Dignity during work-integrated learning: Piloting an online learning resource for placement students and supervisors.

What was the educational challenge?Medical student abuse within work-integrated learning (WIL) is well-reported, with negative consequences for wellbeing, motivation, and learning. Conversely, workplace dignity, described as respecting the worth of others and self, has positive impacts on wellbeing, learning, and relationships for WIL students and supervisors. Stakeholders often struggle to articulate what workplace dignity means, and can downplay or do nothing in the face of WIL indignities.What was the solution and how was this implemented?We created an innovative research-informed online learning resource about WIL dignity to improve stakeholders' understandings and help them get the best from WIL placements ensuring these are dignified, safe, and educationally productive. The resource included three topics: (a) workplace dignity and why it matters; (b) upholding dignity; and (c) strengthening dignity.What lessons were learned?We conducted a pilot qualitative evaluation involving 13 semi-structured interviews with students and supervisors to elicit their views and experiences of the resource. Our key findings across three overarching categories were: (1) perceived benefits (motivations to complete the resource; content of the resource; online pedagogies); (2) potential applications of learning (reinforcing existing knowledge; developing new knowledge; promoting reflection; changing workplace practices); and (3) suggested improvements (barriers to resource use; resource content; online pedagogies; timing of resource implementation; embedding the resource in broader learning).What are the next steps?Although we identified numerous perceived benefits, and applications of learning, the findings suggested opportunities for further development, especially improving the resource's social interactivity. We recommend that further resource implementation includes student-educator and student-peer interactivity to maximise learning, and longitudinal evaluation of the resource.

Conceptualizing weight management for night shift workers: A mixed-methods systematic review.

Shift workers have an increased risk of obesity and metabolic conditions. This mixed-methods systematic literature review on night shift workers aimed to: (1) identify barriers/enablers of weight management; (2) examine effectiveness of weight management interventions; and (3) determine whether interventions addressed enablers/barriers. Six databases were searched, articles screened by title/abstract, followed by full-text review, and quality assessment. Eligible qualitative studies documented experiences of behaviors related to weight change. Eligible quantitative studies were behavior change interventions with weight/body mass index outcomes. A thematic synthesis was undertaken for qualitative studies using the social-ecological model (SEM). Interventions were synthesized narratively including: weight/body composition change; components mapped by behavior change taxonomy; and SEM. A synthesis was undertaken to identify if interventions addressed perceived enablers/barriers. Eight qualitative (n = 169 participants) and 12 quantitative studies (n = 1142 participants) were included. Barriers predominated discussions: intrapersonal (time, fatigue, stress); interpersonal (work routines/cultural norms); organizational (fatigue, lack of: routine, healthy food options, breaks/predictable work); community (lack of healthy food options). The primary outcome for interventions was not weight loss and most did not address many identified enablers/barriers. One intervention reported a clinically significant weight loss result. Weight loss interventions that address barriers/enablers at multiple SEM levels are needed.

A roadmap to realist interviews in health professions education research: Recommendations based on a critical analysis.

CONTEXT: Realist evaluation is increasingly employed in health professions education research (HPER) because it can unpack the extent to which complex educational interventions work (or not), for whom under what circumstances and how. While realist evaluation is not wedded to particular methods, realist interviews are commonly the primary, if not only, data collection method in realist evaluations. While qualitative interviewing from an interpretivist standpoint has been well-articulated in the HPER literature, realist interviewing differs substantially. The former elicits participants' views and experiences of a topic of inquiry, whereas realist interviewing focuses on building, testing and/or refining programme theory. Therefore, this article aims to help readers better understand, conduct, report and critique realist interviews as part of realist evaluations. METHODS: In this paper, we describe what realist approaches are, what realist interviewing is and why realist interviewing matters. We outline five stages to realist interviewing (developing initial programme theory, realist sampling/samples, the interview itself, realist analysis and reporting realist interviews), drawing on two illustrative cases from our own realist evaluations employing interviewing to bring theory to life. We provide a critical analysis of 12 realist evaluations employing interviewing in the HPER literature. Alongside reporting standards, and our own realist interviewing experiences, this critical analysis of published articles serves to foreground our recommendations for realist interviewing. CONCLUSIONS: We encourage HPE researchers to consider realist interviews as part of realist evaluations of complex interventions. Our critical analysis reveals that realist interviews can provide unique insights into HPE, but authors now need to report their sampling approach, type of interviewing and interview questions more explicitly. Studies should also more explicitly draw on existing realist interviewing literature and follow reporting guidelines for realist evaluations. We hope this paper provides a useful roadmap to conducting, reporting and critically appraising realist interviews in HPER.

Evaluation of the "Shifting Weight using Intermittent Fasting in night-shift workers" weight loss interventions: a mixed-methods protocol.

Introduction: Shift workers are at a greater risk for obesity-related conditions. The impacts of working at night presents a challenge for designing effective dietary weight-loss interventions for this population group. The Shifting Weight using Intermittent Fasting in night-shift workers (SWIFt) study is a world-first, randomized controlled trial that compares three weight-loss interventions. While the trial will evaluate the effectiveness of weight-loss outcomes, this mixed-methods evaluation aims to explore for who weight-loss outcomes are achieved and what factors (intervention features, individual, social, organisational and wider environmental) contribute to this. Methods: A convergent, mixed-methods evaluation design was chosen where quantitative and qualitative data collection occurs concurrently, analyzed separately, and converged in a final synthesis. Quantitative measures include participant engagement assessed via: dietary consult attendance, fulfillment of dietary goals, dietary energy intake, adherence to self-monitoring, and rates for participant drop-out; analyzed for frequency and proportions. Regression models will determine associations between engagement measures, participant characteristics (sex, age, ethnicity, occupation, shift type, night-shifts per week, years in night shift), intervention group, and weight change. Qualitative measures include semi-structured interviews with participants at baseline, 24-weeks, and 18-months, and fortnightly audio-diaries during the 24-week intervention. Interviews/diaries will be transcribed verbatim and analyzed using five-step thematic framework analysis in NVivo. Results from the quantitative and qualitative data will be integrated via table and narrative form to interrogate the validity of conclusions. Discussion: The SWIFt study is a world-first trial that compares the effectiveness of three weight-loss interventions for night shift workers. This mixed-methods evaluation aims to further explore the effectiveness of the interventions. The evaluation will determine for who the SWIFt interventions work best for, what intervention features are important, and what external factors need to be addressed to strengthen an approach. The findings will be useful for tailoring future scalability of dietary weight-loss interventions for night-shift workers.Clinical trial registration: This evaluation is based on the SWIFt trial registered with the Australian New Zealand Clinical Trials Registry [ACTRN 12619001035112].

What Really Matters for Supervision Training Workshops? A Realist Evaluation.

PURPOSE: Supervision training supports health care supervisors to perform their essential functions. Realist evaluations are increasingly popular for evaluating complex educational interventions, but no such evaluations exist appraising supervision workshops. Building on an earlier realist synthesis of supervision training, the authors evaluated whether supervision workshops work, for whom and under what circumstances, and why. METHOD: The authors conducted a 2-stage realist evaluation during 2018-2019 to refine and develop program theory. The intervention involved half-day, face-to-face supervision workshops as part of an Australian state-wide government-funded program for health care and human services supervisors. Data collection involved realist interviews with 10 workshop developers (stage 1) and 43 supervisors (stage 2). The authors employed team-based data analysis using realist logic to refine and develop program theory by identifying contexts, mechanisms, outcomes, and context-mechanism-outcome configurations. RESULTS: Despite their brevity, the supervision workshops had many reported benefits for supervisors (e.g., improved satisfaction) through various perceived mechanisms pertaining to pedagogy (e.g., mixed pedagogies), workshops (e.g., optimal duration), and individuals (e.g., supervisor engagement). However, they also yielded negative reported outcomes (e.g., suboptimal knowledge gains) brought about by assorted perceived mechanisms related to pedagogy (e.g., suboptimal peer learning), workshops (e.g., content irrelevance), and individuals (e.g., suboptimal facilitator competence). Such mechanisms were thought to be triggered by diverse contexts including supervisors' levels of experience, sector, and workplace supervision cultures. CONCLUSIONS: While the findings partly support the realist synthesis of supervision training and previous realist evaluations of faculty development, this realist evaluation extends this literature considerably. Health care educators should employ mixed pedagogies (e.g., didactic teaching, peer learning), relevant content, optimal workshop duration, and competent/engaging facilitators. Educators also need to tailor workshops according to supervisors' contexts including the sectors and supervision cultures in which supervision is practiced, and supervisors' levels of experience (e.g., experienced supervisors appreciated workshop brevity).

Study protocol for the Shifting Weight using Intermittent Fasting in night shift workers (SWIFt) study: a three-arm randomised controlled trial comparing three weight loss strategies in night shift workers with obesity.

INTRODUCTION: Shift workers are at an increased risk of developing obesity and type 2 diabetes. Eating and sleeping out of synchronisation with endogenous circadian rhythms causes weight gain, hyperglycaemia and insulin resistance. Interventions that promote weight loss and reduce the metabolic consequences of eating at night are needed for night shift workers. The aim of this study is to examine the effects of three weight loss strategies on weight loss and insulin resistance (HOMA-IR) in night shift workers. METHODS AND ANALYSIS: A multisite 18-month, three-arm randomised controlled trial comparing three weight loss strategies; continuous energy restriction; and two intermittent fasting strategies whereby participants will fast for 2 days per week (5:2); either during the day (5:2D) or during the night shift (5:2N). Participants will be randomised to a weight loss strategy for 24 weeks (weight loss phase) and followed up 12 months later (maintenance phase). The primary outcomes are weight loss and a change in HOMA-IR. Secondary outcomes include changes in glucose, insulin, blood lipids, body composition, waist circumference, physical activity and quality of life. Assessments will be conducted at baseline, 24 weeks (primary endpoint) and 18 months (12-month follow-up). The intervention will be delivered by research dietitians via a combination of face-to-face and telehealth consultations. Mixed-effect models will be used to identify changes in dependent outcomes (weight and HOMA-IR) with predictor variables of outcomes of group, time and group-time interaction, following an intention-to-treat approach. ETHICS AND DISSEMINATION: The study protocol was approved by Monash Health Human Research Ethics Committee (RES 19-0000-462A) and registered with Monash University Human Research Ethics Committee. Ethical approval has also been obtained from the University of South Australia (HREC ID: 202379) and Ambulance Victoria Research Committee (R19-037). Results from this trial will be disseminated via conference presentations, peer-reviewed journals and student theses. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN-12619001035112).

The effectiveness of extended-duration supervision training for nurses and allied health professionals: A realist evaluation.

BACKGROUND: Training helps maintain high-quality supervision and its associated benefits (e.g. reduced burnout, improved care). While studies have previously evaluated extended-duration supervision training programmes, none have treated these as complex interventions so have not employed realist approaches. OBJECTIVES: Building on a previous realist synthesis, this evaluation tests and develops programme theory for extended-duration supervision training to answer the question: to what extent does the supervision training programme work, for whom, under what circumstances and why? DESIGN: We conducted a realist evaluation of a novel state-wide Victorian 3-month supervision training programme including one or two 3.5-h workshops followed by weekly reflexive longitudinal audio diaries (LADs) for up to 12 weeks. METHODS: Realist evaluation data comprised 25 entrance interviews with nurses and allied health professionals, 176 LADs (and 29 written diaries), and 23 exit interviews. We employed team-based realist analysis to identify context-mechanism-outcome configurations (CMOCs) to test and develop programme theory. RESULTS: We refined four recurring CMOCs from the realist synthesis programme theory, found insufficient evidence for two, and established five new recurring CMOCs. We identified multiple positive outcomes from our extended-duration supervision training programme (e.g. improved supervisor practices) through various mechanisms relating to pedagogy (e.g. weekly reflexivity), supervisors (e.g. engagement), and workplaces (e.g. enabling supervision cultures). Some negative outcomes were reported (e.g. decreased engagement) through various mechanisms (e.g. suboptimal training design). Such mechanisms were thought to come about by diverse contexts including supervisors (e.g. inexperienced/experienced), professions (nursing/allied health), and organisations (supervision-enabled/non-enabled cultures). CONCLUSIONS: Our findings extend the realist synthesis programme theory by highlighting various contexts triggering outcome-generating mechanisms. Programme outcomes are maximised through ongoing supervisor reflexivity paying attention to facilitator-supervisor relationships, as well as protected time for supervisors to translate learning into practice.

Student dignity during work-integrated learning: a qualitative study exploring student and supervisors' perspectives.

While University students increasingly participate in work-integrated learning (WIL), their dignity is often violated during WIL. The current literature is limited in so far as it typically focuses on student perspectives within healthcare contexts and does not use the concept of 'dignity'. Instead, this study explored student and supervisor perspectives on student dignity during WIL across healthcare and non-healthcare disciplines. Research questions included: What are: (1) types of student dignity experiences and patterns by groups; (2) factors contributing to experiences; (3) consequences of experiences? Sixty-five semi-structured interviews were conducted using narrative interviewing techniques with 30 supervisors and 46 students from healthcare (medicine, nursing and counselling) and non-healthcare (business, law and education) disciplines. Data were analyzed using framework analysis. Nine common narrative types were identified within 344 stories: verbal abuse, right for learning opportunities, care, inclusion, reasonable expectations, right for appropriate feedback, equality, trust, and right to be informed. Factors contributing to dignity experiences and consequences were often at the individual level (e.g. student/supervisor characteristics). We found some salient differences in perceptions of experiences between students and supervisors, but few differences between healthcare and non-healthcare disciplines. This study extends WIL research based on student perspectives in healthcare, and provides practice and further research guidance to enhance student dignity during WIL.

Treatment of Clostridioides difficile Infection and Non-compliance with Treatment Guidelines in Adults in 10 US Geographical Locations, 2013-2015.

BACKGROUND: Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines describe recommended therapy for Clostridioides difficile infection (CDI). OBJECTIVE: To describe CDI treatment and, among those with severe CDI, determine predictors of adherence to the 2010 IDSA/SHEA treatment guidelines. DESIGN: We analyzed 2013-2015 CDI treatment data collected through the Centers for Disease Control and Prevention's Emerging Infections Program. Generalized linear mixed models were used to identify predictors of guideline-adherent therapy. PATIENTS: A CDI case was defined as a positive stool specimen in a person aged ≥ 18 years without a positive test in the prior 8 weeks; severe CDI cases were defined as having a white blood cell count ≥ 15,000 cells/µl. MAIN MEASURES: Prescribing and predictors of guideline-adherent CDI therapy for severe disease. KEY RESULTS: Of 18,243 cases, 14,257 (78%) were treated with metronidazole, 7683 (42%) with vancomycin, and 313 (2%) with fidaxomicin. The median duration of therapy was 14 (interquartile range, 11-15) days. Severe CDI was identified in 3250 (18%) cases; of 3121 with treatment data available, 1480 (47%) were prescribed guideline-adherent therapy. Among severe CDI cases, hospital admission (adjusted odds ratio [aOR] 2.48; 95% confidence interval [CI] 1.90, 3.24), age ≥ 65 years (aOR 1.37; 95% CI 1.10, 1.71), Charlson comorbidity index ≥ 3 (aOR 1.27; 95% CI 1.04, 1.55), immunosuppressive therapy (aOR 1.21; 95% CI 1.02, 1.42), and inflammatory bowel disease (aOR 1.56; 95% CI 1.13, 2.17) were associated with being prescribed guideline-adherent therapy. CONCLUSIONS: Provider adherence to the 2010 treatment guidelines for severe CDI was low. Although the updated 2017 CDI guidelines, which expand the use of oral vancomycin for all CDI, might improve adherence by removing the need to apply severity criteria, other efforts to improve adherence are likely needed, including educating providers and addressing barriers to prescribing guideline-adherent therapy, particularly in outpatient settings.

Designing a Multistakeholder Collaboration to Improve Preventive Care for Children With Sickle Cell Anemia.

Newly developed measures of health care quality for children with sickle cell anemia (SCA) have revealed significant performance gaps in recommended care. Historically, health systems, Medicaid health plans, and state Medicaid programs have not partnered with patients and families to improve SCA care delivery. We organized 2 novel multistakeholder design meetings to identify potential interventions to deliver high-quality preventive care for children with SCA. Invitees included patients with SCA, families, and representatives from pediatric hematology clinics, Medicaid health plans, community organizations, and a state Medicaid program. Participants identified some barriers to care through presentations and facilitated discussions. Over 35 potential interventions and 6 drivers of high-quality SCA preventive care delivery were organized into a key driver diagram. Many barriers to SCA care delivery could be addressed by Medicaid health plan resources to support members with chronic disease; however, these resources are infrequently used in the pediatric SCA population. Bridging gaps between stakeholder groups identified many potential interventions to improve SCA preventive care delivery at all levels of the health care system. Similar multistakeholder discussions may be useful for other communities interested in improving preventive care for children with SCA or other chronic pediatric diseases.

COPDGene® 2019: Redefining the Diagnosis of Chronic Obstructive Pulmonary Disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) remains a major cause of morbidity and mortality. Present-day diagnostic criteria are largely based solely on spirometric criteria. Accumulating evidence has identified a substantial number of individuals without spirometric evidence of COPD who suffer from respiratory symptoms and/or increased morbidity and mortality. There is a clear need for an expanded definition of COPD that is linked to physiologic, structural (computed tomography [CT]) and clinical evidence of disease. Using data from the COPD Genetic Epidemiology study (COPDGene®), we hypothesized that an integrated approach that includes environmental exposure, clinical symptoms, chest CT imaging and spirometry better defines disease and captures the likelihood of progression of respiratory obstruction and mortality. METHODS: Four key disease characteristics - environmental exposure (cigarette smoking), clinical symptoms (dyspnea and/or chronic bronchitis), chest CT imaging abnormalities (emphysema, gas trapping and/or airway wall thickening), and abnormal spirometry - were evaluated in a group of 8784 current and former smokers who were participants in COPDGene® Phase 1. Using these 4 disease characteristics, 8 categories of participants were identified and evaluated for odds of spirometric disease progression (FEV1 > 350 ml loss over 5 years), and the hazard ratio for all-cause mortality was examined. RESULTS: Using smokers without symptoms, CT imaging abnormalities or airflow obstruction as the reference population, individuals were classified as Possible COPD, Probable COPD and Definite COPD. Current Global initiative for obstructive Lung Disease (GOLD) criteria would diagnose 4062 (46%) of the 8784 study participants with COPD. The proposed COPDGene® 2019 diagnostic criteria would add an additional 3144 participants. Under the new criteria, 82% of the 8784 study participants would be diagnosed with Possible, Probable or Definite COPD. These COPD groups showed increased risk of disease progression and mortality. Mortality increased in patients as the number of their COPD characteristics increased, with a maximum hazard ratio for all cause-mortality of 5.18 (95% confidence interval [CI]: 4.15-6.48) in those with all 4 disease characteristics. CONCLUSIONS: A substantial portion of smokers with respiratory symptoms and imaging abnormalities do not manifest spirometric obstruction as defined by population normals. These individuals are at significant risk of death and spirometric disease progression. We propose to redefine the diagnosis of COPD through an integrated approach using environmental exposure, clinical symptoms, CT imaging and spirometric criteria. These expanded criteria offer the potential to stimulate both current and future interventions that could slow or halt disease progression in patients before disability or irreversible lung structural changes develop.

Intraoperative Venovenous Extracorporeal Membrane Oxygenation as Rescue for a Patient With an Inhalational Burn and Iatrogenic Upper Airway Injury: A Case Report.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a well-established alternative oxygenation method for critically ill patients. A 58-year-old male was transferred to our level 1 trauma and burn center after sustaining an inhalational injury from a carburetor explosion, with subsequent iatrogenic tracheal injury and emergent cricothyrotomy before arrival. During attempted surgical airway stabilization, our ability to ventilate and oxygenate was compromised. Intraoperative VV-ECMO enabled rescue from severe hypoxemia and subsequent recovery without lasting neurologic sequelae. This case highlights the utility of VV-ECMO for acute intraoperative rescue.

Exploring the impact of Aboriginal health placement experiences on the preparation of dietetic graduates for practice with Aboriginal communities.

AIM: A health workforce with the ability to practice with Aboriginal communities is crucial to bridge the health gap between Aboriginal and non-Aboriginal Australians. This study aimed to explore the impact of university Aboriginal health placements on preparing dietetic graduates for practice with Aboriginal communities. METHODS: A mixed methods sequential explanatory design was used. A sample of 594 dietetic graduates was invited to complete a survey that identified Aboriginal health experiences and measured attitudes and self-confidence towards working in Aboriginal health using a five-point Likert scale. Participants were divided into placement versus no-placement groups and compared using chi-squared tests. Sixteen of 33 participants who had completed an Aboriginal health placement were invited to participate in a semi-structured interview to explore how placement influenced practice with Aboriginal communities. Interviews were analysed using content analysis. RESULTS: A final sample of 120 participants showed that placement participants reported significantly higher self-confidence towards working in Aboriginal health compared with no-placement participants (No-placement = 35% agree, 36% neutral, 29% disagree; Placement = 74% agree, 11% neutral, 16% disagree; χ2 (2, 88) = 9.4; P = 0.01). Fifteen participants were interviewed. Interview data indicated that situated learning experiences, breaking down stereotypes, empathy through learning from Aboriginal people, and Aboriginal health role-models were key components of Aboriginal health placements in preparing dietetic graduates for practice with Aboriginal communities. CONCLUSIONS: The results suggest that Aboriginal health placements may be an effective strategy for preparing dietetic graduates for practice with Aboriginal communities. The feasibility of placement or alternative curriculum content needs to be explored.

Transformative effects of Aboriginal health placements for medical, nursing, and allied health students: A systematic review.

The aim of the present systematic review was to investigate whether placements in Aboriginal health affect the self-perceived skill in working in Aboriginal health settings and career aspirations of health students, and in particular, aspects of the placement that had the greatest impact. The Embase, Cinahl, ProQuest, Scopus, Informit, Ovid MEDLINE, PsychINFO, and PubMed databases were searched in April/May 2016. Placements of at least 1 week duration in an Aboriginal health setting involving Australian students of medical, nursing, dentistry, or allied health disciplines, with outcomes relating to changes in students' knowledge, attitudes, and/or career aspirations, were included. The search retrieved 1351 papers. Fourteen studies were eligible for inclusion in this review. Narrative synthesis found that work placements in Aboriginal health increased understanding and awareness of Aboriginal culture, promoted deeper understanding of Aboriginal health determinant complexity, increased awareness of everyday racism toward Aboriginal Australians, and enhanced desire to work in Aboriginal health. There is a need for improved teaching and learning scholarship to understand whether placements improve students' skill working with Aboriginal people in health care or increase the likelihood of future employment in these settings.

Suction evacuation of hemothorax: A prospective study.

BACKGROUND: Although tube thoracostomy is a common procedure after thoracic trauma, incomplete evacuation of fluid places the patient at risk for retained hemothorax. As little as 300 to 500 cm of blood may result in the need for an additional thoracostomy tube or, in more severe cases, lung entrapment and empyema. We hypothesized that suction evacuation of the thoracic cavity before tube placement would decrease the incidence of late complications. METHODS: Patients requiring tube thoracostomy within 96 hours of admission were prospectively identified and underwent suction evacuation of the pleural space (SEPS) before tube placement. These patients were compared to historical controls without suction evacuation. Demographics, admission vital signs, laboratory values, details of chest tube placement, and outcomes were collected on all patients. Multivariable logistic regression was used to compare outcomes between groups. RESULTS: A total of 199 patients were identified, consisting of 100 retrospective controls and 99 SEPS patients. There were no differences in age, sex, admission injury severity score or chest abbreviated injury score, admission laboratory values or vital signs, or hospital length of stay. Mean (SD) volume of hemothorax in SEPS patients was 220 (297) cm; with only 48% having a volume greater than 100 cm at the time of tube placement. Three patients developed empyema, and 19 demonstrated retained blood; there was no difference between SEPS and control patients. Suction evacuation of the pleural space was significantly protective against recurrent pneumothorax after chest tube removal (odds ratio, 0.332; 95% confidence interval, 0.148-0.745). CONCLUSION: Preemptive suction evacuation of the thoracic cavity did not have a significant impact on subsequent development of retained hemothorax or empyema. Suction evacuation of the pleural space significantly decreased incidence of recurrent pneumothorax after thoracostomy removal. Although the mechanism is unclear, such a benefit may make this simple procedure worthwhile. A larger sample size is required for validation and to determine if preemptive thoracic evacuation has a clinical benefit. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Contributions of KATP and KCa channels to cerebral arteriolar dilation to hypercapnia in neonatal brain.

Mechanisms by which Pco2 controls cerebral vascular tone remain uncertain. We hypothesize that potassium channel activation contributes to the neonatal cerebrovascular dilation in response to increases in Paco2. To test this hypothesis, experiments were performed on newborn pigs with surgically implanted, closed cranial windows. Hypercapnia was induced by ventilation with elevated Pco2 gas in the absence and presence of the KATP channel inhibitor, glibenclamide and/or the KCa channel inhibitor, paxillin. Dilations to pinacidil, a selective KATP channel activator, without and with glibenclamide, were used to evaluate the efficacy of KATP channel inhibition. Dilations to NS1619, a selective KCa channel activator, without and with paxillin, were used to evaluate the efficacy of KCa channel inhibition. Cerebrovascular responses to the KATP and KCa channel activators, pinacidil and NS1619, respectively, cAMP-dependent dilator, isoproterenol, and cGMP-dependent dilator, sodium nitroprusside (SNP), were used to evaluate the selectivity of glibenclamide and paxillin. Glibenclamide blocked dilation to pinacidil, but did not inhibit dilations to NS1619, isoproterenol, or SNP. Glibenclamide prior to hypercapnia decreased mean pial arteriole dilation ~60%. Glibenclamide treatment during hypercapnia constricted arterioles ~35%. The level of hypercapnia, Paco2 between 50 and 75 mmHg, did not appear to be involved in efficacy of glibenclamide in blocking dilation to Paco2. Similarly to glibenclamide and KATP channel inhibition, paxillin blocked dilation to the KCa channel agonist, NS1619, and attenuated, but did not block, arteriolar dilation to hypercapnia. Treatment with both glibenclamide and paxillin abolished dilation to hypercapnia. Therefore, either glibenclamide or paxillin that block dilation to their channel agonists, pinacidil or NS1619, respectively, only partially inhibit dilation to hypercapnia. Block of both KATP and KCa channels completely prevent dilation hypercapnia. These data suggest hypercapnia activates both KATP and KCa channels leading to cerebral arteriolar dilation in newborn pigs.

Determinants of health after hospital discharge: rationale and design of the Vanderbilt Inpatient Cohort Study (VICS).

BACKGROUND: The period following hospital discharge is a vulnerable time for patients when errors and poorly coordinated care are common. Suboptimal care transitions for patients admitted with cardiovascular conditions can contribute to readmission and other adverse health outcomes. Little research has examined the role of health literacy and other social determinants of health in predicting post-discharge outcomes. METHODS: The Vanderbilt Inpatient Cohort Study (VICS), funded by the National Institutes of Health, is a prospective longitudinal study of 3,000 patients hospitalized with acute coronary syndromes or acute decompensated heart failure. Enrollment began in October 2011 and is planned through October 2015. During hospitalization, a set of validated demographic, cognitive, psychological, social, behavioral, and functional measures are administered, and health status and comorbidities are assessed. Patients are interviewed by phone during the first week after discharge to assess the quality of hospital discharge, communication, and initial medication management. At approximately 30 and 90 days post-discharge, interviewers collect additional data on medication adherence, social support, functional status, quality of life, and health care utilization. Mortality will be determined with up to 3.5 years follow-up. Statistical models will examine hypothesized relationships of health literacy and other social determinants on medication management, functional status, quality of life, utilization, and mortality. In this paper, we describe recruitment, eligibility, follow-up, data collection, and analysis plans for VICS, as well as characteristics of the accruing patient cohort. DISCUSSION: This research will enhance understanding of how health literacy and other patient factors affect the quality of care transitions and outcomes after hospitalization. Findings will help inform the design of interventions to improve care transitions and post-discharge outcomes.

Association of brief health literacy screening and blood pressure in primary care.

Health literacy impacts health outcomes. However, the relationship to blood pressure is inconsistent. This study aimed to determine whether health literacy, assessed by clinic staff, is associated with blood pressure among patients with hypertension. The design was a cross-sectional study of a large sample of primary care patient encounters in 3 academic medical center clinics in Nashville, Tennessee. Health literacy was assessed using the Brief Health Literacy Screen, with higher scores indicating higher health literacy. Blood pressure was extracted from the electronic health record. Using 23,483 encounters in 10,644 patients, the authors examined the association of health literacy with blood pressure in multivariable analyses, adjusting for age, gender, race, education, and clinic location. Independent of educational attainment, 3-point increases in health literacy scores were associated with 0.74 mmHg higher systolic blood pressure (95% CI [0.38, 1.09]) and 0.30 mmHg higher diastolic blood pressure (95% CI [0.08, 0.51]). No interaction between education and health literacy was observed (p = .91). In this large primary care population of patients with hypertension, higher health literacy, as screened in clinical practice, was associated with a small increase in blood pressures. Future research is needed to explore this unexpected finding.

High-speed microscopic imaging of flagella motility and swimming in Giardia lamblia trophozoites.

We report, in this paper, several findings about the swimming and attachment mechanisms of Giardia lamblia trophozoites. These data were collected using a combination of a high-contrast CytoViva imaging system and a particle image velocimetry camera, which can capture images at speeds greater than 800 frames/s. Using this system, we discovered that, during rapid swimming of Giardia trophozoites, undulations of the caudal region contributed to forward propulsion combined with the beating of the flagella pairs. It was also discovered, in contrast to previous studies with 10 times slower image sampling technique, that the anterior and posterolateral flagella beat with a clearly defined power stroke and not symmetrical undulations. During the transition from free swimming to attachment, trophozoites modified their swimming behavior from a rapid rotating motion to a more stable planar swimming. While using this planar swimming motion, the trophozoites used the flagella for propulsion and directional control. In addition to examination of the posterolateral and anterior flagella, a model to describe the motion of the ventral flagella was derived, indicating that the ventral flagella beat in an expanding sine wave. In addition, the structure of the ventrocaudal groove creates boundary conditions that determine the form of beating of the ventral flagella. The results from this study indicate that Giardia is able to simultaneously generate both ciliary beating and typical eukaryotic flagellar beating using different pairs of flagella.

When similarity leads to sparing: probing mechanisms underlying the attentional blink.

When two targets are embedded in a temporal stream of distractors, second-target identification is initially impaired and then gradually improves as inter-target interval lengthens (attentional blink; AB). Notably, in about half of the published studies, this deficit is partially ameliorated when the targets follow one another directly, a condition known as "lag-1 sparing". Here, we probe the impact of target-distractor similarity on lag-1 sparing, with the surprising finding that while high similarity impairs second-target accuracy at all subsequent lags, it actually improves accuracy when the targets follow one another directly. We suggest that this improvement reflects the positive influence of over-committing resources to target processing in the AB.