Classifying early infant feeding status from clinical notes using natural language processing and machine learning.

The objective of this study is to develop and evaluate natural language processing (NLP) and machine learning models to predict infant feeding status from clinical notes in the Epic electronic health records system. The primary outcome was the classification of infant feeding status from clinical notes using Medical Subject Headings (MeSH) terms. Annotation of notes was completed using TeamTat to uniquely classify clinical notes according to infant feeding status. We trained 6 machine learning models to classify infant feeding status: logistic regression, random forest, XGBoost gradient descent, k-nearest neighbors, and support-vector classifier. Model comparison was evaluated based on overall accuracy, precision, recall, and F1 score. Our modeling corpus included an even number of clinical notes that was a balanced sample across each class. We manually reviewed 999 notes that represented 746 mother-infant dyads with a mean gestational age of 38.9 weeks and a mean maternal age of 26.6 years. The most frequent feeding status classification present for this study was exclusive breastfeeding [n = 183 (18.3%)], followed by exclusive formula bottle feeding [n = 146 (14.6%)], and exclusive feeding of expressed mother's milk [n = 102 (10.2%)], with mixed feeding being the least frequent [n = 23 (2.3%)]. Our final analysis evaluated the classification of clinical notes as breast, formula/bottle, and missing. The machine learning models were trained on these three classes after performing balancing and down sampling. The XGBoost model outperformed all others by achieving an accuracy of 90.1%, a macro-averaged precision of 90.3%, a macro-averaged recall of 90.1%, and a macro-averaged F1 score of 90.1%. Our results demonstrate that natural language processing can be applied to clinical notes stored in the electronic health records to classify infant feeding status. Early identification of breastfeeding status using NLP on unstructured electronic health records data can be used to inform precision public health interventions focused on improving lactation support for postpartum patients.

Observed Use of Clinical Judgment Among New Graduate Nurses.

BACKGROUND: Despite the efforts of academic nursing educators to prepare students to make sound clinical judgments, the literature suggests new graduate nurse (NGN) competence with this critical skill continues to decline. This study sought to identify how practicing nurses describe their observations of the use and outcomes of clinical judgment by NGNs in nursing practice. METHOD: A multisite, cross-sectional survey using multiple-choice, Likert scale, and open response items to identify participants' observations of NGN clinical judgment was sent with snowball sampling and resulted in a sample of 314 participants from 19 U.S. states. RESULTS: Practice partners identified a wide discrepancy between how they expect NGNs to use clinical judgment and what they actually see NGNs do, with resultant negative effects on patients and NGNs. CONCLUSION: These results provide a beginning understanding of NGNs' specific challenges with clinical judgment. Efforts to improve clinical judgment across nursing education and practice are needed. [J Contin Educ Nurs. 202x;5x(x):xx-xx.].

Current practices for assessing clinical judgment in nursing students and new graduates: A scoping review.

OBJECTIVE: To map current assessment practices for learning outcomes related to nurses' clinical judgment from undergraduate education to entry to practice. DESIGN: Scoping review using the Joanna Briggs Institute guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). DATA SOURCES: Electronic databases-Cumulative Index of Nursing and Allied Health Literature (CINAHL Complete; EBSCOhost), EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), and Web of Science (Social Sciences Citation Index, Citation Index Expanded)-using a combination of descriptors and keywords related to nursing students, newly graduated nurses, clinical judgment and related terms (e.g., critical thinking, clinical reasoning, clinical decision-making, and problem-solving), and assessment. METHODS: Two reviewers independently extracted study characteristics and, for each outcome relevant to clinical judgment, the concept, definition and framework, assessment tool, and the number and schedule of assessments. Data were synthesized narratively and using descriptive statistics. RESULTS: Most of the 52 reviewed studies examined the outcome of a discrete educational intervention (76.9 %) in academic settings (78.8 %). Only six studies (11.5 %) involved newly graduated nurses. Clinical judgment (34.6 %), critical thinking (26.9 %), and clinical reasoning (9.6 %) were the three most frequent concepts. Three assessment tools were used in more than one study: the Lasater Clinical Judgment Rubric (n = 22, 42.3 %), the California Critical Thinking Skills Test (n = 9, 17.3 %), and the Health Science Reasoning Test (n = 2, 3.8 %). Eleven studies (21.2 %) used assessment tools designed for the study. CONCLUSION: In addition to a disparate understanding of underlying concepts, there are minimal published studies on the assessment of nursing students and nurses' clinical judgment, especially for longitudinal assessment from education to clinical practice. Although there is some existing research on this topic, further studies are necessary to establish valid and reliable clinical competency assessment methods that effectively integrate clinical judgment in clinical situations at relevant time points.

Drivers of arthropod biodiversity in an urban ecosystem.

Our world is becoming increasingly urbanized with a growing human population concentrated around cities. The expansion of urban areas has important consequences for biodiversity, yet the abiotic drivers of biodiversity in urban ecosystems have not been well characterized for the most diverse group of animals on the planet, arthropods. Given their great diversity, comparatively small home ranges, and ability to disperse, arthropods make an excellent model for studying which factors can most accurately predict urban biodiversity. We assessed the effects of (i) topography (distance to natural areas and to ocean) (ii) abiotic factors (mean annual temperature and diurnal range), and (iii) anthropogenic drivers (land value and amount of impervious surface) on the occurrence of six arthropod groups represented in Malaise trap collections run by the BioSCAN project across the Greater Los Angeles Area. We found striking heterogeneity in responses to all factors both within and between taxonomic groups. Diurnal temperature range had a consistently negative effect on occupancy but this effect was only significant in Phoridae. Anthropogenic drivers had mixed though mostly insignificant effects, as some groups and species were most diverse in highly urbanized areas, while other groups showed suppressed diversity. Only Phoridae was significantly affected by land value, where most species were more likely to occur in areas with lower land value. Los Angeles can support high regional arthropod diversity, but spatial community composition is highly dependent on the taxonomic group.

An integrative review of teaching strategies to support clinical judgment development in clinical education for nurses.

OBJECTIVES: Historically, emphasis on task-completion and lack of intentional approaches that develop students' thinking skills have dominated clinical education. One contributing factor may be the limited literature about teaching to develop clinical reasoning and clinical judgment in the clinical environment. This integrative review accessed available literature to answer the question, What strategies are used to develop clinical judgment in the clinical education environment? DESIGN: The Whittemore and Knafl approach framed the integrative review. The framework includes the following steps 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation. DATASOURCES: The data bases CINAHL Plus with Full Text, OVID, and ProQuest were searched through the period of January 2000 through July of 2022. REVIEW METHODS: The PRISMA protocol informed review and screening of the literature. Authors assessed articles for eligibility via first screening by abstract review, followed by review of the full text. Both authors reviewed the articles, assessing qualification for inclusion and evaluating the content. Data from eligible articles were analyzed and synthesized to answer the research question. RESULTS: Of the initial 427 articles, a total of 20 articles met inclusion criteria for final analysis. Five general themes emerged for clinical judgment during clinical education. The findings identified the teaching strategies nurse educators use. Many of the teaching methods include deliberateness and intentionality in planning and implementing the strategies. In addition to evaluating clinical judgment, nurse educators guided and mentored student thinking. Finally, this review identified reported outcomes and results of the teaching strategies and methods. CONCLUSIONS: A limited number of articles describing teaching for clinical judgment in clinical environment were found. The articles analyzed found that nurse educators used a variety of teaching strategies for the purpose of developing students' clinical judgment. More research is needed to guide best-practices in clinical education. We must move the science forward to transform and leverage clinical education more deliberately to teach thinking in practice and decision-making about patient care.

Current Practices for Teaching Clinical Judgment: Results From a National Survey.

BACKGROUND: Safe patient care is closely linked to clinical judgment. Concerns about inadequate practice readiness and the impending inclusion of clinical judgment items on the NextGen NCLEX have resulted in increasing interest and publications about teaching clinical judgment. However, little is known about actual current practices for teaching this skill. PURPOSE: This research describes findings about current strategies to teach clinical judgment used in US prelicensure nursing programs. METHODS: Cross-sectional methodology was used to survey program deans and directors across the United States. RESULTS: Programs are using multiple strategies to teach clinical judgment. The most common strategies used include case studies and simulation. Participants believed strategies have a positive impact on student thinking, practice readiness, and program outcomes. They described insights into implementation of teaching for clinical judgment. CONCLUSION: The results of this research provide foundational data to inform current teaching practices and further research for this essential skill.

A National Report on Clinical Judgment Model Use in Prelicensure Nursing Curricula.

AIM: This study examined US prelicensure nursing program use of clinical judgment models and teaching strategies to promote students' clinical judgment. BACKGROUND: Growing interest in teaching clinical judgment associated with upcoming changes in NCLEX-RN testing warrants exploration of how models and teaching strategies are currently used. METHOD: A cross-sectional survey with multiple-choice and open-ended response items was used to examine programs' use of clinical judgment educational models. RESULTS: Of 234 participants (9 percent response rate), 27 percent reported using a model; 51 percent intended and 20 percent did not intend to start using a model. Tanner's clinical judgment model was the most used, followed by the clinical reasoning cycle. Models were used to inform design of teaching/learning strategies and facilitate clinical teaching and evaluation. CONCLUSION: Clinical judgment model use may increase as programs prepare for changes in NCLEX-RN. Research is needed to understand how model use contributes to measurable differences in clinical judgment skill.

Developing Students' Clinical Reasoning Skills: A Faculty Guide.

BACKGROUND: Safe patient care relies on the ability of nurses to make timely, sound clinical judgments, yet new nurse graduates are underprepared. Nurse educators must take action with teaching to develop students' clinical reasoning skills and ultimately their clinical judgment. One first step is to consider strategies that integrate clinical judgment and clinical reasoning skills into nursing curriculum. METHOD: The literature was reviewed to uncover what is known about teaching strategies that intentionally teach clinical reasoning skills and are focused on the development of students' clinical judgment. RESULTS: Although not exhaustive, this guide for faculty discusses first steps when considering integrating clinical reasoning and judgment into nursing curriculum, presents teaching strategies, and provides ideas for implementation within nursing curriculum. CONCLUSION: Teaching clinical reasoning skills, using a framework, and incorporating teaching strategies such as concept-learning, high-order questioning, and reflection focused on developing clinical reasoning skills may prove useful in developing students' clinical judgment. [J Nurs Educ. 2021;60(9):485-493.].

Evidence That Daily Vinegar Ingestion May Contribute to Erosive Tooth Wear in Adults.

Vinegar ingestion at mealtime is gaining popularity for its antiglycemic effects; however, it is among the most acidic consumable substances. This study examined tooth wear in healthy adults participating in an 8-week randomized trial examining the effect of daily vinegar ingestion on insulin sensitivity and visceral fat reduction. Twice daily participants consumed a vinegar drink (two tablespoons vinegar in a cup of water; 3.6 g acetic acid) or a commercial vinegar pill (control, 0.045 g acetic acid) at mealtime. Participants were screened for dental erosion using the basic erosive wear examination (BEWE) by a blinded registered dental hygienist at trial baseline and week 8. Mean BEWE scores did not change in the control group but increased 18% in the vinegar group over the 8-week study (P = .038). Given the current popularity of vinegar as a medicinal agent, practitioners should caution patients who utilize this strategy on the possibility of erosive tooth wear. Trial registration: This trial was registered at ClinicalTrials.gov (NCT03577834) on July 5, 2018 and the institutional review board at Arizona State University provided ethical approval (STUDY00005418).

Revision of the Oriental Region genus Epicnemis Borgmeier (Diptera: Phoridae).

The Oriental Region phorid genus Epicnemis Borgmeier is revised, resulting in the recognition of 15 species, 10 of which are new to science: E. alus, chaweewanae, digitalis, disjunctus, dorsalis, latus, projectus, ratanae, setosus, and sinuosus. Only males are treated, as females are highly modified and cannot be associated with their males based on morphology alone.

Daily red wine vinegar ingestion for eight weeks improves glucose homeostasis and affects the metabolome but does not reduce adiposity in adults.

Some studies have reported that vinegar ingestion at mealtime attenuates postprandial glycemia in healthy adults and individuals with type 2 diabetes. Emerging data suggest that chronic vinegar ingestion impacts fat metabolism and reduces adiposity, although no study has yet corroborated the events of vinegar supplementation metabolically through a metabolomics approach. To examine the impact of daily vinegar ingestion on glucose homeostasis, adiposity, and the metabolome, an 8-week, randomized controlled trial design was implemented utilizing two parallel treatment arms: daily red wine vinegar ingestion and a control treatment. Participants were 45 healthy adults at increased risk for metabolic complications as determined by high waist circumferences. Measurements and blood samples were collected pre- and post-intervention. Central adiposity and visceral fat were assessed by waist circumference and dual-energy X-ray absorptiometry, respectively. Plasma metabolites were analyzed using gas chromatography-mass spectrometry (MS) and liquid chromatography-MS/MS. Analysis showed significant reductions in fasting glucose (p = 0.003) and insulin (p < 0.001). Insulin resistance was reduced 8.3% in the red wine vinegar group and increased 9.7% in the control group (p < 0.001). No significant between-group differences in body mass index, body weight, waist circumference, or visceral fat were observed. Significant differences were observed in amino valerate and indole-3-acetic acid (p < 0.05), with high magnitudes of fold change (>2) between groups. Metabolic pathway analysis revealed significant alterations in tryptophan metabolism. Although daily red wine vinegar ingestion for 8 weeks induced significant improvements in glucose homeostasis, our results indicate that daily red wine vinegar ingestion for 8 weeks is not associated with reductions in adiposity. This is the first study to investigate the effects of daily red wine vinegar supplementation using a metabolomics approach. Our results provide strong rationales for larger prospective studies to further clarify associations among obesity, chronic diseases, and functional foods such as vinegar using metabolomics.

Teaching Clinical Reasoning Piece by Piece: A Clinical Reasoning Concept-Based Learning Method.

BACKGROUND: Recent discourse generates a more thorough understanding of what clinical reasoning entails. Although numerous strategies prioritize clinical reasoning development, teaching and evaluating the thinking involved in clinical reasoning remains a struggle for nurse educators, particularly regarding clinical education. METHOD: In response, the author developed a concept-based clinical reasoning teaching method with weekly themes, lessons, and learning activities adapted from Tanner's clinical judgment model and Lasater's Clinical Judgment Rubric. RESULTS: The method offers an organized, consistent approach to teaching and learning clinical reasoning, with multiple opportunities for student reflection, instructor guidance, and discussing clinical reasoning concepts. Clinical education became transformed for both the nurse educator and nursing students as clinical reasoning became a visible part of students' budding nursing practice. CONCLUSION: Nurse faculty must ensure future nurses are prepared to think-inaction. The clinical reasoning teaching method offers one potential solution. [J Nurs Educ. 2018;57(12):727-735.].

Characterization of Recombinant His-Tag Protein Immobilized onto Functionalized Gold Nanoparticles.

The recombinant polyhistidine-tagged hemoglobin I ((His)6-rHbI) from the bivalve Lucina pectinata is an ideal biocomponent for a hydrogen sulfide (H2S) biosensor due to its high affinity for H2S. In this work, we immobilized (His)6-rHbI over a surface modified with gold nanoparticles functionalized with 3-mercaptopropionic acid complexed with nickel ion. The attenuated total reflection Fourier transform infrared spectroscopy (ATR-FTIR) analysis of the modified-gold electrode displays amide I and amide II bands characteristic of a primarily α-helix structure verifying the presence of (His)6-rHbI on the electrode surface. Also, X-ray photoelectron spectroscopy (XPS) results show a new peak after protein interaction corresponding to nitrogen and a calculated overlayer thickness of 5.3 nm. The functionality of the immobilized hemoprotein was established by direct current potential amperometry, using H2S as the analyte, validating its activity after immobilization. The current response to H2S concentrations was monitored over time giving a linear relationship from 30 to 700 nM with a corresponding sensitivity of 3.22 × 10-3 nA/nM. These results confirm that the analyzed gold nanostructured platform provides an efficient and strong link for polyhistidine-tag protein immobilization over gold and glassy carbon surfaces for a future biosensors development.

Engineered (Lys)6-Tagged Recombinant Sulfide-Reactive Hemoglobin I for Covalent Immobilization at Multiwalled Carbon Nanotubes.

The recombinant HbI was fused with a poly-Lys tag ((Lys)6-tagged rHbI) for specific-site covalent immobilization on two carbon nanotube transducer surfaces, i.e., powder and vertically aligned carbon nanotubes. The immobilization was achieved by following two steps: (1) generation of amine-reactive ester from the carboxylic acid groups of the surfaces and (2) coupling these groups with the amine groups of the Lys-tag. We analyzed the immobilization process using different conditions and techniques to differentiate protein covalent attachment from physical adsorption. Fourier transform infrared microspectroscopy data showed a 14 cm-1 displacement of the protein's amide I and amide II peaks to lower the frequency after immobilization. This result indicates a covalent attachment of the protein to the surface. Differences in the morphology of the carbon substrate with and without (Lys)6-tagged rHbI confirmed protein immobilization, as observed by transmission electron microscopy. The electrochemical studies, which were performed to evaluate the redox center of the immobilized protein, show a confinement suitable for an efficient electron transfer system. More importantly, the electrochemical studies allowed determination of a redox potential for the new (Lys)6-tagged rHbI. The data show that the protein is electrochemically active and retains its biological activity toward H2S.

Ciliated Adenosquamous Carcinoma: Expanding the Phenotypic Diversity of Human Papillomavirus-Associated Tumors.

This study describes a unique subset of ciliated, human papillomavirus (HPV) related, adenosquamous carcinomas (AsqCA) of the head and neck that in contrast to most AsqCA, often show areas with lower grade cytonuclear features. They are comprised of largely non-keratinizing squamous cell carcinoma components with cystic change, gland formation, mucin production, and cilia in tumor cells. Seven cases of ciliated AsqCA were retrieved. Site distribution was as follows: palatine tonsil--3/7, base of tongue--1/7, and neck (unknown primary site)--3/7. Despite the occasional resemblance to mucoepidermoid carcinoma (MEC), the tumors showed focal keratinizing morphology and atypia, and all tumors were negative for MAML2 rearrangements. Oropharyngeal and neck tumors were uniformly p16 positive and showed punctate staining by in situ hybridization for high risk HPV DNA. There were two distant metastases (lung), and one tumor related death. Thus, ciliated AsqCA are HPV-associated lesions that pose unique pitfalls, closely mimicking MEC and other salivary gland tumors. These tumors add to the list of those which defy the dogma that ciliated epithelium always equates to a benign process.