Optimizing Care for Military Women: The Value of the Dual-Certified Family and Women's Health Nurse Practitioner.

The number of women in the military has more than tripled over the past 50 years, increasing from 5% in the 1970s to 17% in 2023, making them essential for global health engagement and military operations. Provider competence and confidence are barriers to the consistent availability of preventive, gynecologic, and reproductive services for women across service locations and duty platforms. The Defense Health Board recommends standardizing services and improving the availability and scope of services for women at every point of care. In direct conflict with these recommendations, however, is a congressional call for a drawdown of medical forces, which creates a need for operationally trained clinicians with a broad skill set including comprehensive care for women. Advanced practice registered nurses, such as family and women's health nurse practitioners, are key assets to fill this gap on military medical health-care teams. At the request of the U.S. Air Force, the Graduate School of Nursing at the Uniformed Services University began offering a Women's Health Nurse Practitioner (WHNP) program in 2014. The WHNP curriculum was layered onto the existing Family Nurse Practitioner program so that Family Nurse Practitioner students receive enhanced education in women's health and WHNP students are prepared to meet the holistic, primary care needs of patients across the lifespan in addition to caring for women with obstetric and urogenital health concerns. This article highlights the value of dual-certified Family Nurse Practitioners and WHNPs in the military health-care system. These Uniformed Services University alumni are uniquely prepared to provide comprehensive primary and specialty care for female warfighters across the lifecycle from stable, well-resourced duty stations to austere, operational settings or deployment platforms.

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.

Mitochondrial disorders: Understanding mitochondrial DNA point mutations and deletion syndromes.

ABSTRACT: Mitochondrial disorders arise from DNA mutations in either the mitochondrial DNA (mtDNA) or nuclear DNA genomes. This article focuses on a mtDNA base-pair mutation associated with neuropathy, ataxia, and retinitis pigmentosa and Leigh syndrome and the large-scale mtDNA deletion associated with Kearns-Sayre syndrome. Disease sequelae and management strategies are reviewed, along with implications for the nurse practitioner in primary or specialty care.

The genomics of COVID.

ABSTRACT: Coronaviruses, named for their crown-like appearance, are relative newcomers to the human viral encyclopedia, but they are anything but new to the viral landscape. Initially thought to cause relatively mild disease in humans, it is now clear that coronaviruses can cause significant morbidity and mortality. COVID-19 provided a ringside seat from which to watch scientists use genomics in hundreds of ways to learn about, protect against, and ultimately control the effects of this novel virus. This article provides an overview of how genomics was used from the very first reported case in Wuhan, China to the development of at-home test kits, vaccines, and understanding the genetic association with increased risk for severe illness.

Genomics update 2022: Clinician and patient hot topics.

ABSTRACT: Advances in genomics research and clinical applications continue to accelerate. Coupled with the availability of direct-to-consumer (DTC) marketing of genetic testing and new discoveries, patients are increasingly coming into primary care with genomic questions. This article offers a snapshot of the kinds of questions patients are asking and that providers should be prepared to discuss such as what to do with DTC results or whether pharmacogenetics testing would help make sure "the right" medication is prescribed. Clinicians should understand the value of clinical guidelines (and where to find them), how to find a genetic specialist, what's happening with gene editing (to include gene sequencing), what's on the horizon in cancer care, and what the future might hold.

Dilemma of identifying congenital hemolytic anemias in primary care.

ABSTRACT: Anemia, the overall reduction of red blood cell (RBC) mass in an individual, occurs as a result of an underlying condition. It is probably the most common pathological state worldwide and can be acute, chronic, congenital, or acquired. It can be placed in one of three broad categories: blood loss, hypoproliferative, and hemolytic. The most common and easiest to correct is hypoproliferative anemia caused by nutritional deficiencies. The most common genetic anemias are caused by mutations on the alpha- or beta-globin genes, but there are other mutations that alter red cell membrane function or decrease the bone marrow's ability to manufacture RBCs. Understanding the mechanisms of anemia can help providers interpret the symptom(s)/presentation and guide the clinical workup. Nurse practitioners, especially those in primary care, should be able to recognize when a microcytic anemia is not caused by iron deficiency because these anemias are not corrected by iron supplementation and will need additional workup and referral to hematology.

Understanding the nomenclature of mitochondrial DNA mutations through examples of two specific disease entities: Mitochondrial encephalopathy with lactic acidosis and stroke-like episodes and Leber hereditary optic neuropathy.

ABSTRACT: Mitochondrial diseases are genetic disorders that can arise either from maternally inherited mitochondrial DNA (mtDNA) or from mutations in nuclear DNA. This article is the second in a series of papers reviewing mitochondrial genetics and several of the disorders associated with mitochondrial gene variants. With a prevalence of 1:∼4,300 persons, mitochondrial disorders are diagnostic entities with which nurse practitioners should be familiar. In describing genetic mutations, numbering nucleotides (nuclear or mtDNA) is critical for communicating exactly where a variation has occurred in a stretch of nucleotides. This article discusses the nomenclature associated with mtDNA mutations, using the examples of mutations causing mitochondrial encephalopathy with lactic acidosis and stroke-like episodes and Leber hereditary optic neuropathy. Pathophysiology, symptoms, and treatment options for these disease entities are discussed.

A competency roadmap for advanced practice nursing education using PRIME-NP.

BACKGROUND: Clinical competency validation is essential for nurse practitioner (NP) education and public accountability. While there has been robust discussion around what constitutes clinical competency and assessment, clear and consistent definitions and measurements remain elusive. PURPOSE: This article describes the PRIME-NP clinical competency model that is scalable, reproducible and accurately documents NP student competency across clinical courses. METHODS: To develop the model, work in 5 discrete domains was necessary: (a) model development, (b) assessment tool to be used in Objective Structured Clinical Exams (OSCE), (c) rubrics to accompany the OSCE exam, (d) faculty education, and (e) evaluating the model use. FINDINGS: Faculty and student outcomes reveal that the model and assessment tool acceptability and effectiveness of the model, especially for early identification for at risk students. CONCLUSION: The PRIME-NP offered faculty the opportunity to identify at-risk students, identify a more nuanced remediation plan, and assess student competency in simulated environments.

Precision Medicine-A Demand Signal for Genomics Education.

Pressed by the accumulating knowledge in genomics and the proven success of the translation of cancer genomics to clinical practice in oncology, the Obama administration unveiled a $215 million commitment for the Precision Medicine Initiative (PMI) in 2016, a pioneering research effort to improve health and treat disease using a new model of patient-powered research. The objectives of the initiative include more effective treatments for cancer and other diseases, creation of a voluntary national research cohort, adherence to privacy protections for maintaining data sharing and use, modernization of the regulatory framework, and forging public-private partnerships to facilitate these objectives. Specifically, the DoD Military Health System joined other agencies to execute a comprehensive effort for PMI. Of the many challenges to consider that may contribute to the implementation of genomics-lack of familiarity and understanding, poor access to genomic medicine expertise, needs for extensive informatics and infrastructure to integrate genomic results, privacy and security, and policy development to address the unique requirements of military medical practice-we will focus on the need to establish education in genomics appropriate to the provider's responsibilities. Our hypothesis is that there is a growing urgency for the development of educational experiences, formal and informal, to enable clinicians to acquire competency in genomics commensurate with their level of practice. Several educational approaches, both in practice and in development, are presented to inform decision-makers and empower military providers to pursue courses of action that respond to this need.

Genomics of aging: The role of sirtuin and metabolic health.

ABSTRACT: Healthy aging is not the result of a single factor. Genes, dietary choices/options, exercise, and environmental exposures all play a role. A family of seven nicotinamide adenine dinucleotide (NAD)-dependent sirtuin proteins are very involved in various metabolic functions, such as glucose and fat regulation, and polymorphisms in these genes have been associated with the development of obesity, type 2 diabetes, cancer, cardiovascular disease, and longevity. Nutraceuticals (i.e., resveratrol, quercetin, kaempferol, and curcumin) and other therapies (i.e., synthetic sirtuin-activating compounds, NAD, nicotinamide mononucleotide) are all being explored as in potential therapies in the sirtuin pathway and point to promising treatments to promote metabolic health and reduce obesity and age-related disease. For the clinician looking to reduce the risk of age-related metabolic disorders, evidence points to these supplements and appropriate food choices as the next generation of pharmaceutical grade therapies continue to be researched for human use.

Genomics of aging: Glycosylation.

ABSTRACT: This third article in the Genomics of Aging series explores the process of glycosylation and how abnormal glycosylation contributes to aging and disease (i.e., diabetes, cardiovascular disease [CVD], neurological disorder, and cancer). Glycosylation is an important posttranslational process that contributes to normal protein folding, cell adhesion, protein stability, and motility. Gradual accumulation of molecular errors contributes to the aging process, and specific genetic variants in this pathway have been identified in cancer, CVD, aging, and vulnerability to disease progression. Manipulating glycosylation pathways may be beneficial in reducing disease risk in the future. Smoking cessation has been shown to reverse epigenetic changes in glycosylation pathways that increase cancer, CVD, and all-cause mortality risk, and CVD risk may be reduced if a dimeric glycosylated fusion protein pathway can be regulated. Selective food sources and synthetic vitamins and antioxidants have been shown to support normal glycosylation and help in the cell repair process.

Genomics in nursing education.

Genetics/Genomics is a relatively new science. The basic principles were formally described at the end of the 19th century, the physical structure of genes were described in the middle of the 20th century, and the first gene located in the early 1990s. Later, the human genome was sequenced. More and more genes have been located and described and some are now being manipulated. All health professions are struggling to infuse genomic content into the curriculum. This article traces the roots of the undergraduate and graduate nursing competencies and provides a brief review of the literature describing nursing genetic/genomics education.

Military transgender care.

Transgender individuals have a long-standing history of honorable service in the United States Military. However, politics have had an impact on their ability to openly serve in uniform as policies continually change rapidly with each new administration. This article describes the shifting political landscape of policies related to whether (or not) transgender individuals can serve in the military, and how this has affected the health care experiences of transgender individuals and the ability for nurse practitioners to provide quality health care to the transgender population serving on active duty.

Genomics of aging: Genes, adducts, and telomeres.

Genomics influences the aging process in many different ways. This 10-part series of articles describes what is known about genetics and aging, including genes, adducts, and telomeres, decreased immune defenses, oxidation and inefficient mitochondria, toxins and radiation, glycosylation, caloric intake and sirtuin production, neurotransmitter imbalance, hormone mechanisms, reduced nitric oxide, and stem cell slowdown. This first article explores gene adducts as an epigenetic "sludge," the influence of telomeres and other mutations that contribute to DNA dysfunction, cell stress, and premature aging. Factors that contribute to adduct formation and reduced telomere length are presented along with some changes in behavior, environmental exposure, food/supplement use, weight, sleep, and exercise that have been found to reduce damage, potentially increasing longevity. Adherence to a Mediterranean diet that contains fruits and whole grains along with fiber, antioxidants (e.g., beta-carotene, vitamins C and E), omega-3 fatty acids, and soy protein may reduce DNA adducts and protect telomeres. So providers may want to recommend these simple but key clinical and individual changes to enhance DNA health, wellness, and longevity.

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.

Pharmacogenomics in clinical care.

Health care designed specifically for a person based on their genetic makeup ("personalized" or "precision" medicine) is expanding rapidly, especially in the area of drug selection. Pharmacogenomic (PGx) testing, when drugs and doses are selected based on an individual's genetic profile, is increasingly being used to guide the selection of drugs or therapies to optimize outcomes and minimize side effects. Based on an individual's genetic blueprint, health care providers now have important information about how a drug is likely to behave in that individual's body. Pharmacogenomic information on drug labels is now available for nearly 250 drugs. Health care organizations are also increasingly making this information available to customers to reduce emergency department visits, improve outcomes (selecting the right chemotherapy doses), and reduce cost. This study reviews some of the challenges and benefits on using PGx testing to improve clinical outcomes.

Gene editing: The power and risks of creation.

This article explores the origin of the first cellular structures, briefly examines the process of evolution, explores some of the earlier challenges in human gene editing, explains how bacterial immune systems have provided the secret to a very powerful gene editing tool, and finally explores some of the very troubling ethical issues emerging with gene editing.