Implementing modified family integrated care in a U.S. neonatal intensive care unit: nursing perspectives and effects on parents.

OBJECTIVES: (1) Assess effects of a modified Family Integrated Care (FICare) model on U.S. Neonatal Intensive Care Unit (NICU) parents; (2) Evaluate NICU nurses' perspectives. DESIGN: Case -control design with parental stress assessed before and after NICU-wide FICare implementation using Parent Stressor Scale: NICU (PSS:NICU) questionnaire. In addition, stratification by degree of participation evaluated associations with parental stress, parental-staff communication and discharge readiness. Questionnaires captured nursing perspectives on FICare. RESULTS: 79 parents (88%) participated prior to FICare; 90 (90%) after. Parent stress was lower (p < 0.001) with FICare. Parents learning 5-15 infant-care skills had lower stress compared to those learning <5 (p = 0.008). Parent utilization of an educational app was associated with improved communication frequency (p = 0.007) and quality (p = 0.012). Bedside NICU nurses reported multiple positive associations of FICare for parents and staff. CONCLUSIONS: Any degree of FICare participation decreases parental stress; increased participation has multiple positive associations.

Dosing Activity and Return to Preulcer Function in Diabetes-Related Foot Ulcer Remission.

Diabetes-related foot ulcers are a leading cause of global morbidity, mortality, and health-care costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year after healing, and most occur in the first 3 months after wound healing. Hence, this period after ulceration is called "remission" due to this risk of reulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health-related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate off-loading and monitoring in people with a recently healed foot ulcer, foot reconstruction, or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring, which can identify dangerous "hotspots" prone to recurrence. By understanding areas at risk, patients are empowered to maximize ulcer-free days and to enable an improved quality of life. This perspective outlines a unified strategy to treat patients in the remission period after ulceration and aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patients to ensure a safe transition to footwear and return to activity.

Cumulative impact assessment for ecosystem-based marine spatial planning.

Claims for ocean space are growing while marine ecosystems suffer from centuries of insufficient care. Human pressures from runoff, atmospheric emissions, marine pollution, fishing, shipping, military operations and other activities wear on habitats and populations. Ecosystem-based marine spatial planning (MSP) has emerged worldwide as a strategic instrument for handling conflicting spatial claims among competing sectors and the environment. The twofold objective of both boosting the blue economy and protecting the environment is challenging in practice and marine planners need decision support. Cumulative Impact Assessment (CIA) was originally developed to provide an overview of the human imprint on the world's ocean ecosystems. We have now added a scenario component to the CIA model and used it within Swedish ecosystem-based MSP. This has allowed us to project environmental impacts for different planning alternatives throughout the planning process, strengthening the integration of environmental considerations into strategic decision-making. Every MSP decision may entail a local shift of environmental impact, causing positive or negative consequences for ecosystem components. The results from Swedish MSP in the North Sea and Baltic Sea illustrate that MSP certainly has the potential to lower net cumulative environmental impact, both locally and across sea basins, as long as environmental values are rated high and prevailing pressures derive from activities that are part of MSP. By synthesizing innumerous data into comprehensible decision support that informs marine planners of the likely environmental consequences of different options, CIA enables ecosystem-based MSP in practice.

Spatial risk assessment of global change impacts on Swedish seagrass ecosystems.

Improved knowledge on the risk in ecologically important habitats on a regional scale from multiple stressors is critical for managing functioning and resilient ecosystems. This risk assessment aimed to identify seagrass ecosystems in southern Sweden that will be exposed to a high degree of change from multiple global change stressors in mid- and end-of-century climate change conditions. Risk scores were calculated from the expected overlap of three stressors: sea surface temperature increases, ocean acidification and wind driven turbid conditions. Three high-risk regions were identified as areas likely to be exposed to a particularly high level of pressure from the global stressors by the end of the century. In these areas it can be expected that there will be a large degree of stressor change from the current conditions. Given the ecological importance of seagrass meadows for maintaining high biodiversity and a range of other ecosystem services, these risk zones should be given high priority for incorporation into management strategies, which can attempt to reduce controllable stressors in order to mitigate the consequences of some of the impending pressures and manage for maintained ecosystem resilience.

Sea surface temperature dictates movement and habitat connectivity of Atlantic cod in a coastal fjord system.

While movements of organisms have been studied across a myriad of environments, information is often lacking regarding spatio-seasonal patterning in complex temperate coastal systems. Highly mobile fish form an integral part of marine food webs providing linkages within and among habitats, between patches of habitats, and at different life stages. We investigated how movement, activity, and connectivity patterns of Atlantic cod (Gadus morhua) are influenced by dynamic environmental conditions. Movement patterns of 39 juvenile and subadult Atlantic cod were assessed in two coastal sites in the Swedish Skagerrak for 5 months. We used passive acoustic telemetry and network analysis to assess seasonal and spatial movement patterns of cod and their relationships to different environmental factors, using statistical correlations, analysis of recurrent spatial motifs, and generalized linear mixed models. Temperature, in combination with physical barriers, precludes significant connectivity (complex motifs) within the system. Sea surface temperature had a strong influence on connectivity (node strength, degree, and motif frequency), where changes from warmer summer waters to colder winter waters significantly reduced movement activity of fish. As the seasons changed, movement of fish gradually decreased from large-scale (km) linkages in the summer to more localized movement patterns in the winter (limited to 100s m). Certain localized areas, however, were identified as important for connectivity throughout the whole study period, likely due to these multiple-habitat areas fulfilling functions required for foraging and shelter. This study provides new knowledge regarding inshore movement dynamics of juvenile and subadult Atlantic cod that use complex, coastal fjord systems. The findings show that connectivity, seasonal patterns in particular, should be carefully considered when selecting conservation areas to promote marine stewardship.

Disaggregation of gold nanoparticles by Daphnia magna.

The use of manufactured nanomaterials is rapidly increasing, while our understanding of the consequences of releasing these materials into the environment is still limited and many questions remain, for example, how do nanoparticles affect living organisms in the wild? How do organisms adapt and protect themselves from exposure to foreign materials? How does the environment affect the performance of nanoparticles, including their surface properties? In an effort to address these crucial questions, our main aim has been to probe the effects of aquatic organisms on nanoparticle aggregation. We have, therefore, carried out a systematic study with the purpose to disentangle the effects of the freshwater zooplankter, Daphnia magna, on the surface properties, stability, and aggregation properties of gold (Au) nanoparticles under different aqueous conditions as well as identified the proteins bound to the nanoparticle surface. We show that Au nanoparticles aggregate in pure tap water, but to a lesser extent in water that either contains Daphnia or has been pre-conditioned with Daphnia. Moreover, we show that proteins generated by Daphnia bind to the Au nanoparticles and create a modified surface that renders them less prone to aggregation. We conclude that the surrounding milieu, as well as the surface properties of the original Au particles, are important factors in determining how the nanoparticles are affected by biological metabolism. In a broader context, our results show how nanoparticles released into a natural ecosystem become chemically and physically altered through the dynamic interactions between particles and organisms, either through biological metabolism or through the interactions with biomolecules excreted by organisms into the environment.

Visceral leishmaniasis prevalence and associated risk factors in the saran district of Bihar, India, from 2009 to July of 2011.

India is one of three countries that account for an estimated 300,000 of 500,000 cases of visceral leishmaniasis (VL) occurring annually. Bihar State is the most affected area of India, with more than 90% of the cases. Surveys were conducted in two villages within the Saran district of Bihar, India, from 2009 to July of 2011 to assess risk factors associated with VL. Forty-five cases were identified, and individuals were given an oral survey. The results indicated that men contracted the disease more than women (58%), and cases over the age of 21 years accounted for 42% of the total VL cases. April to June showed the highest number of new cases. Of 135 households surveyed for sleeping conditions, 95% reported sleeping outside, and 98% slept in beds. Proximity to VL cases was the greatest risk factor (cluster 1 relative risk = 11.89 and cluster 2 relative risk = 138.34). The VL case clustering observed in this study can be incorporated in disease prevention strategies to more efficiently and effectively target VL control efforts.

Early quantitative evaluation of indocyanine green angiography in patients with critical limb ischemia.

OBJECTIVE: Patients requiring lower extremity revascularization are increasingly complex. Traditional means of evaluating perfusion before and after revascularization are often limited by the presence of medial calcinosis, open wounds, prior toe or forefoot amputations, and infection. We evaluated the initial application of indocyanine green angiography (ICGA) to patients with severe lower extremity ischemia to develop quantitative, reproducible parameters to assess perfusion. METHODS: ICGA uses a charge-coupled device camera, a laser, and intravenous contrast to visually assess skin surface perfusion. From January 2011 to April 2012, we performed ICGA within 5 days of 31 revascularization procedures in patients with Rutherford class 5 and 6 ischemia. We also compared ICGA before and after revascularization in a subset of 13 patients. We evaluated multiple, quantitative parameters to assess perfusion. RESULTS: Twenty-four patients underwent ICGA associated with 31 revascularization procedures (26 endovascular, four open, one hybrid) for 26 lower limb wounds; 92% were diabetic and 20% were dialysis-dependent. In 50% of these patients, it was not possible to measure ankle-brachial indexes due to medial calcinosis. Paired analysis of ingress (increase in pixel strength [PxS]), ingress rate (slope of increase in PxS), curve integral (area under the curve in PxS over time), end intensity (PxS at end of study), egress (decrease in PxS from maximum), and egress rate (slope of decrease in PxS) increased significantly (P < .05) after revascularization. CONCLUSIONS: ICGA provides rapid visual and quantitative information about regional foot perfusion. We believe this is the first report describing quantification of foot perfusion before and after lower extremity revascularization for severe limb ischemia. Further study is warranted to help define the utility of this intriguing new technology to assess perfusion, response to revascularization, and potentially, to predict likelihood of wound healing.

The role of Palmyra palm trees (Borassus flabellifer) and sand fly distribution in northeastern India.

Visceral leishmaniasis (VL), known as Kala-azar in India, is a parasite transmitted by the bite of the sand fly vector Phlebotomus argentipes. Published information on the species indicates it is a poor flyer, mainly hopping and gliding. This study describes the vector as more arboreal than previously documented. Data collected indicate the ability of P. argentipes and Sergentomyia spp to attain vertical heights in Palmyra palm trees Borassus flabellifer up to 18.4 m above ground level. To determine if sand flies were either climbing the tree trunk to rest in the canopy or flying, sticky traps were set around the tree trunk and checked for captures overnight. CDC traps set in the palm tree canopy resulted in the capture of 5,067 sand flies, 3,990 of which were P. argentipes. Traps were set during daylight hours to determine if sand flies remained and rested in the canopy. A total of 128 sand flies were trapped over 29 trap days in the palm trees. With the CDC traps, 130 P. argentipes and no Sergentomyia spp were captured. The converse was true for the sticky traps set around tree trunks 3 m below the CDC traps. Of the 105 sand flies collected, only one was P. argentipes and 104 were Sergentomyia spp. As reported elsewhere, this indicates Sergentomyia spp tend to climb and hop, wheareas P. argentipes are capable of longer and more sustained flight. Data presented herein suggest that P. argentipes is more exophylic and exophagic than previously reported. These findings have implications for sand fly control.

Intraoperative fluorescence vascular angiography: during tibial bypass.

Preventing amputations in persons with lower extremity complications of diabetes is a complex endeavor, particularly in those with concomitant ischemia and tissue loss. Fluorescence angiography (Novadaq SPY system) may provide a tool for objective evaluations of tissue viability in the diabetic foot, which is an important indicator of the ability of the diabetic ulcer to heal adequately. The SPY system uses a low-power laser coupled with a charge-coupled device camera and indocyanine green (ICG) to sequence perfusion at the surface of the skin. We present an illustrated example of the potential utility of ICG fluorescence angiography (ICGFA) before and after vascular intervention in a high-risk limb. ICGFA appeared to reveal demarcation between viable and nonviable tissue and real-time perfusion, specifically capillary fill. ICGFA clarified the extent of necessary debridement and provided an immediate indication of improvement in regional perfusion status following revascularization. Future studies involving ICGFA may include pre- and postdebridement and closure perfusion, comparison of tissue perfusion pre- and post-endovascular therapy, and lower extremity flap viability. Future works will also address the consistency of results with ICGFA by analyzing a larger cohort of patients being treated by our unit.