Interprofessional Simulation Learning Game Increases Socialization and Teamwork Among Students of Health Professions Programs.

BACKGROUND: Interprofessional (IP) socialization is important to develop early in the training of health professions students. PURPOSE: This study compared changes in health professions students' IP socialization and readiness to function in IP teams and sought to understand students' participation experiences using a simulation learning game ( Friday Night at the ER [FNER]). METHODS: The single-center study targeted students in 13 health professions programs using a mixed-methods design. Student teams engaged in open discussion, played the game, and participated in team debriefing. RESULTS: IP socialization increased from fairly great to great extent among all students. Qualitative analyses revealed 3 overarching themes supporting the development of IP communication and systems-based thinking. Program evaluation data revealed that students highly valued this experience as being effective and important to their professional development. CONCLUSIONS: An IP experience consisting of FNER gameplay and structured debriefing can improve IP socialization and lay the foundation for the development of IP skills among early health professions students.

Communication Openings: A Novel Approach for Serious Illness Communication in Homecare.

Serious illness communication in homecare about hospice and/or palliative care transitions is lacking due to clinical culture. The purpose of the current study was to understand communication openings using COMFORT™, a palliative care communication model used to train nurses. Qualitative, focus group interviews with 31 homecare nurses were conducted. Data were transcribed verbatim and thematically analyzed using NVivo software, followed by hand-sorting. Four themes for communication openings for initiating discussions about potential hospice and/or palliative care transitions were identified: Organizational Openings (homecare appropriateness, eligibility requirements, and staffing); Patient Openings (patient physical decline, psychosocial changes, safety concerns, and denying/stopping care); Caregiver Openings (caregiver physical changes and patient readiness); and Nurse Openings (need for hospice, checking for prognosis understanding, increasing interprofessional care needs, and providing end-of-life care). This study extends the concept of communication openings in the COMFORT model. Further development of communication openings as part of COMFORT communication is needed in educational and intervention research. [Journal of Gerontological Nursing, 49(11), 33-41.].

Conformational changes in the negative arm of the circadian clock correlate with dynamic interactomes involved in post-transcriptional regulation.

Biology is tuned to the Earth's diurnal cycle by the circadian clock, a transcriptional/translational negative feedback loop that regulates physiology via transcriptional activation and other post-transcriptional mechanisms. We hypothesize that circadian post-transcriptional regulation might stem from conformational shifts in the intrinsically disordered proteins that comprise the negative arm of the feedback loop to coordinate variation in negative-arm-centered macromolecular complexes. This work demonstrates temporal conformational fluidity in the negative arm that correlates with 24-h variation in physiologically diverse macromolecular complex components in eukaryotic clock proteins. Short linear motifs on the negative-arm proteins that correspond with the interactors localized to disordered regions and known temporal phosphorylation sites suggesting changes in these macromolecular complexes could be due to conformational changes imparted by the temporal phospho-state. Interactors that oscillate in the macromolecular complexes over circadian time correlate with post-transcriptionally regulated proteins, highlighting how time-of-day variation in the negative-arm protein complexes may tune cellular physiology.

Promoting Evidence-Based Practice in Clinical Education at a Hospice Designated Education Unit.

Integration of palliative care principles into undergraduate nursing curriculum is essential to prepare students to provide supportive care services across the continuum of care for individuals with serious illness. Baccalaureate nursing curricula emphasize development and application of evidence-based practice (EBP); however, development of nursing skills often overshadows teaching students how to deliver care or facilitate practice changes based on evidence in clinical education. Problems revealed in clinical practice are a valuable tool for improving student use and appreciation of EBP in clinical settings. The EBP project presented in this article provides a process to promote palliative and end-of-life EBP in clinical education. This project highlights the proposed American Association of Colleges of Nursing hospice/palliative/supportive care sphere of care in a hospice dedicated education unit following The Seven Steps of EBP. Students participating in the project developed core skills to search, appraise, and translate evidence and the ability to lead EBP projects guided by the dedicated education unit model. Dedicated education units serve as ideal clinical education sites to develop student EBP competencies and support transition to practice through collaboration with practice partner stakeholders.

Homecare nurses guide goals for care and care transitions in serious illness: A grounded theory of relationship-based care.

AIMS: To identify the process that homecare nurses use when recognizing serious illness, engaging patients and families in goals-for-care discussions and guiding transitions to comfort-focused care. DESIGN: Constructivist grounded theory. METHODS: Semi-structured focus group interviews of 31 homecare Registered Nurses were recorded and transcribed (June-August 2019). Line-by-line coding using the constant comparative method until saturation was achieved and a grounded theory was identified. Credibility, transferability, and confirmability establish study rigor. RESULTS: A grounded theory of relationship-based care. Nurses cogitate and act when recognizing serious illness. They have difficult conversations and support care transitions with wisdom and knowing, by identifying changes in illness trajectories and being informed and alert to diminishing quality of life. Nurses are skilled at engaging patients, families, and the team and accommodate care in the home for as long as possible, while manoeuvring through complex systems of care; ultimately relinquishing and guiding care to other providers and settings. However, nurses feel inadequately prepared and frustrated with a fragmented healthcare system and lack of collaboration among the team. CONCLUSION: This study identifies a grounded theory to support clinical decision-making and position homecare nurses as leaders in guiding goal care discussions and transitions to comfort-focused care. These findings reinforce the importance of developing health policy that ensures care continuity in serious illness. Further research is needed to improve relationships across care settings and enhance training for the delivery of comfort-focused care in the home as changing needs emerge during serious illness management.

Salvage Lung Resections After Definitive Chemoradiotherapy: A Safe and Effective Oncologic Option.

BACKGROUND: Patients with locally advanced, non-small cell lung cancer treated with definitive chemoradiotherapy alone often demonstrate persistent or recurrent disease. In the absence of systemic progression, salvage lung resection after definitive chemoradiotherapy has been used as a treatment option. Given the paucity of data, we sought to evaluate the safety and efficacy of salvage pulmonary resections occurring greater than 90 days after definitive chemoradiotherapy. METHODS: Retrospective institutional database review identified patients undergoing salvage lung resection at least 90 days after the completion of definitive chemoradiotherapy. Primary outcomes evaluated were overall survival and recurrence-free survival. RESULTS: Thirty patients met inclusion criteria between January 1, 2004 and December 31, 2015. Median time to surgery after definitive radiotherapy was 279 days (interquartile range, 168-474 days). Extended resections were performed in 11 patients (37%). Ottawa Thoracic Morbidity and Mortality Classification System grade IIIA or greater complications occurred in 12 patients (40%). Thirty-day mortality was 6.7% (2 patients). Median overall survival after salvage resection was 24 months. Median overall survival for an R1 resection was 5.3 months vs 108 months for an R0 resection (P = .001). Persistent pN1-positive salvage resections also did less well compared with pN0 (8.9 vs 28.2 months; P = .06). For patients who underwent nonextended salvage resection (simple lobectomy or simple pneumonectomy), median overall survival was 108.4 months, vs 8.9 months for extended salvage resections (P = .02). CONCLUSIONS: With proper patient selection, salvage lung resections can be performed with acceptable morbidity, mortality, and oncologic outcomes, particularly when a ypN0R0 resection can be achieved by nonextended surgical means.

ECHO: an application for detection and analysis of oscillators identifies metabolic regulation on genome-wide circadian output.

MOTIVATION: Time courses utilizing genome scale data are a common approach to identifying the biological pathways that are controlled by the circadian clock, an important regulator of organismal fitness. However, the methods used to detect circadian oscillations in these datasets are not able to accommodate changes in the amplitude of the oscillations over time, leading to an underestimation of the impact of the clock on biological systems. RESULTS: We have created a program to efficaciously identify oscillations in large-scale datasets, called the Extended Circadian Harmonic Oscillator application, or ECHO. ECHO utilizes an extended solution of the fixed amplitude oscillator that incorporates the amplitude change coefficient. Employing synthetic datasets, we determined that ECHO outperforms existing methods in detecting rhythms with decreasing oscillation amplitudes and in recovering phase shift. Rhythms with changing amplitudes identified from published biological datasets revealed distinct functions from those oscillations that were harmonic, suggesting purposeful biologic regulation to create this subtype of circadian rhythms. AVAILABILITY AND IMPLEMENTATION: ECHO's full interface is available at https://github.com/delosh653/ECHO. An R package for this functionality, echo.find, can be downloaded at https://CRAN.R-project.org/package=echo.find. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

Providing Palliative Care: Oncology Nurses' Perceptions of Their Self-Reported Abilities.

BACKGROUND: Oncology nurses are pivotal in the provision of primary palliative care. However, nurses working in oncology settings, where the goal is often curative, may lack knowledge about and comfort in providing palliative care. OBJECTIVES: The purpose of this study is to determine how oncology nurses perceive their ability to provide palliative care services to patients and their families. METHODS: Using Benner's theory of skill acquisition as a basis for self-evaluation, this cross-sectional, descriptive pilot study surveyed oncology nurses. FINDINGS: All participants reported ranges from capable to very capable in ability to provide precepts of palliative care. Results showed a small but statistically significant association between years of experience and perceived ability to honor patient and family preferences, provide patient and family support, appreciate demands placed on families, and provide supportive services to caregivers.

Sublobar Resection in the Treatment of Peripheral Typical Carcinoid Tumors of the Lung.

BACKGROUND: The role of sublobar resection in the treatment of pulmonary typical carcinoids is controversial. This study aims to compare long-term outcomes between sublobar and lobar resections in patients with peripheral typical carcinoid. METHODS: We retrospectively compared consecutive patients who underwent curative sublobar resection with patients who underwent lobectomy for cT1-3 N0 M0 peripheral pulmonary typical carcinoid in eight centers between 2000 and 2015. Primary outcomes were rates and patterns of recurrence and overall survival. Cox regression modeling was performed to identify factors influencing overall survival and recurrence. Propensity score analysis was done, and overall survival was compared between the two groups. RESULTS: In all, 177 patients were analyzed, consisting of 74 sublobar resections and 103 lobectomies, with a total of 857 person-years of follow-up. The R1 resection rates were 7% and 1% after sublobar resection and lobectomy, respectively (P = .08). One of 5 patients with sublobar R1 resection had recurrence. Recurrence rate was 0.02 (95% confidence interval [CI]: 0.009 to 0.044) per person-year of follow-up after sublobar resection and 0.008 (95% CI: 0.003 to 0.02) after lobectomy (P = .15). Five-year survival rates were 91.7% (95% CI: 78.5% to 96.9%) and 97.4% (95% CI: 90.1% to 99.4%) after sublobar and lobar resection, respectively (P = .08). Extent of resection was not a predictor of recurrence or survival. Propensity score analysis confirmed a similar survival and freedom from recurrence between the two groups. CONCLUSIONS: Sublobar resection of peripheral cT1-3 N0 M0 pulmonary typical carcinoid was not associated with worse short- or long-term outcomes compared with lobectomy. In select patients, sublobar resection may be considered for treatment of peripheral typical carcinoids if an R0 resection is obtained.

Large Cell Neuroendocrine Tumor Size >3 cm Negatively Impacts Long-Term Outcomes After R0 Resection.

BACKGROUND: Minimal knowledge exists regarding the outcome, prognosis and optimal treatment strategy for patients with pulmonary large cell neuroendocrine carcinomas (LCNEC) due to their rarity. We aimed to identify factors affecting survival and recurrence after resection to inform current treatment strategies. METHODS: We retrospectively reviewed 72 patients who had undergone a curative resection for LCNEC in 8 centers between 2000 and 2015. Univariable and multivariable analyses were performed to identify the factors influencing recurrence, disease-specific survival and overall survival. These included age, gender, previous malignancy, ECOG performance status, symptoms at diagnosis, extent of resection, extent of lymphadenectomy, additional chemo- and/or radiotherapy, tumor location, tumor size, pT, pleural invasion, pN and pStage. RESULTS: Median follow-up was 47 (95%CI 41-79) months; 5-year disease-specific and overall survival rates were 57.6% (95%CI 41.3-70.9) and 47.4% (95%CI 32.3-61.1). There were 22 systemic recurrences and 12 loco-regional recurrences. Tumor size was an independent prognostic factor for systemic recurrence [HR: 1.20 (95%CI 1.01-1.41); p = 0.03] with a threshold value of 3 cm (AUC = 0.71). For tumors ≤3 cm and >3 cm, 5-year freedom from systemic recurrence was 79.2% (95%CI 43.6-93.6) and 38.2% (95%CI 20.6-55.6) (p < 0.001) and 5-year disease-specific survival was 60.7% (95%CI 35.1-78.8) and 54.2% (95%CI 32.6-71.6) (p = 0.31), respectively. CONCLUSIONS: A large proportion of patients with surgically resected LCNEC will develop systemic recurrence after resection. Patients with tumors >3 cm have a significantly higher rate of systemic recurrence suggesting that adjuvant chemotherapy should be considered after complete resection of LCNEC >3 cm, even in the absence of nodal involvement.

Improvement in TNM staging of pulmonary neuroendocrine tumors requires histology and regrouping of tumor size.

OBJECTIVE: Neuroendocrine tumors of the lung are currently staged with the 7th edition TNM non-small cell lung cancer staging system. This decision, based on data analysis without data on histology or disease-specific survival, makes its applicability limited. This study proposes a specific staging system for these tumors. METHODS: We retrospectively analyzed 510 consecutive patients (female/male, 313/197; median age, 61 years; interquartile range, 51-70) undergoing lung resection for a primary neuroendocrine tumor between 2000 and 2015 in 8 centers. Multivariable analysis was performed using a Cox proportional hazard model to identify factors associated with disease-specific survival. A new staging system was proposed on the basis of the results of this analysis. Kaplan-Meier disease-specific survival was analyzed by stage using the proposed and the 7th TNM staging system. RESULTS: Follow-up was completed in 490 of 510 patients at a median of 51 months (interquartile range, 18-99). Histology (G1-typical carcinoid vs G2-atypical carcinoid vs G3-large-cell neuroendocrine carcinoma) and pT were independently associated with survival, but pN was not. After regrouping histology and pT, we proposed the following staging system: IA (pT1-2G1), IB (pT3G1, pT1G2), IIA (pT4G1, pT2-3G2, pT1G3), IIB (pT4G2, pT2-3G3), and III (pT4G3). The 5-year survivals were 97.9%, 81.0%, 69.1%, 51.8%, and 0%, respectively. By using the 7th TNM, 5-year survivals were 95.0%, 92.3%, 67.7%, 70.9%, and 65.1% for stage IA, IB, IIA, IIB, and III, respectively. CONCLUSIONS: Incorporating histology and regrouping tumor stage create a unique neuroendocrine tumor staging system that seems to predict survival better than the 7th TNM classification.

External Validation of a Prognostic Model of Survival for Resected Typical Bronchial Carcinoids.

BACKGROUND: This study aimed to assess the reliability and the validity of a prognostic model of survival recently developed by the European Society of Thoracic Surgery Neuroendocrine Tumor Working Group to predict 5-year overall survival after surgical resection of pulmonary typical carcinoid. METHODS: We retrospectively collected data on 240 consecutive patients (164 men, 76 women; median age, 58 years [interquartile range, 47 to 68]) who underwent curative lung resection for pulmonary typical carcinoid in seven centers between 2000 and 2015. For each patient, we calculated the corresponding risk class (A, B, C, D) using the following variables: male, age, previous malignancy, Eastern Cooperative Oncology Group performance status, peripheral tumor, TNM stage. Kaplan-Meier method, and Cox proportional hazards model were used for the statistical analysis. RESULTS: During a median follow-up of 42 months (interquartile range, 11 to 84), the 5-year overall survival was 94.2% (95% confidence interval [CI]: 90.2% to 98.2%); 15 of 240 patients died. A significantly decreasing rate of survival was observed from class A to class D (p = 0.004) with rates of 100% (95% CI: 100% to 100%), 96.3% (95% CI: 88.6% to 98.8%), 86.7% (95% CI: 63.0% to 95.7%), and 33.3% (95% CI: 0.9% to 77.4%), respectively, for class A, B, C, and D. This difference persisted also using clinical stage as a variable in the risk class calculation (p = 0.006). No differences were observed in term of overall survival among TNM stage I, II, and III patients (p = 0.94). CONCLUSIONS: This prognostic model of survival is easily applicable, it is validated by our independent cohort, and it appears to stratify better than the traditional TNM staging. Therefore, it may be useful in counseling patients about their outcomes from surgical treatment and in tailoring treatment for high-risk patients.

Is there a role for traditional nuclear medicine imaging in the management of pulmonary carcinoid tumours?

OBJECTIVES: The clinical utility of fluorodeoxyglucose-positron emission tomography (FDG-PET) and somatostatin receptor scintigraphy (SRS) in pulmonary carcinoids staging is unclear. This study aims to determine the role of FDG-PET and SRS in detecting hilar-mediastinal lymph node metastasis from these tumours. METHODS: We retrospectively collected the data of 380 patients who underwent lung resection for primary pulmonary carcinoid in seven centres between 2000 and 2015. Patients without nodal sampling ( n = 78) were excluded. In 302 patients [35% men, median age 58 (interquartile range 47-68) years] the results of preoperative computed tomography (CT) scan, FDG-PET and SRS were analysed and compared to the pathological findings after resection to determine the respective utility of these two nuclear tests. RESULTS: The sensitivity, specificity and negative predictive value in detecting N1 and N2 disease were respectively 33% and 46%, 93% and 90%, 88% and 95% for computed-tomography-scan, 38% and 60%, 93% and 95%, 88% and 95% for FDG-PET, 22% and 33%, 95% and 98%, 84% and 87% for SRS. The diagnostic accuracy for N1 and N2 disease of CT scan was not significantly different from that of FDG-PET ( P = 1.0 and P = 0.37 for N1 and N2 disease respectively) and of SRS ( P = 0.47 and P = 0.35 for N1 and N2 disease respectively). The sensitivity and specificity of these imaging tests were also similar when analysed by typical vs atypical histology. CONCLUSIONS: CT scan, FDG-PET and SRS showed similar performance in terms of nodal staging for pulmonary carcinoid. These findings suggest that additional nuclear imaging beyond CT scan is not required as long as a lymphadenectomy or nodal sampling is completed at resection.

Alcohol-related content in undergraduate nursing curricula in the northeastern United States.

Societal alcohol abuse and misuse is disproportionate to the number of related didactic and clinical hours reported by traditional baccalaureate nursing programs in the United States. Because no recent research re-examines the findings from earlier studies, a survey was developed and then electronically distributed to all nursing department deans or program chairs of traditional baccalaureate nursing programs in the Northeast (N=117). Twenty-seven (23%) schools responded. Results showed limited didactic and clinical offerings. Most schools cover content related to definition, psychological and medical complications, and treatment and rehabilitation. Clinical applications were limited as was content addressing public dimensions of alcohol misuse. The current findings showed little change from those of studies conducted more than 20 years ago. Based on the current findings, further survey development is encouraged with the intent of continuing exploration of curricular offerings related to alcohol misuse.

Endotracheal tube and laryngeal mask airway cuff volume changes with altitude: a rule of thumb for aeromedical transport.

BACKGROUND: Helicopters and light (unpressurised) aircraft are used increasingly for the transport of ventilated patients. Most of these patients are ventilated through endotracheal tubes (ETTs), others through laryngeal mask airways (LMAs). The cuffs of both ETTs and LMAs inflate with increases in altitude as barometric pressure decreases (30 mbar/1000 feet). Tracheal mucosa perfusion becomes compromised at a pressure of approximately 30 cm H2O; critical perfusion pressure is 50 cm H2O. METHODS: The change in dimensions of the inflated cuffs of a size 8 ETT and a size 5 LMA were measured with digital callipers at 1000 feet intervals in the unpressurised cabin of an Agusta 109 helicopter used by the Warwickshire and Northamptonshire Air Ambulance. RESULTS: A linear expansion in cuff dimensions as a function of altitude increase was identified. For ETTs, a formula for removal of air from the cuff with increasing altitude was calculated and is recommended for use in aeromedical transfers. This is 1/17x1.1 = 0.06 ml/1000 foot ascent/ml initial cuff inflation. CONCLUSION: The data for LMA cuff expansion failed to show significant correlation with altitude change. Further work is required to determine a similar rule of thumb for LMA cuff deflation.