High-Dose Methotrexate: Nursing Considerations for Administration and Supportive Care.

BACKGROUND: High-dose methotrexate (HDMTX) is the backbone of many pediatric and adult oncology treatment protocols. It requires appropriate monitoring and supportive care because delayed elimination of MTX can lead to serious toxicities. No reviews specifically addressing nursing management regarding standard treatment protocols and delayed MTX elimination exist. OBJECTIVES: This article provides an overview of HDMTX treatment and nursing considerations, including toxicities, components of supportive care management, and strategies to manage administration and delayed elimination of MTX. METHODS: A review of published literature and guidelines was performed to evaluate nursing considerations for patients receiving HDMTX. FINDINGS: Using existing and novel tools, nurses can closely monitor patients and provide supportive care to mitigate HDMTX toxicity. Early identification of delayed MTX elimination and subsequent treatment with glucarpidase, if appropriate, has been associated with shorter length of hospital stay and decreased incidence of grade 4 toxicities and mortality.

"Clinical Teachers: Teaching Tips for the Busy Veterinary Team": Reflections on the Development of a Multimodal Resource for Veterinarians and Veterinary Nurses/ Technologists New to Clinical Teaching.

Clinical practice-based training/work-integrated learning is an applied, social, and high-impact element of the veterinary curriculum. Within this context, students are learning on the job with clinician-educators who are carrying out their professional duties at the same time as supporting learning. To equip clinician-educators with role awareness and general teaching skills, it is recommended that all have access to basic teacher training. However, delivering this training can be challenging to organize and potentially costly when busy, time-poor clinician-educators are distributed across many geographical locations. This Teaching Tip shares our insights about developing and delivering a set of novel clinical teacher resources for veterinarians and veterinary nurses/technologists new to clinical teaching. The resources, underpinned by the principles of participatory design, integrate contemporary clinical educational theories with practical strategies and are interwoven with video clips capturing staff and student perspectives on key topics. While initially focused on creating just an online resource, we ultimately produced an A6 ring-bound booklet version and face-to-face workshops. In this article, we unpack considerations involved in committing to such a project and designing and creating the resources. We hope that this information may be of use to others when developing similar resources.

Funders' responsibility to ensure value in research: a self-audit by the Health Research Board Ireland.

As a public funder of health research, the Health Research Board (HRB) Ireland has an obligation to manage its funds well and to maximise the value of the research that it funds. Ways in which research funding can be wasted have been examined by researchers over the years, and a seminal series on research waste was published in the Lancet in 2014. The series systematically analysed every step of the funding lifecycle in five major stages and made recommendations to various actors including research funders. Prompted by its participation in the Ensuring Value in Research Funders' Forum, between June and October 2019 the HRB undertook a self-audit against the 17 recommendations identified in the Lancet series. Key HRB staff collated relevant policies and practices regarding each recommendation and sub-recommendation and assessed the HRB's performance under each heading. The self-assessment reflects the state of HRB policies and practices in October 2019.  Of the 17 recommendations, five were found to be areas of strength and six were found to be areas of partial strength. Areas of strength reflect work over many years such as support for evidence synthesis, strong processes around award selection, driving research integrity and open data including an HRB-funded open publishing platform. Four recommendations were found to be areas for growth. These mostly revolve around real time reporting of study protocols and of ongoing funded research outside of clinical trials. Work is progressing to address some of these areas. Two were found not to apply to the HRB.

The Medical Device Unique Device Identifier as the Single Source of Truth in Healthcare Enterprises - Roadmap for Implementation of the Clinically Integrated Supply Chain.

Documentation and tracking of supplies, equipment and medical devices is central to operational, financial, and clinical aspects of safe, efficient, and effective patient care. The labeling of medical devices with a unique device identifier (UDI) creates the opportunity to tightly integrate device information across health information systems by using the UDI as the index "source of truth". Across 3 hospitals of the Duke University Health System, we executed a comprehensive implementation of UDI-based device and supply information management in our cardiac catheterization and electrophysiology laboratories. Following are our key insights. Implementing a UDI-centric environment is a complex undertaking requiring integration of information systems, management processes, and clinical workflows involving leadership, inventory management, supply chain, clinical and billing teams. Implementation involves the domains of procedure documentation, electronic health records (EHRs), charge capture and billing, and interface and information technology systems, including information systems vendors. Replacing manual processes with electronic messages is not simply an exercise in programming information systems - successful execution requires orchestrated re-engineering of clinical and operational workflows. Our initiative resulted in a more efficient and effective supply chain, eliminated operational and clinical documentation errors, automated the posting of device implant data to the EHR, reduced clinician burden, improved charge capture, and produced a substantial financial benefit, with return on investment recognized in well under 1 year. We believe our stepwise approach to accomplishing a clinically integrated supply chain can serve as a roadmap for other healthcare enterprises to follow.

Use of Virtual Reality for minor procedures in the Emergency Department: A scoping review.

BACKGROUND: The objective of this review was to collate, summarise and report evidence on the use of VR as an interventional tool for pain and anxiety management during ED procedures. METHODS: Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) we searched Medline, Embase, CINAHL, Scopus and PsychInfo databases, grey literature and reference lists of included studies. RESULTS: From 162 articles, 4 fulfilled the selection criteria and demonstrated VR was effective as an intervention for management of pain and anxiety during ED procedures. The level of evidence was variable: 2 randomised controlled trials (RCT); a descriptive study; and a commentary on a literature review. Participants were aged 4-17 years and the sample sizes were small (n = 20, 59, 64). One RCT compared efficacy of VR to 2 other standard of care (SOC) distractors while the other RCT assessed for VR efficacy and safety. All four articles cited benefits of VR distraction as a procedural intervention in ED. CONCLUSIONS: A small number of studies involving children undergoing needle insertion in ED found VR to be a safe and effective means of managing procedural anxiety, providing a more effective strategy than standard care. Studies with larger samples, involving different procedures and across age groups are required.

An open toolkit for tracking open science partnership implementation and impact.

Serious concerns about the way research is organized collectively are increasingly being raised. They include the escalating costs of research and lower research productivity, low public trust in researchers to report the truth, lack of diversity, poor community engagement, ethical concerns over research practices, and irreproducibility. Open science (OS) collaborations comprise of a set of practices including open access publication, open data sharing and the absence of restrictive intellectual property rights with which institutions, firms, governments and communities are experimenting in order to overcome these concerns. We gathered two groups of international representatives from a large variety of stakeholders to construct a toolkit to guide and facilitate data collection about OS and non-OS collaborations. Ultimately, the toolkit will be used to assess and study the impact of OS collaborations on research and innovation. The toolkit contains the following four elements: 1) an annual report form of quantitative data to be completed by OS partnership administrators; 2) a series of semi-structured interview guides of stakeholders; 3) a survey form of participants in OS collaborations; and 4) a set of other quantitative measures best collected by other organizations, such as research foundations and governmental or intergovernmental agencies. We opened our toolkit to community comment and input. We present the resulting toolkit for use by government and philanthropic grantors, institutions, researchers and community organizations with the aim of measuring the implementation and impact of OS partnership across these organizations. We invite these and other stakeholders to not only measure, but to share the resulting data so that social scientists and policy makers can analyse the data across projects.

Recommendations for a Standardized Pulmonary Function Report. An Official American Thoracic Society Technical Statement.

BACKGROUND: The American Thoracic Society committee on Proficiency Standards for Pulmonary Function Laboratories has recognized the need for a standardized reporting format for pulmonary function tests. Although prior documents have offered guidance on the reporting of test data, there is considerable variability in how these results are presented to end users, leading to potential confusion and miscommunication. METHODS: A project task force, consisting of the committee as a whole, was approved to develop a new Technical Standard on reporting pulmonary function test results. Three working groups addressed the presentation format, the reference data supporting interpretation of results, and a system for grading quality of test efforts. Each group reviewed relevant literature and wrote drafts that were merged into the final document. RESULTS: This document presents a reporting format in test-specific units for spirometry, lung volumes, and diffusing capacity that can be assembled into a report appropriate for a laboratory's practice. Recommended reference sources are updated with data for spirometry and diffusing capacity published since prior documents. A grading system is presented to encourage uniformity in the important function of test quality assessment. CONCLUSIONS: The committee believes that wide adoption of these formats and their underlying principles by equipment manufacturers and pulmonary function laboratories can improve the interpretation, communication, and understanding of test results.

Client Perspectives on Desirable Attributes and Skills of Veterinary Technologists in Australia: Considerations for Curriculum Design.

Client or service user perspectives are important when designing curricula for professional programs. In the case of veterinary technology, an emerging profession in the veterinary field in Australasia, client views on desirable graduate attributes, skills, and knowledge have not yet been explored. This study reports on a survey of 441 veterinary clients (with 104 responses) from four veterinary practices in Brisbane, Queensland, conducted between October 2008 and February 2009. The included veterinary practices provided clinical placements for veterinary technology undergraduates and employment for veterinary technology graduates (2003-2007). Client socio-demographic data along with ratings of the importance of a range of technical (veterinary nursing) skills, emotional intelligence, and professional attributes for veterinary technology graduates were collected and analyzed. Overall, the majority of clients viewed technical skills, emotional intelligence, and professional attributes as important in the clinical practice of veterinary technology graduates with whom they interacted in the veterinary practice. Client interviews (n=3) contextualized the survey data and also showed that clients attached importance to graduates demonstrating professional competence. Agglomerative hierarchical cluster analysis revealed four distinct groupings of clients within the data based on their differing perceptions. Using a multivariable proportional-odds regression model, it was also found that some client differences were influenced by demographic factors such as gender, age, and number of visits annually. For example, the odds of female clients valuing emotionality and sociability were greater than males. These findings provide useful data for the design of a professionalizing and market-driven veterinary technology curriculum.

OA34†Forum on end of life: working to influence policy.

BACKGROUND: The Forum on End of Life in Ireland was launched in 2009 and has conducted a year-long public consultation about end of life issues. A National Council was set up to carry out the work of the Forum. Think Ahead is a public awareness initiative of the Forum on End of Life in Ireland which guides people in recording important information in the event that they are unable to speak for themselves, due to serious illness, emergency or death. AIM: The Forum has advocated for legislation of advance health care directives and has worked to raise awareness among members of the public in relation to their rights. Currently in Ireland while common law recognises people's right to express preferences and make directives, there has been no legislative framework for this, despite European and international law regarding personal autonomy and the right to self-determination. METHOD: Organised briefings and information seminars for public representatives Organised public meetings and national conferences which deal with the importance of advance healthcare directives Spoke of the importance of advance healthcare directives and advance care planning as part of the Oireachtas (Irish Parliament) Health Committee hearings on end of life Called for wider national end of life strategy to take a comprehensive approach to end of life issues, including health, legal, administrative, financial and social. RESULTS: Advance healthcare directives are provided for in the Assisted Decision Making (Capacity) Bill 2013. CONCLUSION: The aforementioned Bill has yet to be enacted and there remains work to be done in developing policy in this area.

Demographics and employment destinations of a new group of veterinary technologists in Australia.

This article provides a descriptive analysis of the demographics and employment destinations of the first three cohorts (2003-2005) of graduates (N=69) from a program that is unique in Australia: the Bachelor of Applied Science (Veterinary Technology) at the University of Queensland. Data for this study were collected in February 2006 via e-mail, telephone, or personal communication with graduates, and from university records. Ninety-three percent (64/69) of the graduates were female. The mean age was 23 years, and 58% (40/69) had entered university directly from high school. Employment destinations were determined for 96% of the graduates (N=66). Of those, 52% (34/66) were employed in veterinary practices. Government agencies and allied animal industries accounted for 15% (10/66). Another 14% (9/66) had enrolled in further undergraduate study. Three percent (2/66) had enrolled in a research honors year or a doctor of philosophy (PhD) degree program at the School of Veterinary Science. Eight percent (5/66) were employed in wildlife parks, zoos, or universities, and the remaining 9% (6/66) were traveling overseas, seeking employment, or employed outside the field. The study revealed that graduates were employed in diverse veterinary and allied animal health occupations. There appears to be a niche for Australian veterinary technology graduates educated in a university environment that complements the role of the veterinary profession in the twenty-first century. This reflects trends emerging in other countries, most notably the United States and the United Kingdom.

'Event tree' analysis of out-of-hospital cardiac arrest data: confirming the importance of bystander CPR.

OBJECTIVE: The British National Service Framework (NSF) for heart disease commended the 'Utstein style' for auditing out-of-hospital cardiac arrests. The NSF also set standards for pre-hospital treatment and response times. To increase the flexibility of Utstein, an 'event tree' technique is proposed as an audit tool. Event trees consist of nodes and branches on which numbers, percentages or probability values are entered. METHODS: Using the London Ambulance Service's (LAS) 1997 database on 3,759 out-of-hospital cardiac arrests, 2,772 arrests witnessed by lay bystanders or unwitnessed were analysed focusing on bystander cardiopulmonary resuscitation (BCPR) and response times. RESULTS: The Utstein template showed that witnessed arrests in ventricular fibrillation (VF) or ventricular tachycardia (VT) who had received BCPR achieved a return of spontaneous circulation (ROSC) in the field significantly more often than non-BCPR recipients-26 versus 16% (P=0.006). But the likelihood of being admitted to a hospital bed, and discharged alive, was only marginally better for BCPR recipients. To examine the influence of BCPR on the presenting rhythm an event tree showed that in 48% of witnessed BCPR cases the presenting rhythm was VF/VT, whereas, for witnessed non-BCPR cases, 27% were in VF/VT (P<0.0001). With unwitnessed arrests, 31% of BCPR cases were in VF/VT compared with 18% for non-BCPR cases (P<0.0001). Call to scene time was less than 8 min for 66% of all VF/VT arrests. CONCLUSION: The event trees, when combined with the Utstein template, demonstrated the importance of examining comprehensively datasets for both witnessed and unwitnessed cardiac arrests when monitoring performance standards. The analyses also emphasised the relevance of community programmes in Greater London for teaching basic life saving skills.

Unresolved issues in mammalian fertilization.

This review considers the role of the sperm in fertilization, addressing areas of misunderstanding and unfounded assumptions and taking particular advantage of the large body of data resulting from work with rodent species in vitro. Considerable attention is given to the appropriate use and interpretation of assays for capacitation, acrosomal exocytosis, hyperactivation, and sperm protein phosphorylation, as well as tests for sperm-zona and sperm-oocyte membrane interactions. The lack of general agreement on the means of sperm adhesion to and penetration of the zona pellucida is addressed, and the need for new approaches to this problem is pointed out. Some molecular advances in our understanding of specific steps in the process of fertilization are discussed in the context of intact cell-matrix and cell-cell interaction. This review should provide practical information for researchers just beginning the study of fertilization and interesting but not widely known observations to stimulate new ideas in experienced scientists.

Male infertility, impaired sperm motility, and hydrocephalus in mice deficient in sperm-associated antigen 6.

Gene targeting was used to create mice lacking sperm-associated antigen 6 (Spag6), the murine orthologue of Chlamydomonas PF16, an axonemal protein containing eight armadillo repeats predicted to be important for flagellar motility and stability of the axoneme central apparatus. Within 8 weeks of birth, approximately 50% of Spag6-deficient animals died with hydrocephalus. Spag6-deficient males surviving to maturity were infertile. Their sperm had marked motility defects and was morphologically abnormal with frequent loss of the sperm head and disorganization of flagellar structures, including loss of the central pair of microtubules and disorganization of the outer dense fibers and fibrous sheath. We conclude that Spag6 is essential for sperm flagellar motility and that it is important for the maintenance of the structural integrity of mature sperm. The occurrence of hydrocephalus in the mutant mice also implicates Spag6 in the motility of ependymal cilia.