Determining Which Combinatorial Combat-Relevant Factors Contribute to Heterotopic Ossification Formation in an Ovine Model.

Traumatic heterotopic ossification (HO) is frequently observed in Service Members following combat-related trauma. Estimates suggest that ~65% of wounded warriors who suffer limb loss or major extremity trauma will experience some type of HO formation. The development of HO delays rehabilitation and can prevent the use of a prosthetic. To date there are limited data to suggest a standard mechanism for preventing HO. This may be due to inadequate animal models not producing a similar bone structure as human HO. We recently showed that traumatic HO growth is possible in an ovine model. Within that study, we demonstrated that 65% of sheep developed a human-relevant hybrid traumatic HO bone structure after being exposed to a combination of seven combat-relevant factors. Although HO formed, we did not determine which traumatic factor contributed most. Therefore, in this study, we performed individual and various combinations of surgical/traumatic factors to determine their individual contribution to HO growth. Outcomes showed that the presence of mature biofilm stimulated a large region of bone growth, while bone trauma resulted in a localized bone response as indicated by jagged bone at the linea aspera. However, it was not until the combinatory factors were included that an HO structure similar to that of humans formed more readily in 60% of the sheep. In conclusion, data suggested that traumatic HO growth can develop following various traumatic factors, but a combination of known instigators yields higher frequency size and consistency of ectopic bone.

Critical Access Hospital Nurses' Perceptions of Obstacles to End-of-Life Care: A Qualitative Study.

BACKGROUND: Critical care nurses working in urban settings have reported obstacles in caring for dying patients. However, the perceptions of such obstacles by nurses working in critical access hospitals (CAHs), which are located in rural areas, are unknown. OBJECTIVE: To study stories and experiences related to obstacles in providing end-of-life care reported by CAH nurses. METHODS: This exploratory, cross-sectional study presents the qualitative stories and experiences of nurses working in CAHs as reported on a questionnaire. Quantitative data have been previously reported. RESULTS: Sixty-four CAH nurses provided 95 categorizable responses. Two major categories emerged: (1) family, physician, and ancillary staff issues and (2) nursing, environment, protocol, and miscellaneous issues. Issues with family behaviors were families' insistence on futile care, intrafamily disagreement about do-not-resuscitate and do-not-intubate orders, issues with out-of-town family members, and family members' desire to hasten the patient's death. Issues with physician behaviors were providing false hope, dishonest communication, continuation of futile treatments, and not ordering pain medications. Nursing-related issues were not having enough time to provide end-of-life care, already knowing the patient or family, and compassion for the dying patient and the family. CONCLUSION: Family issues and physician behaviors are common obstacles in rural nurses' provision of end-of-life care. Education of family members on end-of-life care is challenging because it is most families' first experience with intensive care unit terminology and technology. Further research on end-of-life care in CAHs is needed.

Frequency and Magnitude of Obstacles and Helpful Behavior Items in End-of-Life Care as Perceived by Nurses Working in Critical-Access Hospitals.

BACKGROUND: Twenty percent of Americans live in rural areas where most of their health care is provided in critical-access hospitals (CAHs). It is unknown how frequently obstacle and helpful behavior items occur in end-of-life (EOL) care in CAHs. OBJECTIVES: The aims of this study were to determine the frequency of occurrence scores of obstacle and helpful behavior items in providing EOL care in CAHs and to also determine which obstacles and helpful behaviors have the greatest or least impact on EOL care based on the magnitude scores. METHODS: A questionnaire was sent to nurses working in 39 CAHs in the United States. Nurse participants were asked to rate obstacle and helpful behavior items by size and frequency of occurrence. Data were analyzed to quantify the impact of obstacle and helpful behavior items on EOL care in CAHs by multiplying the mean size by the mean frequency of items to determine mean magnitude scores. RESULTS: Items with the highest and lowest frequency were determined. In addition, obstacle and helpful behavior item magnitude scores were calculated. Seven of the top 10 obstacles were related to patients' families. Seven of the top 10 helpful behaviors involved nurses ensuring families had positive experiences. CONCLUSION: Nurses in CAHs perceived issues around patient family members as significant obstacles to EOL care. Nurses work to ensure that families have positive experiences. Visiting hour issues seemed to be irrelevant. The use of technology, such as telehealth, seemed to provide little benefit in EOL care in CAHs.

Plume height and surface coverage analysis of methicillin-resistant Staphylococcus aureus isolates grown in a CDC biofilm reactor.

Biofilm formation is a dynamic process that leads to mature communities over time. Despite a general knowledge of biofilm community formation and the resultant limitations of antibiotic therapy, there is a paucity of data describing specific plume heights, surface coverage and rates of maturation. Furthermore, little is published on the effect that the broth medium might have on the degree of biofilm maturation. In this study, three strains of methicillin-resistant Staphylococcus aureus (MRSA) (USA300, USA400 and a clinical isolate) were grown in brain heart infusion broth (BHI) or tryptic soy broth (TSB). Following growth, SEM images were captured for 3-D analysis to assess plume height. TSB produced significantly higher plume heights of USA300 and USA400 compared to BHI. Broth type was less influential on the clinical isolate. The data indicate that broth type and time may be important factors to consider when assessing maturation and plume height formation of MRSA biofilms.

Emergency Nurses' Department Design Recommendations for Improved End-of-Life Care.

INTRODUCTION: Although death is common in emergency departments, there is limited research regarding ED design as an obstacle to end-of-life care. This study identifies emergency nurses' recommendations regarding ways designs have negative or positive impact on care for dying patients and their families. METHODS: A 25-item questionnaire was sent to a national random sample of 500 emergency nurses. Inclusion criteria were nurses who could read English, worked in emergency departments, and had cared for at least 1 patient at the end of life (EOL). Responses were individually reviewed and coded. RESULTS: Major obstacles included (1) issues related to limited space, (2) poor department layout and design, and (3) lack of privacy. Despite emergency departments being a challenging place to provide EOL care, positive ED design characteristics had impact on EOL care. DISCUSSION: Emergency nurses understand the need for family presence during resuscitation, for secure body stowage areas, and for more resuscitation rooms so that families have time to grieve before being removed because of the immediate needs of a second trauma patient. Nurses can evaluate existing facilities to identify areas in which potential change and remodeling could improve care, increase patient privacy, or further utilize space. Understanding ED design's impact on EOL care is crucial. Modifications to ED layout and design may be challenging; however, improvements to space, layout, and privacy need to be considered when planning new emergency departments or remodeling existing departments. Further research is required to determine the impact of ED design on EOL care.

The Nicotine Content of a Sample of E-cigarette Liquid Manufactured in the United States.

OBJECTIVES: Use of electronic cigarettes has dramatically increased in the United States since 2010, with a forecasted growth of 37% between 2014 and 2019. There is little research on e-liquid nicotine concentration from domestic manufacturers. However, limited research outside of the United States found wide inconsistencies between the labeled concentration of nicotine in e-liquids and the actual nicotine concentration. METHODS: The 7 most popular online manufacturers or distributors were identified. E-liquid samples of the 5 most popular flavors from each manufacturer were purchased in nicotine concentrations of 0 and 18 mg/mL. Of the samples purchased (n = 70), all were labeled as produced in the United States of America. The researchers anonymized the samples before sending them to an independent university laboratory for testing. RESULTS: The 35 e-liquid samples labeled 18 mg/mL nicotine measured between 11.6 and 27.4 mg/mL (M = 18.7, SD = 3.3) nicotine. The labeled 18 mg/mL samples measured as little as 35% less nicotine and as much as 52% greater nicotine. In the 35 samples labeled 0 mg/mL, nicotine was detected (>0.01 mg/mL) in 91.4% of the samples (range 0-23.9 mg/mL; M = 2.9, SD = 7.2). Six samples from 2 manufacturers labeled as 0 mg/mL were found to contain nicotine in amounts ranging from 5.7 to 23.9 mg/mL. CONCLUSION: This study demonstrates the nicotine labeling inaccuracies present in current e-liquid solutions produced in the United States. Incorrect labeling poses a significant risk to consumers and supports the recent regulation changes enacted by the US Food and Drug Administration. Additional routine testing of nicotine concentrations should be conducted to evaluate the effectiveness of the regulations on future e-liquid production.

Evaluation of indicated non-cosmetic panniculectomy at time of gynecologic surgery.

OBJECTIVE: To report postoperative outcomes among patients undergoing indicated non-cosmetic panniculectomy at the time of gynecologic surgery. METHODS: Medical charts were retrospectively reviewed for patients who underwent panniculectomy coupled with gynecologic surgery at a university-affiliated hospital in the USA in 1990-2014. The data reviewed included age, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), surgical procedure, estimated blood loss, pathology, wound complication, diabetes, hypertension, smoking, and readmission rate. One-way analysis of variance and logistic regression were used to evaluate the data. RESULTS: In total, 300 patients underwent panniculectomy; the mean age was 51 years and the mean BMI was 46. Overall, there were 94 (31.3%) complications, including 85 (28.3%) cases of superficial cellulitis and 9 (3.0%) cases of surgical-site infection. In logistic regression, diabetes, hypertension, and smoking were significant predictors of wound complications, identifying 78% of women who subsequently developed wound complications. CONCLUSION: Panniculectomy combined with gynecologic surgery was found to be safe and effective for obese patients, with an acceptable incidence of wound infection. History of diabetes, hypertension, and smoking increased the risk of postoperative wound complications. These factors will help to predict patients at risk of wound complication.

Rural Emergency Nurses' End-of-Life Care Obstacle Experiences: Stories from the Last Frontier.

Rural emergency nurses face unique obstacles to providing quality end-of-life (EOL) care. Stories provided by emergency nurses embody their most difficult EOL care obstacles. METHODS: A questionnaire was sent to 53 rural hospitals. Respondents were asked to share stories that epitomized the obstacles faced while providing EOL care in the rural emergency setting. RESULTS: The lack of an ideal death (eg, the nurse personally knows the patient, issues with family members, and unknown patient wishes) was the top obstacle. Other reported obstacles were insufficient ED staff and power struggles between nurses and physicians. DISCUSSION: Rural emergency nurses often provide EOL care to friends and family members, whereas their urban counterparts are likely to transfer care to nurses with no relation to the dying patient. Not only does caring for patients whom the nurse knows or is related to cause great distress to rural emergency nurses, but this unfortunately common situation also may prevent patients from receiving the highest quality EOL care.

Emergency nurses' perception of department design as an obstacle to providing end-of-life care.

INTRODUCTION: Of the 119.2 million visits to the emergency department in 2006, it was estimated that about 249,000 visits resulted in the patient dying or being pronounced dead on arrival. In 2 national studies of emergency nurses' perceptions of end-of-life (EOL) care, ED design was identified as a large and frequent obstacle to providing EOL care. The purpose of this study was to determine the impact of ED design on EOL care as perceived by emergency nurses and to determine how much input emergency nurses have on the design of their emergency department. METHODS: A 25-item questionnaire regarding ED design as it affects EOL care was sent to a national, geographically dispersed, random sample of 500 members of ENA. Inclusion criteria were nurses who could read English, worked in an emergency department, and had cared for at least one patient at the EOL. Descriptive statistics were calculated for the Likert-type and demographic items. Open-ended questions were analyzed using content analysis. RESULTS: Two mailings yielded 198 usable responses. Nurses did not report that ED design was as large an obstacle to EOL care as previous studies had suggested. Nurses reported that the ED design helped EOL care at a greater rate than it obstructed EOL care. Nurses also believed they had little input into unit design or layout changes. The most common request for design change was private places for family members to grieve. Thirteen nurses also responded with an optional drawing of suggested ED designs. DISCUSSION: Overall, nurses reported some dissatisfaction with ED design and believed they had little to no input in unit design improvement. Improvements to EOL care might be achieved if ED design suggestions from emergency nurses were considered by committees that oversee remodeling and construction of emergency departments. Further research is needed to determine the impact of ED design on EOL care in the emergency department.

Cervical spine injuries; an outcome analysis.

Cervical spine injury (CSI) in octogenarians continues to carry a high morbidity and mortality rate. The incidence of CSI among individuals who are below the age of 80 is declining, whereas the incidence of CSI for those 80 years and above is rising.The aim of the study was to evaluate outcomes of cervical spine injuries in octogenarians caused by different mechanisms: motor vehicle accidents, compared to a fall.Material and methods. The National Trauma Data Bank (NTDB) was queried for patients ages 80 and above, who sustained a cervical spine injury via motor vehicle collision and falls. Patient demographics, mechanism of injury, Glasgow Coma Score (GCS), injury severity score (ISS), days in Intensive Care Unit, Temperature on arrival, blood pressure on arrival, CT Scan of head results, complications, sex, and mortality.Results. Three-thousand three hundred seventy-five patients, 80 years of age and older with CSI were included in the study; fifteen percent of these octogenarians with cervical spine injuries died. It was observed that patients in the motor vehicle accident (MVA) group have 1.737 (95% CI 1.407, 2.144 p-value < 0.0001) times the odds of dying, compared to those in the fall group. Patients over the age of 80 who were in a MVA have 1.209 (95% CI 0.941, 1.554 p-value = 0.1372) times the odds of having a positive head CT, compared with people over the age of 80 who experienced a fall. Patients involved in a motor vehicle accident with associated CSI were more likely to be a younger age, have a lower GCS on arrival, have a longer length of stay in the Intensive Care Unit, and a higher ISS (p<0.05).Conclusions. Cervical spine injury in octogenarians carries a high mortality regardless of mechanism. Elderly patients who suffer cervical spine injuries in motor vehicle accidents have a lower SBP, a higher ISS and are nearly twice as likely to die as those who were injured in a fall.