Could artificial intelligence write mental health nursing care plans?

WHAT IS KNOWN ON THE SUBJECT?: Artificial intelligence (AI) is freely available, responds to very basic text input (such as a question) and can now create a wide range of outputs, communicating in many languages or art forms. AI platforms like OpenAI's ChatGPT can now create passages of text that could be used to create plans of care for people with mental health needs. As such, AI output can be difficult to distinguish from human-output, and there is a risk that its use could go unnoticed. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Whilst it is known that AI can produce text or pass pre-registration health-profession exams, it is not known if AI can produce meaningful results for care delivery. We asked ChatGPT basic questions about a fictitious person who presents with self-harm and then evaluated the quality of the output. We found that the output could look reasonable to laypersons but there were significant errors and ethical issues. There are potential harms to people in care if AI is used without an expert correcting or removing these errors. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: We suggest that there is a risk that AI use could cause harm if it was used in direct care delivery. There is a lack of policy and research to safeguard people receiving care - and this needs to be in place before AI should be used in this way. Key aspects of the role of a mental health nurse are relational and AI use may diminish mental health nurses' ability to provide safe care in its current form. Many aspects of mental health recovery are linked to relationships and social engagement, however AI is not able to provide this and may push the people who are in most need of help further away from services that assist recovery. ABSTRACT: Background Artificial intelligence (AI) is being increasingly used and discussed in care contexts. ChatGPT has gained significant attention in popular and scientific literature although how ChatGPT can be used in care-delivery is not yet known. Aims To use artificial intelligence (ChatGPT) to create a mental health nursing care plan and evaluate the quality of the output against the authors' clinical experience and existing guidance. Materials & Methods Basic text commands were input into ChatGPT about a fictitious person called 'Emily' who presents with self-injurious behaviour. The output from ChatGPT was then evaluated against the authors' clinical experience and current (national) care guidance. Results ChatGPT was able to provide a care plan that incorporated some principles of dialectical behaviour therapy, but the output had significant errors and limitations and thus there is a reasonable likelihood of harm if used in this way. Discussion AI use is increasing in direct-care contexts through the use of chatbots or other means. However, AI can inhibit clinician to care-recipient engagement, 'recycle' existing stigma, and introduce error, which may thus diminish the ability for care to uphold personhood and therefore lead to significant avoidable harms. Conclusion Use of AI in this context should be avoided until a point where policy and guidance can safeguard the wellbeing of care recipients and the sophistication of AI output has increased. Given ChatGPT's ability to provide superficially reasonable outputs there is a risk that errors may go unnoticed and thus increase the likelihood of patient harms. Further research evaluating AI output is needed to consider how AI may be used safely in care delivery.

Intracellular Diversity of WNV within Circulating Avian Peripheral Blood Mononuclear Cells Reveals Host-Dependent Patterns of Polyinfection.

Arthropod-borne virus (arbovirus) populations exist as mutant swarms that are maintained between arthropods and vertebrates. West Nile virus (WNV) population dynamics are host-dependent. In American crows, purifying selection is weak and population diversity is high compared to American robins, which have 100- to 1000-fold lower viremia. WNV passed in robins leads to fitness gains, whereas that passed in crows does not. Therefore, we tested the hypothesis that high crow viremia allows for higher genetic diversity within individual avian peripheral blood mononuclear cells (PBMCs), reasoning that this could have produced the previously observed host-specific differences in genetic diversity and fitness. Specifically, we infected cells and birds with a molecularly barcoded WNV and sequenced viral RNA from single cells to quantify the number of WNV barcodes in each. Our results demonstrate that the richness of WNV populations within crows far exceeds that in robins. Similarly, rare WNV variants were maintained by crows more frequently than by robins. Our results suggest that increased viremia in crows relative to robins leads to the maintenance of defective genomes and less prevalent variants, presumably through complementation. Our findings further suggest that weaker purifying selection in highly susceptible crows is attributable to this higher viremia, polyinfections and complementation.

Intracellular diversity of WNV within circulating avian peripheral blood mononuclear cells reveals host-dependent patterns of polyinfection.

Error-prone replication of RNA viruses generates the genetic diversity required for adaptation within rapidly changing environments. Thus, arthropod-borne virus (arbovirus) populations exist in nature as mutant swarms that are maintained between arthropods and vertebrates. Previous studies have demonstrated that West Nile virus (WNV) population dynamics are host dependent: In American crows, which experience extremely high viremia, purifying selection is weak and population diversity is high compared to American robins, which have 100 to 1000-fold lower viremia. WNV passed in robins experiences fitness gains, whereas that passed in crows does not. Therefore, we tested the hypothesis that high crow viremia allows higher genetic diversity within individual avian peripheral-blood mononuclear cells (PBMCs), reasoning that this could have produced the previously observed host-specific differences in genetic diversity and fitness. Specifically, we infected cells and birds with a novel, barcoded version of WNV and sequenced viral RNA from single cells to quantify the number of WNV barcodes that each contained. Our results demonstrate that the richness of WNV populations within crows far exceeds that in robins. Similarly, rare WNV variants were maintained by crows more frequently than by robins. Our results suggest that increased viremia in crows relative to robins leads to maintenance of defective genomes and less prevalent variants, presumably through complementation. Our findings further suggest that weaker purifying selection in highly susceptible crows is attributable to this higher viremia, polyinfections and complementation. These studies further document the role of particular, ecologically relevant hosts in shaping virus population structure. Author Summary: WNV mutational diversity in vertebrates is species-dependent. In crows, low frequency variants are common, and viral populations are more diverse. In robins, fewer mutations become permanent fixtures of the overall viral population. We infected crows, robins and a chicken cell line with a genetically marked (barcoded) WNV. Higher levels of virus led to multiple unique WNV genomes infecting individual cells, even when a genotype was present at low levels in the input viral stock. Our findings suggest that higher levels of circulating virus in natural hosts allow less fit viruses to survive in RNA virus populations through complementation by more fit viruses. This is significant as it allows less represented and less fit viruses to be maintained at low levels until they potentially emerge when virus environments change. Overall our data reveal new insights on the relationships between host susceptibility to high viremia and virus evolution.

The lived experience of remembering a 'good' interview: Micro-phenomenology applied to itself.

Micro-phenomenology is an interview and analysis method for investigating subjective experience. As a research tool, it provides detailed descriptions of brief moments of any type of subjective experience and offers techniques for systematically comparing them. In this article, we use an auto-ethnographic approach to present and explore the method. The reader is invited to observe a dialogue between two authors that illustrates and comments on the planning, conducting and analysis of a pilot series of five micro-phenomenological interviews. All these interviews asked experienced researchers of micro-phenomenology to browse their memories to identify one successful and one challenging instance of working with micro-phenomenology. The interview then focused on this reflective task to investigate whether applying the method to itself might reveal quality criteria. The article starts by presenting a shortened and edited version of the first of these interviews. Keeping the dialogue format, we then outline the micro-phenomenological analysis procedure by demonstrating its application to part of this data and corresponding passages of other interviews. We focus on one unexpected finding: interviewed researchers judge the quality of an interview in part based on a connection or contact between interviewer and interviewee. We discuss these results in the context of the means and intentions of the method and suggest avenues for future research.

E-cigarette puffing topography: The importance of assessing user behaviour to inform emissions testing.

Analysis of the chemical composition of e-cigarette emissions is an important step in determining whether e-cigarettes offer both individual and population-level harm reduction potential. Commonly, e-cigarette emissions for chemical analysis are collected when using e-cigarettes according to standardised puffing regimens, such as those recommended by the International Organization for Standardization (ISO) or the Cooperation Centre for Scientific Research Relative to Tobacco (CORESTA). While the use of such standard puffing regimens affords a degree of uniformity between studies and are also recommended by regulatory authorities who require the submission of e-cigarette emissions data to make decisions regarding allowing a product to be commercially marketed, the standardised regimens do not necessarily reflect human puffing behaviour. This can lead to under- or over-estimating real-world emissions from e-cigarettes and inaccuracy in determining their harm reduction potential. In this review, we describe how human puffing behaviour (topography) information can be collected both in the clinical laboratory and in the real world using a variety of different methodologies. We further discuss how this information can be used to dictate e-cigarette puffing regimens for collecting emissions for chemical analyses and how this may lead to better predictions both of human yields of e-cigarette emissions constituents and of risk assessments to predict e-cigarette tobacco harm reduction potential.

National Exposure Models for Source-Specific Primary Particulate Matter Concentrations Using Aerosol Mass Spectrometry Data.

This paper investigates the feasibility of developing national empirical models to predict ambient concentrations of sparsely monitored air pollutants at high spatial resolution. We used a data set of cooking organic aerosol (COA) and hydrocarbon-like organic aerosol (HOA; traffic primary organic PM) measured using aerosol mass spectrometry across the continental United States. The monitoring locations were selected to span the national distribution of land-use and source-activity variables commonly used for land-use regression modeling (e.g., road length, restaurant count, etc.). The models explain about 60% of the spatial variability of the measured data (R2 0.63 for the COA model and 0.62 for the HOA model). Extensive cross-validation suggests that the models are robust with reasonable transferability. The models predict large urban-rural and intra-urban variability with hotspots in urban areas and along the road corridors. The predicted national concentration surfaces show reasonable spatial correlation with source-specific national chemical transport model (CTM) simulations (R2: 0.45 for COA, 0.4 for HOA). Our measured data, empirical models, and CTM predictions all show that COA concentrations are about two times higher than HOA. Since COA and HOA are important contributors to the intra-urban spatial variability of the total PM2.5, our results highlight the potential importance of controlling commercial cooking emissions for air quality management in the United States.

Student nurses' views on shift patterns: What do they prefer and why? Results from a Tweetchat.

AIM: The main aim of the study was to understand student nurses' views around shift patterns. DESIGN: Qualitative study. METHOD: We held a Tweetchat in May 2019, where we asked questions around the frequency of 12-hr shifts working on placement; schedule flexibility while on placement; which shift patterns they preferred and why. Data from the Tweetchat were analysed using reflexive thematic analysis to generate themes from initial codes. RESULTS: Seventy-three nursing students participated in the Tweetchat. The majority reported that they work 12-hr shifts on placements, particularly when based in a hospital. We identified three themes: 'Achieving a personal equilibrium'; 'Meeting the needs of the care environment'; 'Factors affecting negotiation capacity'. Data highlighted a conflict for most students, where they preferred 12-hr shifts because of more time off for study, paid work and leisure, while acknowledging 12-hr shifts negatively affected their fatigue, exhaustion and led them to follow a poor diet and neglect exercise and sleep.

Cost-effectiveness of Physical Therapy vs Intra-articular Glucocorticoid Injection for Knee Osteoarthritis: A Secondary Analysis From a Randomized Clinical Trial.

Importance: Physical therapy and glucocorticoid injections are initial treatment options for knee osteoarthritis, but available data indicate that most patients receive one or the other, suggesting they may be competing interventions. The initial cost difference for treatment can be substantial, with physical therapy often being more expensive at the outset, and cost-effectiveness analysis can aid patients and clinicians in making decisions. Objective: To investigate the incremental cost-effectiveness between physical therapy and intra-articular glucocorticoid injection as initial treatment strategies for knee osteoarthritis. Design, Setting, and Participants: This economic evaluation is a secondary analysis of a randomized clinical trial performed from October 1, 2012, to May 4, 2017. Health economists were blinded to study outcomes and treatment allocation. A randomized sample of patients seen in primary care and physical therapy clinics with a radiographically confirmed diagnosis of knee osteoarthritis were evaluated from the clinical trial with 96.2% follow-up at 1 year. Interventions: Physical therapy or glucocorticoid injection. Main Outcomes and Measures: The main outcome was incremental cost-effectiveness between 2 alternative treatments. Acceptability curves of bootstrapped incremental cost-effectiveness ratios (ICERs) were used to identify the proportion of ICERs under the specific willingness-to-pay level ($50 000-$100 000). Health care system costs (total and knee related) and health-related quality-of-life based on quality-adjusted life-years (QALYs) were obtained. Results: A total of 156 participants (mean [SD] age, 56.1 [8.7] years; 81 [51.9%] male) were randomized 1:1 and followed up for 1 year. Mean (SD) 1-year knee-related medical costs were $2113 ($4224) in the glucocorticoid injection group and $2131 ($1015) in the physical therapy group. The mean difference in QALY significantly favored physical therapy at 1 year (0.076; 95% CI, 0.02-0.126; P = .003). Physical therapy was the more cost-effective intervention, with an ICER of $8103 for knee-related medical costs, with a 99.2% probability that results fall below the willingness-to-pay threshold of $100 000. Conclusions and Relevance: A course of physical therapy was cost-effective compared with a course of glucocorticoid injections for patients with knee osteoarthritis. These results suggest that, although the initial cost of delivering physical therapy may be higher than an initial course of glucocorticoid injections, 1-year total knee-related costs are equivalent, and greater improvement in QALYs may justify the initial higher costs. Trial Registration: ClinicalTrials.gov Identifier: NCT01427153.

Volatile Chemical Product Enhancements to Criteria Pollutants in the United States.

Volatile chemical products (VCPs) are a significant source of reactive organic carbon emissions in the United States with a substantial fraction (>20% by mass) serving as secondary organic aerosol (SOA) precursors. Here, we incorporate a new nationwide VCP inventory into the Community Multiscale Air Quality (CMAQ) model with VCP-specific updates to better model air quality impacts. Model results indicate that VCPs mostly enhance anthropogenic SOA in densely populated areas with population-weighted annual average SOA increasing 15-30% in Southern California and New York City due to VCP emissions (contribution of 0.2-0.5 µg m-3). Annually, VCP emissions enhance total population-weighted PM2.5 by ∼5% in California, ∼3% in New York, New Jersey, and Connecticut, and 1-2% in most other states. While the maximum daily 8 h ozone enhancements from VCP emissions are more modest, their influence can cause a several ppb increase on select days in major cities. Printing Inks, Cleaning Products, and Paints and Coatings product use categories contribute ∼75% to the modeled VCP-derived SOA and Cleaning Products, Paints and Coatings, and Personal Care Products contribute ∼81% to the modeled VCP-derived ozone. Overall, VCPs enhance multiple criteria pollutants throughout the United States with the largest impacts in urban cores.

Does the nursing curriculum influence feelings of gender-role conflict in a cohort of nursing degree male students?

It is estimated that more than 9% of the global nursing workforce is male and that this share will gradually rise over the next decade. Although there are some positive aspects of having a male nursing workforce, men in the profession still experience discriminatory behaviours and practices. Fortunately, this does not deter a number of men entering undergraduate degree programmes. The aim of this study was to understand the experiences of 14 male nursing students in their first year of the adult Bachelor of Nursing programme. Using the Inventory of Male Friendliness in Nursing Programs and the Gender Role Conflict Scale, this study found that the male students felt welcomed, supported and included into the nursing programme. In addition, they felt no overall gender-role conflict, although feelings of success and achievement caused some challenges. The results of this study suggest that the male students did not necessarily experience those inequitable behaviours and practices reported in the literature. It has been suggested that perhaps the reality of clinical practice may change the perception of nursing for male students. Therefore, implications for further research could include a longitudinal study to ascertain where the perceptions of the nursing programme change for the male nursing students over time.

Characterizing the Air Emissions, Transport, and Deposition of Per- and Polyfluoroalkyl Substances from a Fluoropolymer Manufacturing Facility.

Per- and polyfluoroalkyl substances (PFASs) have been released into the environment for decades, yet contributions of air emissions to total human exposure, from inhalation and drinking water contamination via deposition, are poorly constrained. The atmospheric transport and fate of a PFAS mixture from a fluoropolymer manufacturing facility in North Carolina were investigated with the Community Multiscale Air Quality (CMAQ) model applied at high resolution (1 km) and extending ∼150 km from the facility. Twenty-six explicit PFAS compounds, including GenX, were added to CMAQ using current best estimates of air emissions and relevant physicochemical properties. The new model, CMAQ-PFAS, predicts that 5% by mass of total emitted PFAS and 2.5% of total GenX are deposited within ∼150 km of the facility, with the remainder transported out. Modeled air concentrations of total GenX and total PFAS around the facility can reach 24.6 and 8500 ng m-3 but decrease to ∼0.1 and ∼10 ng m-3 at 35 km downwind, respectively. We find that compounds with acid functionality have higher deposition due to enhanced water solubility and pH-driven partitioning to aqueous media. To our knowledge, this is the first modeling study of the fate of a comprehensive, chemically resolved suite of PFAS air emissions from a major manufacturing source.

Transitioning Transdiagnostic CBT from Face-to-Face to Telephone Delivery During the Coronavirus Pandemic: A Case Study.

The coronavirus pandemic led to worldwide disruption in the delivery of face-to-face mental health services. This impact was marked for individuals with long-term health conditions and comorbid depression and anxiety. Many face-to-face mental health services switched to remote delivery or paused therapeutic input entirely, despite the lack of research on the efficacy of switching between modalities mid-therapy or having breaks in therapy. This paper presents the case of a patient with long-term health conditions who experienced both breaks in therapy and a switch in modalities from face-to-face to telephone delivery. The intervention used was based on transdiagnostic cognitive behavioral therapy and self-report measures were completed at the beginning and end of the twelve sessions. Despite the shift in modalities, the patient experienced clinically significant recovery on all measures, indicating the efficacy of therapy was not greatly affected by the shift in modalities. Long breaks in therapy were linked to deterioration in mental health, although this could be due to the deterioration in physical health that necessitated these breaks. This case highlights the benefits and challenges of a shifting modality of therapy during treatment and in response to a pandemic for a shielding population. From the work presented here, it seems beneficial for services to be able to work across multiple modalities to suit the needs of the patients and ensure continuity of treatment. It also indicates that pauses in therapy may risk deterioration. Further work is needed to prevent digital exclusion of patients.

Criteria pollutant impacts of volatile chemical products informed by near-field modeling.

Consumer, industrial, and commercial product usage is a source of exposure to potentially hazardous chemicals. In addition, cleaning agents, personal care products, coatings, and other volatile chemical products (VCPs), evaporate and react in the atmosphere producing secondary pollutants. Here, we show high air emissions from VCP usage (≥ 14 kg person-1 yr-1, at least 1.7× higher than current operational estimates) are supported by multiple estimation methods and constraints imposed by ambient levels of ozone, hydroxyl radical (OH) reactivity, and the organic component of fine particulate matter (PM2.5) in Pasadena, California. A near-field model, which estimates human chemical exposure during or in the vicinity of product use, indicates these high air emissions are consistent with organic product usage up to ~75 kg person-1 yr-1, and inhalation of consumer products could be a non-negligible exposure pathway. After constraining the PM2.5 yield to 5% by mass, VCPs produce ~41% of the photochemical organic PM2.5 (1.1 ± 0.3 µg m-3) and ~17% of maximum daily 8-hr average ozone (9 ± 2 ppb) in summer Los Angeles. Therefore, both toxicity and ambient criteria pollutant formation should be considered when organic substituents are developed for VCPs in pursuit of safer and sustainable products and cleaner air.

Simulation of organic aerosol formation during the CalNex study: updated mobile emissions and secondary organic aerosol parameterization for intermediate-volatility organic compounds.

We describe simulations using an updated version of the Community Multiscale Air Quality model version 5.3 (CMAQ v5.3) to investigate the contribution of intermediate-volatility organic compounds (IVOCs) to secondary organic aerosol (SOA) formation in southern California during the CalNex study. We first derive a model-ready parameterization for SOA formation from IVOC emissions from mobile sources. To account for SOA formation from both diesel and gasoline sources, the parameterization has six lumped precursor species that resolve both volatility and molecular structure (aromatic versus aliphatic). We also implement new mobile-source emission profiles that quantify all IVOCs based on direct measurements. The profiles have been released in SPECIATE 5.0. By incorporating both comprehensive mobile-source emission profiles for semivolatile organic compounds (SVOCs) and IVOCs and experimentally constrained SOA yields, this CMAQ configuration best represents the contribution of mobile sources to urban and regional ambient organic aerosol (OA). In the Los Angeles region, gasoline sources emit 4 times more non-methane organic gases (NMOGs) than diesel sources, but diesel emits roughly 3 times more IVOCs on an absolute basis. The revised model predicts all mobile sources (including on- and off-road gasoline, aircraft, and on- and off-road diesel) contribute ~ 1 µgm-3 to the daily peak SOA concentration in Pasadena. This represents a ~ 70% increase in predicted daily peak SOA formation compared to the base version of CMAQ. Therefore, IVOCs in mobile-source emissions contribute almost as much SOA as traditional precursors such as single-ring aromatics. However, accounting for these emissions in CMAQ does not reproduce measurements of either ambient SOA or IVOCs. To investigate the potential contribution of other IVOC sources, we performed two exploratory simulations with varying amounts of IVOC emissions from nonmobile sources. To close the mass balance of primary hydrocarbon IVOCs, IVOCs would need to account for 12% of NMOG emissions from nonmobile sources (or equivalently 30.7 t d-1 in the Los Angeles-Pasadena region), a value that is well within the reported range of IVOC content from volatile chemical products. To close the SOA mass balance and also explain the mildly oxygenated IVOCs in Pasadena, an additional 14.8% of nonmobile-source NMOG emissions would need to be IVOCs (assuming SOA yields from the mobile IVOCs apply to nonmobile IVOCs). However, an IVOC-to-NMOG ratio of 26.8% (or equivalently 68.5 t d-1 in the Los Angeles-Pasadena region) for nonmobile sources is likely unrealistically high. Our results highlight the important contribution of IVOCs to SOA production in the Los Angeles region but underscore that other uncertainties must be addressed (multigenerational aging, aqueous chemistry and vapor wall losses) to close the SOA mass balance. This research also highlights the effectiveness of regulations to reduce mobile-source emissions, which have in turn increased the relative importance of other sources, such as volatile chemical products.

Heterogenetic parabiosis between healthy and dystrophic mice improve the histopathology in muscular dystrophy.

Duchenne muscular dystrophy (DMD) is a progressive muscle disease, characterized by mutations in the X-linked dystrophin, that has several therapeutic options but no curative treatment. Transplantation of muscle progenitor cells for treatment of DMD has been widely investigated; however, its application is hindered by limited cell survival due to the harmful dystrophic microenvironment. An alternative approach to utilize progenitor cells and circulatory factors and to improve the dystrophic muscle pathology and microenvironment is through parabiotic pairing, where mice are surgically sutured to create a joint circulatory system. Parabiotic mice were generated by surgically joining wild type (WT) mice expressing green fluorescent protein (GFP) with mdx mice. These mice developed a common circulation (approximately 50% green cells in the blood of mdx mice) 2-weeks after parabiotic pairing. We observed significantly improved dystrophic muscle pathology, including decreased inflammation, necrotic fibers and fibrosis in heterogenetic parabionts. Importantly, the GFP + cells isolated from the mdx mice (paired with GFP mice) underwent myogenic differentiation in vitro and expressed markers of mesenchymal stem cells and macrophages, which may potentially be involved in the improvement of dystrophic muscle pathology. These observations suggest that changing the dystrophic microenvironment can be a new approach to treat DMD.

Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee.

BACKGROUND: Both physical therapy and intraarticular injections of glucocorticoids have been shown to confer clinical benefit with respect to osteoarthritis of the knee. Whether the short-term and long-term effectiveness for relieving pain and improving physical function differ between these two therapies is uncertain. METHODS: We conducted a randomized trial to compare physical therapy with glucocorticoid injection in the primary care setting in the U.S. Military Health System. Patients with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year (scores range from 0 to 240, with higher scores indicating worse pain, function, and stiffness). The secondary outcomes were the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale, all assessed at 1 year. RESULTS: We enrolled 156 patients with a mean age of 56 years; 78 patients were assigned to each group. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (mean between-group difference, 18.8 points; 95% confidence interval, 5.0 to 32.6), a finding favoring physical therapy. Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection. CONCLUSIONS: Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection. (ClinicalTrials.gov number, NCT01427153.).

Impact of a care delivery redesign initiative for vascular surgery.

OBJECTIVE: A hospital-wide quality improvement process through a care delivery redesign (CDR) was initiated to improve patient care efficiency, clinical documentation, and length of stay (LOS). The impact of CDR was assessed through LOS, unplanned readmission rates, and hospital financial metrics. METHODS: The CDR team consisted of the Chief of Vascular Surgery, inpatient nurse practitioner, dedicated case manager, clinical documentation improvement specialist, and vascular surgery residents and faculty. The nurse practitioner facilitated patient care coordination, resident system-based education, and multidisciplinary collaboration. Tools created to track performance and to ensure sustainability included daily discussions of patient care barriers and solutions; standardized order sets; a mobile app for residents containing resident service expectations, disease-specific resources, and vascular surgery journal links; and a weekly inpatient tracker showing real-time patient care data. Outcome measures included LOS, case mix index, contribution margin, and unplanned readmissions. Each outcome was determined for all inpatient admissions the year before and the 12 months after CDR was initiated. Outcomes were compared between the two groups. RESULTS: Implementation of CDR resulted in a 23% decrease in LOS (P = .003), reducing the gap to the Centers for Medicare and Medicaid Services geometric mean LOS from 2.1 days to 0.5 day (P < .001). Clinical documentation resulted in an increase in case mix index of 10% (P = .011). The 30-day unplanned readmission rates did not change in the 12 months after CDR was initiated compared with the year before (P = .92). Financial data demonstrated decreased variable cost and increased revenue resulting in a $1.89 million increase in contribution margin. CONCLUSIONS: A CDR predicated on a dedicated service line advanced practitioner, clinical documentation education, weekly service tracker review, and real-time management of system-related barriers to patient care is described. Implementation of the CDR reduced hospital LOS with no change in unplanned readmissions and provided significant financial benefit to the hospital by increasing revenue and decreasing variable cost.

Partner involvement in treatment-related decision making in triadic clinical consultations - A systematic review of qualitative and quantitative studies.

OBJECTIVE: Explore how partners are involved in treatment-related decision-making within triadic clinical encounters. METHODS: Studies were identified via database searches and reference lists. One author assessed eligibility of studies, which were verified by an additional co-author. Data were extracted by one author and cross-checked for accuracy by a second. Quality of articles was assessed using Qualsyst. Retrieved studies were categorised by one author, and agreed through discussion. RESULTS: From 2442 records, 14 studies were included and categorised as: (1) Descriptions of partner role and behaviour; (2) Role intentions of partners; (3) Relationship between partner and patient behaviour; (4) HCP-Partner interactions. CONCLUSION: Partners are often involved in triadic clinical consultations that have implications for treatment-related decision making. Most studies offered general descriptions but lacked detailed investigation of communicative processes in triads and how these may operate with partners vs. other companions. PRACTICE IMPLICATIONS: Existing studies lack detailed investigation through direct observation of the processes of partner involvement. Research in other areas of clinical communication suggests that future interventions could be informed by attention to the following areas: partner behaviour vs. other companion types in triads; relationships between partner involvement and decision-making processes; partner involvement in triads vs. other groups (e.g. quadratic).

The work and relatedness of ties mediated online in supporting long-term condition self-management.

The 'care transition' is characterised by reduced state involvement in chronic illness management in response to socio-political movements aimed at meeting the challenges presented by an increased prevalence of chronic illness. Amongst these changes has been online communities' rising importance in everyday interactions and attention is being increasingly paid towards the ways online contacts might contribute to self-management. Whilst research has illuminated the relevance of personal networks in long-term condition management, it is relevant to extend this work to consider the place of ties mediated online in this bricolage of support, including better understanding the work drawn from them and the strategies involved in eliciting it. This study examined the work and relatedness of 30 participants, who used online communities. Participants were asked about the role of on and offline ties and ego network mapping was used to frame conversations about the nature of this support. The context of engagement followed three main themes. Participants drew from online communities in response to deficits in offline support, they used online ties to leverage support or action from offline ties and they used online ties to substitute offline support, with less intimate online ties.