluation of lymphoid follicular centers could provide valuable prognostic information to help to stratify patients.

The utility of adaptive eLearning in cervical cytopathology education.

BACKGROUND: Adaptive eLearning allows students to experience a self-paced, individualized curriculum based on prior knowledge and learning ability. METHODS: The authors investigated the effectiveness of adaptive online modules in teaching cervical cytopathology. eLearning modules were created that covered basic concepts in cervical cytopathology, including artifacts and infections, squamous lesions (SL), and glandular lesions (GL). The modules used student responses to individualize the educational curriculum and provide real-time feedback. Pathology trainees and faculty from the authors' institution were randomized into 2 groups (SL or GL), and identical pre-tests and post-tests were used to compare the efficacy of eLearning modules versus traditional study methods (textbooks and slide sets). User experience was assessed with a Likert scale and free-text responses. RESULTS: Sixteen of 17 participants completed the SL module, and 19 of 19 completed the GL module. Participants in both groups had improved post-test scores for content in the adaptive eLearning module. Users indicated that the module was effective in presenting content and concepts (Likert scale [from 1 to 5], 4.3 of 5.0), was an efficient and convenient way to review the material (Likert scale, 4.4 of 5.0), and was more engaging than lectures and texts (Likert scale, 4.6 of 5.0). Users favored the immediate feedback and interactivity of the module. Limitations included the inability to review prior content and slow upload time for images. Learners demonstrated improvement in their knowledge after the use of adaptive eLearning modules compared with traditional methods. CONCLUSIONS: Overall, the modules were viewed positively by participants. Adaptive eLearning modules can provide an engaging and effective adjunct to traditional teaching methods in cervical cytopathology. Cancer Cytopathol 2018;126:129-35. © 2017 American Cancer Society.

High ALDH1 expression correlates with better prognosis in tumorigenic malignant melanoma.

Aldehyde dehydrogenase 1 (ALDH1) has been proposed as biomarker of stem cells for certain human cancers. ALDH1 expression has been correlated with poor patient outcomes in a variety of malignancies but better patient outcomes in others, and its prognostic significance in malignant melanoma is unclear. Thus, 68 melanoma patients with comprehensive clinical and pathologic follow-up data were used to construct a tissue microarray. A modified histological score (H-score) with a maximum score of 300 was used to quantify immunohistochemical staining for ALDH1. Survival time was defined as the time between diagnosis and melanoma-specific death. Using univariate logistic regression, a low (<80 H-score) ALDH1 score showed 3.7-fold increase in risk for melanoma-specific death within 10 years when compared with high (>80) ALDH1 levels (P=0.017). Odds of MSD were lower by a factor of ~0.9 for each 10-point increase in H-Score. Median survival time was 44.1 months and 180.9 months for patients with low and high ALDH1 expression, respectively. Using multivariate analysis, ALDH1 H-score was found to be an independent prognostic factor. These findings suggest that ALDH1 expression in malignant melanoma has a favorable effect on patient survival. Further study is needed elucidate the function of this enzymatic protein in melanoma progression.

Atypical retiform hemangioendothelioma arising in a patient with Milroy disease: a case report and review of the literature.

Retiform hemangioendothelioma (RH) is a rare vascular neoplasm with a high rate of local recurrence and low metastatic potential. We describe an unusual case of RH in a 45-year-old patient with Milroy disease, with a prominent solid component diffusely involving a chronic lymphedematous leg. This case is consistent with the postulated relationship between lymphedema and vascular neoplasms developing as a result of local immune dysfunction, and highlights the need to closely monitor patients with Milroy disease for pathologic changes. Our case highlights a unique example of RH with atypical features. There are several noteworthy unusual clinical and histologic findings including diffuse involvement of an entire limb, solid component with cytologic atypia, D2-40 expression, and first-time-reported association with Milroy disease. Given the atypical histologic presentation of cytologic atypia, solid areas and atypical immunohistochemical profile with D2-40 positivity, this case could cause diagnostic difficulty, especially in the setting of such a broad clinical differential.

p15 Expression Differentiates Nevus from Melanoma.

Most melanomas are driven by BRAF(V600E)-activating mutations, while nevi harboring the same mutations have growth arrest. Although decreased p16 expression has been associated with melanoma formation, in recent work, p15 represented a primary effector of oncogene-induced senescence in nevomelanocytes that was diminished in melanomas. This study determined whether decreased p15 levels represent a general biomarker for the transition from nevus to melanoma. We performed p15 and p16 IHC analyses on a random series of nevi and melanomas. Staining was evaluated and graded for percentage and intensity to determine the H score. For real-time quantitative RT-PCR analysis of p15, RNA was extracted from FFPE sections from 14 nevus and melanoma samples via macrodissection. A two-sided t-test was used to evaluate between-group differences in mean H scores and qΔCt values. p15 Expression was significantly increased in melanocytic nevi compared with melanomas (mean H scores, 254.8 versus 132.3; P < 0.001). On p15 staining, the H score differential was greater than that with p16 staining [122.5 (P < 0.001) and 64.8 (P = 0.055), respectively]. Real-time quantitative RT-PCR analysis revealed a lower mean qΔCt value in melanomas, consistent with lower p15 expression (P = 0.018). Together, these data support the hypothesis that decreased p15 expression is a robust biomarker for distinguishing nevus from melanoma.

A High-Throughput, Arbitrary-Waveform, MPI Spectrometer and Relaxometer for Comprehensive Magnetic Particle Optimization and Characterization.

Magnetic Particle Imaging (MPI) is a promising new tracer modality with zero attenuation deep in tissue, high contrast and sensitivity, and an excellent safety profile. However, the spatial resolution of MPI is limited to around 1 mm currently and urgently needs to be improved for clinical applications such as angiography and brain perfusion. Although MPI resolution is highly dependent on tracer characteristics and the drive waveforms, optimization is limited to a small subset of possible excitation strategies by current MPI hardware that only does sinusoidal drive waveforms at very few frequencies. To enable a more comprehensive and rapid optimization of drive waveforms for multiple metrics like resolution and signal strength simultaneously, we demonstrate the first untuned MPI spectrometer/relaxometer with unprecedented 400 kHz excitation bandwidth and capable of high-throughput acquisition of harmonic spectra (100 different drive-field frequencies in only 500 ms). It is also capable of arbitrary drive-field waveforms which have not been experimentally evaluated in MPI to date. Its high-throughput capability, frequency-agility and tabletop size makes this Arbitrary Waveform Relaxometer/Spectrometer (AWR) a convenient yet powerfully flexible tool for nanoparticle experts seeking to characterize magnetic particles and optimize MPI drive waveforms for in vitro biosensing and in vivo imaging with MPI.