Simulated Forest Immersion Therapy: Methods Development.

Shinrin-yoku, forest bathing, may provide relief from chronic and breakthrough pain in patients with axial spondyloarthritis and improve immune function through increasing NK cell numbers and activity and their downstream effectors, perforin and granulysin, after chemo- or radiation therapy in breast and prostate cancer patients. The aim of this paper is to describe the study protocol for a simulated forest immersion therapy using virtual reality and atomized phytoncides, volatile organic compounds found in forested areas designed to effect positive change for these two patient populations. The setting, including the room set up and samples with inclusion/exclusion specific to this type of intervention, is outlined. Measures and calibration procedures pertinent to determining the feasibility of simulated forest immersion therapy are presented and include: ambient and surface room temperatures and relative humidity in real time, ambient ultrafine particulate matter, ambient droplet measurement that coincides with volatile organic compounds, specific phytoncides, and virtual reality and atomization of phytoncide set up. Particular lessons learned while training and setting up the equipment are presented. Simulated forest immersion therapy is possible with attention to detail during this early phase when development of methods, equipment testing, and feasibility in deploying the intervention become operational. The expected outcome of the development of the methods for this study is the creation of a standardized approach to simulating forest therapy in a controlled laboratory space.

Greenspace Interventions, Stress and Cortisol: A Scoping Review.

BACKGROUND: Engaging with nature can profoundly impact psychological and physiological health of persons across the lifespan. Greenspace interventions (GSI) encompass a broad range of strategic, nature-based activities for overall health and wellbeing. Within the past 20 years there has been a growing interest in the access to and management of greenspace to mediate the deleterious impact of acute and chronic stress, particularly, physiologic biomarkers of stress such as cortisol. OBJECTIVE: This review aims to describe the impact of greenspace interventions on cortisol, to present the current state of the science on GSIs as they impact cortisol, and to uncover any limitations of current research strategies to best inform future research. METHODS: A scoping methodology was conducted to systematically study this emerging field and inform future research by mapping the literature based on the GSI category, interventional design, cortisol metrics, and subsequent analysis of cortisol. CONCLUSION: Considerable heterogeneity in research design, aim(s), interventional strategy, and cortisol metrics were identified from a total of 18 studies on GSIs and cortisol outcomes. While studies demonstrated a potential for the positive association between GSIs and stress relief, more rigorous research is needed to represent GSIs as an intervention to mitigate risks of stress.

The Influence of ß-Adrenergic Receptor Kinase-1 on Stroke-induced Immunodeficiency Syndrome.

BACKGROUND: Immunodeficiency in acute ischemic stroke (AIS) is thought to be a result of norepinephrine suppression of the lymphoid tissue. The possible differences in the distribution of lymphocytes after stroke may be due to differences in responsiveness of lymphocyte ß-adrenergic receptors to their kinase (BARK-1). OBJECTIVE: The objective was to quantify the influence of lymphocyte BARK-1 on stroke-induced immunodeficiency in AIS patients. METHODS: A prospective clinical cohort study was conducted (N = 44). Measures included age, gender, race, risk factors for stroke, stroke severity, comorbidities, presence of infection, white blood cell counts and differential proportions, and lymphocyte BARK-1. Student t tests, effect sizes, and linear and logistic regressions were conducted to test the study objective. The study was approved by the Oregon Health & Science University Institutional Review Board. RESULTS: There were significant changes in all white blood cells and differential proportions and in the National Institutes of Health Stroke Scale from admission to 48 hours after onset of stroke deficits. Higher BARK-1 influenced the lower lymphocyte proportion at 48 hours, independent of age, P < .0001. Furthermore, BARK-1 also was associated with an increase in the likelihood of having sustained or stroke-induced immunodeficiency at 48 hours: odds ratio, 2.41; 95% confidence interval, 1.10-5.25; P = .027, and odds ratio, 2.79; 95% confidence interval, 1.03-7.52; P = .043, respectively. In all backward stepwise selection of factors, BARK-1 was the only factor consistently retained in the models. CONCLUSIONS: ß-Adrenergic receptor kinase-1 has a significant quantifiable influence on lymphocyte proportion at 48 hours and on the classification of sustained stroke-induced immunodeficiency. CLINICAL IMPLICATIONS: ß-Adrenergic stimulation influences immunodeficiency in AIS.

Effects of Work Environment on Quality of Care in ICUs: A Multisite Survey in China.

This study estimated the effects of the work environment on the quality of care in intensive care units (ICUs). Nurses in ICUs with good work environments or high nurse staffing were significantly less likely to report poor or fair quality of care (odds ratio [OR] = 0.37-0.47), rationing of nursing care (OR = 0.38-0.76), and health care-associated infections (OR = 0.28-0.68). Favorable ICU work environments and adequate nurse staffing can predict better quality of care.

Influence of Gender and Age on the Peripheral Immune Response in Stroke.

BACKGROUND: Women and men have unique stroke risk factors and can experience different poststroke infections. OBJECTIVE: The aim of this study is to determine the influence of gender, age, and risk factors on the peripheral immune response in stroke/transient ischemic attack (TIA). METHOD: A total of 192 adult acute stroke/TIA cases were analyzed for age, gender, risk factors for stroke/TIA, and white blood cell with differential count. χ Test and analysis of variance were conducted to test for differences between genders and age groups related to stroke risk factors and the immune response. Growth modeling was used to test for trended differences in the immune response. RESULTS: Women were 4 years older than men; fewer women had strokes in the younger age group (<79 years) and more men currently smoked. Trended lymphocyte percentages for the young and old (slope, P = .04; pattern, P = .02) and admission monocyte percentages by gender were significantly different (P = .01). CONCLUSIONS: Age influenced trended lymphocyte numbers and gender influenced monocyte percentage on admission.

Description and Identification of the Peripheral Immune Response Trajectories Over Time in First-Time and Recurrent Stroke/Transient Ischemic Attack.

A unique extant database to explain heterogeneity in peripheral immune response (PIR) over time in response to stroke/transient ischemic attack (TIA) was used to compare changes in PIR between first-time and recurrent stroke/TIA and to identify distinct and common trajectories of change in the PIR in stroke/TIA. Associations between risk factors for stroke (hypertension, smoking, diabetes, hypercholesterolemia, infection) and PIR trajectory were quantified using multivariate random effects modeling. With comparable admission values, patients with recurrent stroke/TIA had a persistent elevation in lymphocyte percentage as opposed to the significant decline in lymphocyte percentages over time observed in those with first-time stroke/TIA. Two naturally occurring trajectories of the PIR to stroke/TIA were observed, one indicative of a primed PIR and one indicative of an unprimed PIR. A large proportion of the sample, 80%, was classified as having persistently higher lymphocyte percentages and lower neutrophil percentages over time compared with the remainder of the sample. When controlling for risk factors for stroke, adults admitted with recurrent stroke/TIA without infection were more than three times as likely to have a primed PIR (i.e., the high lymphocyte-low neutrophil trajectory) than those with first-time stroke with infection. Interventions for reduction of neurological deficits require tight implementation windows early after stroke occurs. The outlined classification of cases in these primed and unprimed trajectories of the PIR adds to the knowledge of optimal clinical timing for de novo immune-based interventions.

International classification of functioning, disability and health categories for spinal cord injury nursing in China.

PURPOSE: To explore a set of International Classification of Functioning, Disability and Health (ICF) categories that cover the spinal cord injury (SCI) nursing practice in China through a national expert survey. METHODS: An internet-based email survey was used. An original set of ICF categories specifically for SCI nursing has been developed from the preliminary studies based on an international perspective. For cultural adaptation in China, a national expert survey was conducted with Chinese experts on SCI nursing to identify the ICF categories that were specifically for SCI nursing in China. The ICF categories which received more than 80% support from the experts would be reported. RESULTS: Twenty-nine Chinese experts on SCI nursing participated. There were 81 ICF categories which received more than 80% agreement among the experts, including 33 Body Functions categories, eight Body Structures, 24 Activities and Participation, six Environmental Factors and 10 Personal Factors items. CONCLUSIONS: A set of ICF categories that cover the SCI nursing practice in China was identified. It reflects the main issues that Chinese nurses focus on in caring SCI patients. These categories can facilitate Chinese nurses to use the ICF in multidisciplinary teamwork and improve the participation of nurses in the team. Implications for Rehabilitation In China, nurses lack of an effective model or tool to communicate with the other health professionals in the rehabilitation team for spinal cord injury (SCI) patients. International Classification of Functioning, Disability and Health (ICF) is a tool for multidisciplinary use, which can promote the communication and collaboration in the healthcare team by establishing a common language across different disciplines and sectors. This set of ICF categories developed from this study can serve as a roadmap for important items for use in clinical practice of Chinese SCI nursing.

Creation of a virtual health system for leadership clinical experiences.

Students had difficulty integrating leadership and outcomes management skills into their burgeoning novice practice. Further, the Baccalaureate Completion Program for RNs, an online program, expanded student enrollment, which created difficulty in finding enough clinical placements in agencies with staff experienced in leading teams and conducting performance improvement projects. The Leadership and Outcomes Management course was changed from a live clinical agency placement course to a virtual clinical agency experience. Students worked in teams on a virtual quality care delivery case within a virtual health care system. Students selected the case and where they worked within our full-service virtual health system. The virtual health system required interactions with staff, and faculty assumed several roles within the virtual health system as they guided the students through leadership skill development and the creation of a performance improvement system process. It also eliminated the need for live clinical agency placements.

Peripheral immune response and infection in first-time and recurrent ischemic stroke or transient ischemic attack.

GOALS: The aims of this study were to determine if the infection rate differs between the first and recurrent ischemic stroke/transient ischemic attack (TIA), if the pattern of the peripheral immune response (PIR) differs between the first and recurrent ischemic stroke/TIA and if infection further influenced the pattern of the PIR. METHODS: Retrospective review of 500 stroke cases with strict exclusion criteria (e.g., hemorrhagic stroke, subarachnoid hemorrhage, or spontaneous intracerebral hemorrhage; history of cancer; on steroids or immune suppressive drugs; recent invasive procedure) resulted in inclusion of 198 cases. Independent variables were first stroke or recurrent stroke and not infected or infected cases. Main-effect dependent variables were the white blood cell (WBC) and differential leukocyte counts (percentages of 100 cell counts for neutrophils, lymphocytes, and monocytes and absolute counts of neutrophils, lymphocytes, and monocytes). FINDINGS: Infection rate was not different between the first versus recurrent stroke (p = .279). The pattern of WBC and differential counts were not different between groups, but addition of the covariate of infection showed group differences (p = .05). A four-group comparison of the dependent variables with the laboratory normal ranges showed lymphocyte percentages below the lower range limit in all four groups. Generalized linear modeling showed a modest rise (15%) in WBC counts in both groups with concomitant infection, a modestly low (-18%) lymphocyte percentage in recurrent stroke with infection, and a more substantial rise (22%-26%) in absolute neutrophil count in both groups with concomitant infection. CONCLUSIONS: Infection influences the pattern of the PIR in the first and recurrent stroke/TIA, and this difference can be quantified.

Re-valuing nursing's currency: shifting away from hierarchical binary opposition.

This paper starts a discussion amongst nurse educators internationally regarding the nature of curricula for initial nursing licensure. Nursing is compelled by traditional views of nursing into taking a long-established and expected place in the health care hierarchy, which is reflected in current curricula. In order to establish a re-valued nursing currency within healthcare, nursing educators are required to re-examine these established norms and re-design these curricula, based on the premise that nursing is now set in a complex and unpredictable system.

Spiraling evidence-based practice and outcomes management concepts in an undergraduate curriculum: a systematic approach.

Preparing undergraduate nursing students to practice nursing in the 21st century requires a focus on the development of evidence-based practice and outcomes management knowledge and skills throughout the nursing curriculum. To this end, seven learning activities were created that spiral and increase in complexity while building on previously acquired skills. Working in teams and practicing team-building techniques, students learned how to develop a clinical question, search the literature, synthesize the current knowledge, identify the significance of the issue in an ecological model, decipher existing quality data and compare that data to national benchmarks, investigate a health care quality issue using quality improvement methods, and draft a proposal for implementation of a continuous quality improvement initiative. Work was presented in both written and oral presentation formats, with emphasis on engaging various audiences in a compelling health care issue.

Evidence of the peripheral inflammatory response in patients with transient ischemic attack.

The peripheral inflammatory response, as a proxy for the acute-phase response (a known mechanism for ischemic preconditioning), and non-damage-producing transient ischemia must exist together in humans if this candidate mechanism confers ischemic tolerance. The present study was aimed at determining whether the peripheral inflammatory response (ie, elevated white blood cell, neutrophil, and monocyte counts) exists in transient ischemic attack (TIA) and stroke patients at the time of emergency room admission. The null hypothesis was tested for the variables of the peripheral inflammatory response between the mean of the laboratory normal population versus stroke and TIA patients. A retrospective review of 1041 medical records yielded 12 first-time TIA patients and 34 first-time stroke patients with no confounding evidence of other inflammatory processes. In both groups, neutrophil and monocyte percentages were significantly higher than the laboratory means (in TIA cases: neutrophils, 67.9% [12.67%], P = .001; monocytes, 8.2% [2.7%], P = .020; in stroke cases: neutrophils, 64.9% [9.1%], monocytes, 7.7% [1.6%]; both P < .001). Absolute neutrophil count was significantly higher than the laboratory mean for the stroke cases (5.13 [1.88] K/UL; P = .022). Lymphocyte percentages and absolute lymphocyte count in both groups were significantly and abnormally lower than the laboratory mean (in TIA cases, 21.7% [10.5%] and 1.4 [0.6] K/UL, respectively; in stroke cases, 24.7% [8.4%] and 1.9 [0.7] K/UL, respectively; all P