Risk factors for perioperative blood transfusion in patients undergoing hysterectomy for benign disease in a teaching institution.

PURPOSE: The purpose is to identify risk factors for perioperative blood transfusion in patients undergoing hysterectomy for benign disease. METHODS: This study is a retrospective chart review including all the patients who underwent hysterectomy for benign disease between January 1st 2018 and December 31st 2019. Patients who received perioperative blood transfusion were identified and compared to those who did not. The following risk factors for blood transfusion were analyzed: route of hysterectomy, BMI, presence of adhesions, history of cesarean section, uterine weight. Descriptive statistics was used to analyze the data. RESULTS: A total of 517 patients were identified and included in the study. Forty-seven patients (9.09%) received a perioperative blood transfusion. The abdominal hysterectomy route (TAH) was a significant risk factor for receiving blood transfusion (p = 0.012). Other identified risk factors for blood transfusion included: Body mass index above 33.0 (p = 0.002), and uterine weight (p = 0.002). There was no association between the presence of pelvic adhesions (p = 0.91) or a personal history of cesarean section (p = 0.89) and receiving perioperative blood transfusion. When analyzing only the patients who underwent TLH, the presence of pelvic adhesion was found as a risk factor for perioperative blood transfusion (p = 0.024). CONCLUSION: The abdominal hysterectomy route, the presence of a large uterus, and obesity are risk factors for receiving a blood transfusion. Early identification of the patient at risk of requiring perioperative blood transfusion provides better patient counseling and surgical preparation.

Comparison of Ultrasound-Marked Versus Standard Lumbar Puncture Success in Infants.

OBJECTIVES: The aim of this study was to compare ultrasound (US)-marked versus standard lumbar puncture success in infants. METHODS: This was a prospective cohort study at an academic pediatric emergency department. Standard lumbar puncture success in a retrospective control was compared with success in a US-marked group. Spinal US was performed with infants in the sitting and lateral decubitus position to identify the interspinous space with the most cerebrospinal fluid. The optimal position was determined, and this space was marked. The proceduralist performed the lumbar puncture at the level of the markings. The primary outcome was a successful lumbar puncture by the first provider, defined as a collection of cerebrospinal fluid with less than 1000 red blood cells/mm3. Secondary outcomes were successful lumbar puncture after attempts by more than 1 provider and collection of any spinal fluid. RESULTS: Between June 2017 and April 2019, we enrolled 284 infants younger than 12 months, 210 in the retrospective standard group and 74 in the prospective US-marked group. Baseline characteristics of both groups were similar. The primary outcome showed no difference between US-marked group and control (38% vs 36%; difference: 1.6% [95% confidence interval (CI), -14.7 to 10.7]). Secondary outcomes showed no significant success differences by more than 1 provider (51% vs 39%; difference: 12.8% [95% CI, -25.7 to 0.3]) or in obtaining any spinal fluid (82% vs 79%; difference: 3.9% [95% CI -13.3 to 7.5]). CONCLUSIONS: There were no differences in success between US-marked and standard lumbar punctures in infants by different providers.

A principle-based approach to justify the use of HIV self-testing in South Africa.

The South African government introduced the use of an HIV self-testing (HIVST) kit in 2016 to expand access to HIV testing services and to increase HIV testing uptake among men and key populations who may otherwise not test. By reviewing existing empirical data, including existing guidelines regarding the implementation and use of HIV self-testing, this research explores the ethical implications of using the HIV self-testing kit and draws arguments from the ethical principles: respect for autonomy, beneficence, non-maleficence, and social justice. The implementation of HIV self-testing in South Africa does not violate any ethical principles; however, the potential occurrences of coercion and intimate partner violence surrounding HIV self-testing remain issues of concern challenging the principle of non-maleficence. Furthermore, the available empirical data on potential harm does not provide compelling ethical grounds for restricting the sale of HIVST kits in South Africa. Hence, HIVST in South Africa remains an ethically justified intervention.

The maternal-age-associated risk of congenital heart disease is modifiable.

Maternal age is a risk factor for congenital heart disease even in the absence of any chromosomal abnormality in the newborn. Whether the basis of this risk resides with the mother or oocyte is unknown. The impact of maternal age on congenital heart disease can be modelled in mouse pups that harbour a mutation of the cardiac transcription factor gene Nkx2-5 (ref. 8). Here, reciprocal ovarian transplants between young and old mothers establish a maternal basis for the age-associated risk in mice. A high-fat diet does not accelerate the effect of maternal ageing, so hyperglycaemia and obesity do not simply explain the mechanism. The age-associated risk varies with the mother's strain background, making it a quantitative genetic trait. Most remarkably, voluntary exercise, whether begun by mothers at a young age or later in life, can mitigate the risk when they are older. Thus, even when the offspring carry a causal mutation, an intervention aimed at the mother can meaningfully reduce their risk of congenital heart disease.

Critical Thinking Medication Storytelling: A Teaching Strategy to Engage Thoughts, Emotions, and Creativity.

ABSTRACT: Nursing students struggle to learn medications that their patients have been prescribed, often regurgitating information found in a drug book or on a drug card. Watching students do this led to the development of the Critical Thinking Medication Storytelling assignment. The assignment was designed to bring information to life in a creative and meaningful way, enabling students to see how specific medications interrelate with the patient's condition. Qualitative results from students revealed that students embraced this teaching strategy; the strategy was effective for acquiring drug knowledge.

Empirical treatment of urinary tract infections: how rational are our guidelines?

Objectives: This study considers susceptibility test results obtained over a 6 month period for Enterobacteriaceae that caused urinary tract infections (UTIs) in the Cork region of Ireland and uses these results to examine the suitability of Irish empirical treatment guidelines. Patients and methods: UTI-causing Enterobacteriaceae isolates were analysed using EUCAST guidelines to determine resistance to a set of commonly prescribed antimicrobial agents, i.e. ampicillin, amoxicillin/clavulanate, cefalexin, ciprofloxacin, nitrofurantoin and trimethoprim. Patients were categorized by age and patient type, based on origin (hospital inpatients, patients in long-term care facilities and all other non-hospitalized patients). In total, 8999 test results were analysed using the IBM Cognos Analytics Series 7 interrogation tool and Microsoft Office Excel. Results: A variety of resistance patterns were observed. Only one antimicrobial agent, nitrofurantoin, demonstrated a resistance rate of less than 20% for all patient categories considered. Conclusions: Previous studies determined that a resistance rate of >20% renders an antimicrobial agent unsuitable for use as an empirical treatment option. This study demonstrated that this resistance rate is exceeded in many cases, potentially rendering some antimicrobial agents unsuitable for use as empirical treatment. We suggest that the focus on susceptibility when producing surveillance data to create empirical treatment guidelines may inadvertently camouflage resistance rates. The findings of this study highlight the need for laboratory-guided treatment of UTIs and ideally a pre-emptive sample should be obtained for laboratory investigation prior to commencement of antimicrobial therapy.

Centering pregnancy in Missouri: a system level analysis.

BACKGROUND: Centering Pregnancy (CP) is an effective method of delivering prenatal care, yet providers have been slow to adopt the CP model. Our main hypothesis is that a site's adoption of CP is contingent upon knowledge of the CP, characteristics health care personnel, anticipated patient impact, and system readiness. METHODS: Using a matched, pretest-posttest, observational design, 223 people completed pretest and posttest surveys. Our analysis included the effect of the seminar on the groups' knowledge of CP essential elements, barriers to prenatal care, and perceived value of CP to the patients and to the system of care. RESULTS: Before the CP Seminar only 34% of respondents were aware of the model, while knowledge significantly after the Seminar. The three greatest improvements were in understanding that the group is conducted in a circle, the health assessment occurs in the group space, and a facilitative leadership style is used. Child care, transportation, and language issues were the top three barriers. The greatest improvements reported for patients included improvements in timeliness, patient-centeredness and efficiency, although readiness for adoption was influenced by costs, resources, and expertise. DISCUSSION: Readiness to adopt CP will require support for the start-up and sustainability of this model.

Coping while caring for the dying child: nurses' experiences in an acute care setting.

The aim of this study was to describe and understand behavior and coping strategies used by pediatric nurses caring for dying children on an inpatient acute care cardiology unit. Qualitative descriptive methods consisting of semistructured questions were presented to acute care nurses participating in focus groups. The nurses who participated in the focus groups had cared for an acutely ill child who died. Conventional content analysis was used to analyze data and organize results. The categories that emerged included the following: boundaries, memories, disconnecting, and labeling. Colleague support, institutional resources, and nurses' experience level were critical to the process of coping. Coping and grieving are facilitated by colleague and unit resources. Studies exploring job dissatisfaction, stress, and burnout from an inadequate grieving process are required.

Effect of Sub-Inhibitory Concentrations of Nitrofurantoin, Ciprofloxacin, and Trimethoprim on In Vitro Biofilm Formation in Uropathogenic Escherichia coli (UPEC).

The purpose of this study was to determine the effect of sublethal concentrations of nitrofurantoin, ciprofloxacin, and trimethoprim on biofilm formation in 57 uropathogenic Escherichia coli strains (UPEC). The minimum inhibitory concentration of nitrofurantoin, ciprofloxacin, and trimethoprim was determined and the biofilm formation for each isolate with and without sub-lethal concentrations of each antibiotic was then quantified. The statistical significance of changes in biofilm formation was ascertained by way of a Dunnett's test. A total of 22.8% of strains were induced to form stronger biofilms by nitrofurantoin, 12% by ciprofloxacin, and 19% by trimethoprim; conversely 36.8% of strains had inhibited biofilm formation with nitrofurantoin, 52.6% with ciprofloxacin, and 38.5% with trimethoprim. A key finding was that even in cases where the isolate was resistant to an antibiotic as defined by EUCAST, many were induced to form a stronger biofilm when grown with sub-MIC concentrations of antibiotics, especially trimethoprim, where six of the 22 trimethoprim resistant strains were induced to form stronger biofilms. These findings suggest that the use of empirical treatment with trimethoprim without first establishing susceptibility may in fact potentiate infection in cases where a patient who is suffering from a urinary tract infection (UTI) caused by trimethoprim resistant UPEC is administered trimethoprim. This emphasizes the need for laboratory-guided treatment of UTI.

Impact of using words with unpleasant emotional connotations on perceived patient discomfort during vaginal speculum examinations: A randomized controlled trial.

OBJECTIVES: Many providers often use terms such as "this might hurt", or "you might feel pressure" during exams with the intention to be compassionate and to help decrease discomfort. No evidence exists to support this practice. Our objective was to evaluate the impact of the use of words with unpleasant emotional connotation on perceived discomfort at the time of vaginal speculum examination. STUDY DESIGN: A randomized trial was performed on premenopausal women undergoing a routine well-woman speculum exam. 120 total patients were included and randomized into one of two groups; phrases with unpleasant connotation (n = 60) vs. objective phrases (n = 60). During the speculum exam, the provider used either phrases with unpleasant connotation (i.e., "You are going to feel a lot of pressure"), or objective phrases (i.e., "I am going to introduce the speculum"). Following the exam, patients were asked to rate the level of discomfort/pain experienced during the exam and to compare their actual experience to their anticipated experience. Descriptive statistics were performed. Chi-square and independent samples t-test were used with a significance of p < 0.05. RESULTS: Patients in the phrases with unpleasant connotation group had significantly higher pain scores than the objective phrases group (2.9 ± 1.5 vs. 0.8 ± 0.8 (p < .01)). The majority of the patients in the phrases with unpleasant connotation group reported the exam "as painful as anticipated" or "more painful than anticipated" whereas the majority of the patients in the objective phrases group reported the exam as "pain free" or "less painful than anticipated". CONCLUSION: Healthcare providers performing speculum examinations should use objective statements and avoid the use of phrases with unpleasant connotation with the intention to minimize perceived pain during exams.

Impact of physician attire on patients' impression of their gynecologist: Results from a large single-center survey analysis.

OBJECTIVE: To assess the impact of physician attire in a gynecology office setting on a patient's level of trust and perception regarding medical advice, performing vaginal exams, and physician's ability to perform major and minor procedures. STUDY DESIGN: Cross sectional anonymous survey at a large academic medical center. The survey was distributed to 200 patients of a single-physician gynecology office, between January 1st 2018 and March 31st 2018. The survey contained an image depicting a hypothetical gynecologist and hypothetical questions regarding clinical situations. Participants were asked to answer which doctor from the image shown they preferred for a given scenario. RESULTS: White coat was reported to be preferred physician attire in almost every clinical situation (p < 0.05). There were only two clinical scenarios, a gynecologic emergency (p < 0.01) and in the setting of major surgery (p < 0.07), in which patients did not have a preference for the gynecologist wearing a white coat. Attire did not have a significant effect on respondent's perception of the gynecologist's knowledge, level of compassion, authority, or ability to communicate. CONCLUSION: The majority of patients preferred a physician wearing a white coat in the presented gynecologic scenarios, with the exception of gynecologic emergencies and gynecologic surgery, in which surgical scrubs were preferred.

Uropathogenic Escherichia coli Biofilm-Forming Capabilities are not Predictable from Clinical Details or from Colonial Morphology.

Antibiotic resistance is increasing to an extent where efficacy is not guaranteed when treating infection. Biofilm formation has been shown to complicate treatment, whereby the formation of biofilm is associated with higher minimum inhibitory concentration values of antibiotic. The objective of the current paper was to determine whether biofilm formation is variable among uropathogenic Escherichia coli isolates and whether formation is associated with recurrent urinary tract infection (UTI), and whether it can be predicted by phenotypic appearance on culture medium A total of 62 E. coli isolates that were reported as the causative agent of UTI were studied (33 from patients denoted as having recurrent UTI and 29 from patients not specified as having recurrent UTI). The biofilm forming capability was determined using a standard microtitre plate method, using E. coli ATCC 25922 as the positive control. The majority of isolates (93.6%) were found to be biofilm formers, whereby 81% were denoted as strong or very strong producers of biofilm when compared to the positive control. Through the use of a Wilcox test, the difference in biofilm forming propensity between the two patient populations was found to not be statistically significant (p = 0.5). Furthermore, it was noted that colony morphology was not a reliable predictor of biofilm-forming propensity. The findings of this study indicate that biofilm formation is very common among uropathogens, and they suggest that the biofilm-forming capability might be considered when treating UTI. Clinical details indicating a recurrent infection were not predictors of biofilm formation.

Protective Effects of Indian Spice Curcumin Against Amyloid-ß in Alzheimer's Disease.

The purpose of our article is to assess the current understanding of Indian spice, curcumin, against amyloid-ß (Aß)-induced toxicity in Alzheimer's disease (AD) pathogenesis. Natural products, such as ginger, curcumin, and gingko biloba have been used as diets and dietary supplements to treat human diseases, including cancer, cardiovascular, respiratory, infectious, diabetes, obesity, metabolic syndromes, and neurological disorders. Products derived from plants are known to have protective effects, including anti-inflammatory, antioxidant, anti-arthritis, pro-healing, and boosting memory cognitive functions. In the last decade, several groups have designed and synthesized curcumin and its derivatives and extensively tested using cell and mouse models of AD. Recent research on Aß and curcumin has revealed that curcumin prevents Aß aggregation and crosses the blood-brain barrier, reach brain cells, and protect neurons from various toxic insults of aging and Aß in humans. Recent research has also reported that curcumin ameliorates cognitive decline and improves synaptic functions in mouse models of AD. Further, recent groups have initiated studies on elderly individuals and patients with AD and the outcome of these studies is currently being assessed. This article highlights the beneficial effects of curcumin on AD. This article also critically assesses the current limitations of curcumin's bioavailability and urgent need for new formulations to increase its brain levels to treat patients with AD.

Protective effects of a natural product, curcumin, against amyloid ß induced mitochondrial and synaptic toxicities in Alzheimer's disease.

The purpose of our study was to investigate the protective effects of a natural product-'curcumin'- in Alzheimer's disease (AD)-like neurons. Although much research has been done in AD, very little has been reported on the effects of curcumin on mitochondrial biogenesis, dynamics, function and synaptic activities. Therefore, the present study investigated the protective effects against amyloid ß (Aß) induced mitochondrial and synaptic toxicities. Using human neuroblastoma (SHSY5Y) cells, curcumin and Aß, we studied the protective effects of curcumin against Aß. Further, we also studied preventive (curcumin+Aß) and intervention (Aß+curcumin) effects of curcumin against Aß in SHSY5Y cells. Using real time RT-PCR, immunoblotting and immunofluorescence analysis, we measured mRNA and protein levels of mitochondrial dynamics, mitochondrial biogenesis and synaptic genes. We also assessed mitochondrial function by measuring hydrogen peroxide, lipid peroxidation, cytochrome oxidase activity and mitochondrial ATP. Cell viability was studied using the MTT assay. Aß was found to impair mitochondrial dynamics, reduce mitochondrial biogenesis and decrease synaptic activity and mitochondrial function. In contrast, curcumin enhanced mitochondrial fusion activity and reduced fission machinery, and increased biogenesis and synaptic proteins. Mitochondrial function and cell viability were elevated in curcumin treated cells. Interestingly, curcumin pre- and post-treated cells incubated with Aß showed reduced mitochondrial dysfunction, and maintained cell viability and mitochondrial dynamics, mitochondrial biogenesis and synaptic activity. Further, the protective effects of curcumin were stronger in pretreated SHSY5Y cells than in post-treated cells, indicating that curcumin works better in prevention than treatment in AD-like neurons. Our findings suggest that curcumin is a promising drug molecule to treat AD patients.

Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program.

Adolescent pregnancy remains a significant social, economic, and health issue in the United States. The unique developmental needs of the pregnant adolescent require attention when designing prenatal care services. The CenteringPregnancy model of group prenatal care provides education and support for young women in an active and developmentally appropriate environment. Thirteen groups of adolescents (N = 124) have completed the Centering program at the Teen Pregnancy Center at Barnes Jewish Hospital in St. Louis, Missouri. Evaluation data suggest that the model has encouraged excellent health care compliance, satisfaction with prenatal care, and low rates of preterm birth and low birth weight infants.

Using focus groups and social marketing to strengthen promotion of group prenatal care.

Centering Pregnancy, an innovative group model of prenatal care, shows promise to reduce persistent adverse maternal-infant outcomes and contain costs. Because this innovation requires systemwide change, clinics reported needing support enrolling women into groups and obtaining organizational buy-in. This study used the 3-step social marketing communication strategy to help clinic staff identify key customers and customer-specific barriers to adopting or supporting Centering Pregnancy. They developed targeted information to reduce barriers and built skills in communicating with different customers through role-playing. Findings provide practical information for others to use this communication strategy to improve implementation of Centering Pregnancy.

Gather ye rosebuds while ye may: a College of Nursing History Project.

Knowledge of nursing history is a stated competency in professional nursing education. The authors describe one college of nursing's oral history project designed to build a historical archive and document the career paths of our retired faculty. Practical details about the project and insights of participating students and faculty are shared. The stories of these expert nurses are living testimony to the exciting progress of our profession and nursing education over the last 60 years.

Treatment of femoral fracture nonunion after long-term bisphosphonate use.

Bisphosphonates are a class of drugs that prevent bone loss by decreasing bone resorption. They represent a major treatment for osteoporosis and other metabolic bone diseases. Recent reports suggest that a potential complication of long-term bisphosphonate therapy may be atypical insufficiency fractures of the femur. Concern exists about delayed union after fracture stabilization in patients taking bisphosphonates.This article describes 2 patients on long-term bisphosphonate therapy treated for atypical femur fractures that failed to heal with intramedullary nailing. Both patients' fractures occurred after at least 4.5 years of bisphosphonate use and displayed classic findings of bisphosphonate fractures reported in the literature, including a subtrochanteric location, presentation after minimal trauma, transverse fracture, no comminution, and cortical beaking. The original fractures were treated at other institutions with intramedullary nails. Subsequently, both patients presented with pain and atrophic nonunion of their fractures. Evaluation included a computed tomography scan of the fracture and a metabolic workup. The patients discontinued bisphosphonate therapy. They were treated with nail removal and definitive plating to achieve compression across the fracture site. Both fractures went on to heal after this treatment with no further complications.The literature currently recommends treating bisphosphonate fractures with an intramedullary nail. Perhaps initial treatment of these fractures should be similar to an atrophic nonunion, involving compression plating to obtain bone-on-bone contact and promote healing. This would address the biologic and mechanical etiologies of the bisphosphonate fracture.