Socioeconomic status fails to account for worse outcomes in non-Hispanic black patients undergoing carotid revascularization.

OBJECTIVE: Previous studies have reported an association of Black race with worse carotid revascularization outcomes, but rarely include socioeconomic status as a confounding covariate. We aimed to assess the association of race and ethnicity with in-hospital and long-term outcomes following carotid revascularization before and after accounting for socioeconomic status. METHODS: We identified non-Hispanic Black and non-Hispanic white patients who underwent carotid endarterectomy, transfemoral carotid stenting, or transcarotid artery revascularization between 2003 and 2022 in the Vascular Quality Initiative. Primary outcomes were in-hospital stroke/death and long-term stroke/death. Multivariable logistic regression and Cox proportional hazards models were used to assess the association of race with perioperative and long-term outcomes after adjusting for baseline characteristics using a sequential model approach without and with consideration of Area Deprivation Index (ADI), a validated composite marker of socioeconomic status. RESULTS: Of 201,395 patients, 5.1% (n = 10,195) were non-Hispanic Black, and 94.9% (n = 191,200) were non-Hispanic white. Mean follow-up time was 3.4±0.01 years. A disproportionately high percentage of Black patients were living in more socioeconomically deprived neighborhoods relative to their white counterparts (67.5% vs 54.2%; P < .001). After adjusting for demographic, comorbidity, and disease characteristics, Black race was associated with greater odds of in-hospital (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.10-1.40) and long-term stroke/death (adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.23). These associations did not substantially change after additionally adjusting for ADI; Black race was persistently associated with greater odds of in-hospital (aOR, 1.23; 95% CI, 1.09-1.39) and long-term stroke/death (aHR, 1.12; 95% CI, 1.03-1.21). Patients living in the most deprived neighborhoods were at greater risk of long-term stroke/death compared with patients living in the least deprived neighborhoods (aHR, 1.19; 95% CI, 1.05-1.35). CONCLUSIONS: Non-Hispanic Black race is associated with worse in-hospital and long-term outcomes following carotid revascularization despite accounting for neighborhood socioeconomic deprivation. There appears to be unrecognized gaps in care that prevent Black patients from experiencing equitable outcomes following carotid artery revascularization.

Attention-deficit/hyperactivity disorder and adverse health outcomes in adults.

Whereas the adverse impact of attention-deficit/hyperactivity disorder (ADHD) on emotional and psychosocial well-being has been well investigated, its impact on physical health has not. The main aim of this study was to assess the impact of ADHD on lifestyle behaviors and measures of adverse health risk indicators. Subjects were 100 untreated adults with ADHD and 100 adults without ADHD of similar age and sex. Unhealthy lifestyle indicators included assessments of bad health habits, frequency of visits to healthcare providers, and follow through with recommended prophylactic tests. Assessments of adverse health risk indicators included measurements of cardiovascular and metabolic parameters, weight, body mass index, and waist circumference. No differences were identified in health habits between subjects with and without ADHD, but robust differences were found in a wide range of adverse health risk indicators. ADHD is associated with an adverse impact in health risk indicators well known to be associated with high morbidity and mortality.

Effect of Red-Beetroot-Supplemented Diet on Gut Microbiota Composition and Metabolite Profile of Weaned Pigs-A Pilot Study.

Red beetroot is a well-recognized and established source of bioactive compounds (e.g., betalains and polyphenols) with anti-inflammatory and antimicrobial properties. It is proposed as a potential alternative to zinc oxide with a focus on gut microbiota modulation and metabolite production. In this study, weaned pigs aged 28 days were fed either a control diet, a diet supplemented with zinc oxide (3000 mg/kg), or 2% and 4% pulverized whole red beetroot (CON, ZNO, RB2, and RB4; respectively) for 14 days. After pigs were euthanized, blood and digesta samples were collected for microbial composition and metabolite analyses. The results showed that the diet supplemented with red beetroot at 2% improved the gut microbial richness relative to other diets but marginally influenced the cecal microbial diversity compared to a zinc-oxide-supplemented diet. A further increase in red beetroot levels (4%-RB4) led to loss in cecal diversity and decreased short chain fatty acids and secondary bile acid concentrations. Also, an increased Proteobacteria abundance, presumably due to increased lactate/lactic-acid-producing bacteria was observed. In summary, red beetroot contains several components conceived to improve the gut microbiota and metabolite output of weaned pigs. Future studies investigating individual components of red beetroot will better elucidate their contributions to gut microbiota modulation and pig health.

Defining Foundational Competence for Prelicensure and Graduate Nursing Students: A Concept Analysis and Conceptual Model.

AIM: To define the concept of foundational competence as it pertains to prelicensure and graduate nursing students during their educational program, thereby informing pedagogical and assessment practices. BACKGROUND: Competence has many definitions and uses, however a lack of consensus of a clear and useful definition in nursing persists. Without shared language, competence remains open for interpretation across and among groups and impedes the ability to teach and assess it in a competency-based education framework. METHOD: Using the Walker & Avant method of concept analysis, literature was reviewed and synthesized to define and explain the concept of foundational competence in nursing using evidence and practice from various disciplines. FINDINGS: Antecedents, attributes, empirical referents and consequences of foundational competence were identified. DISCUSSION: The components and uses of the concept of foundational competence are presented to guide pedagogical and assessment practices necessary for competency-based education in nursing.

Integration of a Simulation Curriculum Across Semesters in an Acute Care Pediatric Nurse Practitioner Program.

INTRODUCTION: Simulation is a common strategy for health care education. Research regarding simulation for nurse practitioner education is sparse. This paper describes the integration of a nine simulation session curriculum into a nurse practitioner program, including motivating factors, process description, and lessons learned. RESULTS: Students report high satisfaction and improved perception of confidence and competence of knowledge, skills, and performance. DISCUSSION: Integrated learning experiences and outcomes that span an educational program are needed in thetransition to competency-based education. This description serves as a guide for other programs seeking to incorporate simulation-based education.

Overexpression of Peroxiredoxin 3 in Cartilage Reduces the Severity of Age-Related Osteoarthritis But Not Surgically Induced Osteoarthritis in Mice.

OBJECTIVE: The study objective was to determine whether overexpression of the mitochondrial antioxidant peroxidase, peroxiredoxin 3 (Prx3), reduces the severity of osteoarthritis (OA) in mice. METHODS: Age-related OA (age 18 and 24 months) and OA induced by destabilization of the medial meniscus (DMM at age 6 months) were assessed in male mice that overexpress a human Prdx3 transgene encoding the Prx3 protein. Lox-stop-lox-Prdx3 (iPrdx3) mice were crossed with aggrecan-CreERT2 mice to produce iPrdx3AgCreERT2 or with Col2Cre to produce iPrdx3Col2Cre mice. Germline transgenics (Prdx3Tg) were also evaluated. Prx3 protein level was assessed by immunoblotting and functionally after induction of elevated mitochondrial hydrogen peroxide (H2 O2 ) using menadione. Histological sections of stifle joints were scored for cartilage damage (Articular Cartilage Structure score [ACS]), osteophytes, and synovial hyperplasia and were evaluated by histomorphometry. RESULTS: Overexpression of Prx3 maintained mitochondrial membrane integrity and inhibited p38 phosphorylation in the presence of elevated H2 O2 . ACS scores of 18-month-old iPrdx3AgCreERT2 mice (mean ± SD, 4.88 ± 5.05) were significantly lower than age-matched iPrdx3 controls (11.75 ± 6.34, P = 0.002) and trended lower in the 18-month Prdx3Tg group (P = 0.14), whereas no significant differences between experimental and control groups at 24 months of age or in OA induced by DMM surgery were noted. Osteophyte scores trended lower in the 18-month-old Prdx3Tg group (P = 0.09) and at 24 months in the iPrdx3Col2Cre mice (P = 0.05). There were no significant group differences in synovial hyperplasia or histomorphometric measures. CONCLUSION: Overexpression of the mitochondrial peroxidase Prx3 reduced the severity of age-related OA, but not at advanced ages and not in DMM-induced OA in younger mice.

Effects of olfactory stimulus on group performance and individual stress responses in university students.

Group work is essential in professional settings to encourage effective communication and optimize outcomes. Stress can reduce teamwork effectiveness and aromatherapy might be able to reduce feelings of stress/anxiety in individuals. However, it is unclear if aromatherapy impacts stress levels or performance during group activities. Therefore, we examined if essential oil exposure impacted stress responses and performance of individuals and groups during a team-based task involving a challenging medical decision. Subjects (n = 36) were part of a 3-person group (12 groups total) that completed a timed moral reasoning dilemma wearing a mask that contained a purported stimulatory essential oil (peppermint), a purported relaxing essential oil (lavender) or masks that contained neither odor (3 groups/mask type). Heart rate (HR) responses were recorded continuously before, during and after the task. The time to complete the task, decision making during the task, and subject's perceptions of the task were also recorded. Control subjects and subjects exposed to peppermint demonstrated a significant stress-induced increase in HR during the group task. However, subjects exposed to lavender demonstrated a significantly attenuated HR. Subjects in the control group who perceived high stress levels during the task demonstrated further elevations in HR than those not reporting stress, however, this pattern was not observed in subjects exposed to either essential oil. Groups did not differ in the time required to complete the task although only the groups exposed to lavender used decision making consistent with medical practice. Therefore, exposure to lavender was associated with differential physiological responses during a stressful group task, potentially due to olfactory system stimulation of anxiolytic and/or trust promoting central nervous system pathways. Aromatherapy might be a useful tool in group settings to mitigate the impact of stress and improve group performance.

Development of a Standardized Clinical Assessment and Management Plan for Pediatric Acute Respiratory Distress Syndrome.

Pediatric acute respiratory distress syndrome (PARDS) is one of the most challenging patient populations for a clinician to manage with mortality between 8 and 31%. The project was designed to identify patients with PARDS, implement management guidelines with the goal of standardizing practice. Our objectives were to describe the development and implementation of a protocolized approach to identify patients with PARDS and institute ventilator management guidelines. Patients who met criteria for moderate or severe PARDS as per the Pediatric Acute Lung Injury Consensus Conference (PALICC) definitions were identified using the best practice alert (BPA) in the electronic health record (EHR). Patients who did not meet exclusion criteria qualified for management using the Standardized Clinical Assessment and Management Plan (SCAMP), a quality improvement (QI) methodology with iterative cycles. The creation of a BPA enabled identification of patients with PARDS. With our second cycle, the number of false BPA alerts due to incorrect data decreased from 66.7 (68/102) to 29.2% (19/65; p < 0.001) and enrollment increased from 48.3 (14/29) to 73.2% (30/41; p = 0.03). Evaluation of our statistical process control chart (SPC) demonstrated a shift in the adherence with the tidal volume guideline. Overall, we found that SCAMP methodology, when used in the development of institutional PARDS management guidelines, allows for development of a process to aid identification of patients and monitor adherence to management guidelines. This should eventually allow assessment of impact of deviations from clinical practice guidelines.

Living the Manatt report: Advancing the future of nursing through joint academic appointments.

In 2016, the American Association of Colleges of Nursing published the Manatt Report which outlines recommendations to address the future of academic nursing. This report asserts that in order to influence the direction of healthcare, academic nursing needs to partner with academic health centers in leadership positions, embrace current clinical practice, and prioritize research. The following paper details the successful implementation of joint academic appointments between a college of nursing and a medical college. Joint appointments have formalized the role of clinician-educator, brought current clinical knowledge to academia, and allowed for protected academic time that is focused on enhancing the nursing curriculum. The development of joint appointments must be approached in a structured fashion ensuring a symbiotic relationship for all parties. This arrangement validates the commitment of both organizations to the education of future providers within the interdisciplinary team.

Acute Care Pediatric Nurse Practitioners as Leaders: Perceptions, Self-Identity, and Role Congruity.

INTRODUCTION: This study aimed to gain an understanding of practicing acute care pediatric nurse practitioners' (AC-PNPs') perceptions of themselves as leaders in both clinical and professional contexts. METHOD: This qualitative study was conducted at a midwestern quaternary care children's hospital. Cultural domain analysis, semistructured interviews, and free listing techniques were employed to identify areas of consensus and variation among a convenience sample of AC-PNPs. RESULTS: Findings demonstrated the AC-PNPs have a limited self-view of leadership. DISCUSSION: Nurse practitioners need additional leadership capacity and capability building during graduate education, the transition to practice, and throughout their careers.

Cross Inoculation of Rumen Fluid to Improve Dry Matter Disappearance and Its Effect on Bacterial Composition Using an in vitro Batch Culture Model.

Environmental pressures of ruminant production could be reduced by improving digestive efficiency. Previous in vivo attempts to manipulate the rumen microbial community have largely been unsuccessful probably due to the influencing effect of the host. Using an in vitro consecutive batch culture technique, the aim of this study was to determine whether manipulation was possible once the bacterial community was uncoupled from the host. Two cross inoculation experiments were performed. Rumen fluid was collected at time of slaughter from 11 Holstein-Friesian steers from the same herd for Experiment 1, and in Experiment 2 were collected from 11 Charolais cross steers sired by the same bull and raised on a forage only diet on the same farm from birth. The two fluids that differed most in their in vitro dry matter disappearance (IVDMD; "Good," "Bad") were selected for their respective experiment. The fluids were also mixed (1:1, "Mix") and used to inoculate the model. In Experiment 1, the mixed rumen fluid resulted in an IVDMD midway between that of the two rumen fluids from which it was made for the first 24 h batch culture (34, 29, 20 g per 100 g DM for the Good, Mix, and Bad, respectively, P < 0.001) which was reflected in fermentation parameters recorded. No effect of cross inoculation was seen for Experiment 2, where the Mix performed most similarly to the Bad. In both experiments, IVDMD increased with consecutive culturing as the microbial population adapted to the in vitro conditions and differences between the fluids were lost. The improved performance with each consecutive batch culture was associated with reduced bacterial diversity. Increases in the genus Pseudobutyrivibrio were identified, which may be, at least in part, responsible for the improved digestive efficiency observed, whilst Prevotella declined by 50% over the study period. It is likely that along with host factors, there are individual factors within each community that prevent other microbes from establishing. Whilst we were unable to manipulate the bacterial community, uncoupling the microbiota from the host resulted in changes in the community, becoming less diverse with time, likely due to environmental heterogeneity, and more efficient at digesting DM.

Memantine in the Treatment of Executive Function Deficits in Adults With ADHD.

OBJECTIVE: To evaluate the efficacy and safety of memantine hydrochloride as an adjunct to stimulant pharmacotherapy for treating executive function deficits (EFDs) in adults with ADHD. METHOD: This was a 12-week, double-blind, placebo-controlled, randomized clinical trial of memantine added to open-label treatment with stimulant medication. Because of the small sample size, we considered a standardized mean difference (equivalent to effect size) of ≥0.5 and odds ratios ≥2 as indicators of trend improvements. RESULTS: Twelve participants received memantine and 14 received a placebo. Trend improvements favoring memantine were observed on Behavior Rating Inventory of Executive Functions-Adult Inhibition and Self-Monitor subscales when compared with Placebo. No significant changes were noted on the Cambridge Neuropsychological Test Automated Battery. CONCLUSION: Among adults with ADHD and EFDs, adjunct treatment with memantine to osmotic release oral system-methylphenidate (OROS-MPH) was associated with improvements in selective areas of executive functioning, supporting the need for further research.

Initial Experience With the New Ahmed Glaucoma Valve Model M4: Short-term Results.

PURPOSE: To evaluate the clinical outcomes of the new Ahmed glaucoma valve (AGV) model M4. The device consists of a porous polyethylene shell designed for improved tissue integration and reduced encapsulation of the plate for better intraocular pressure (IOP) control. METHODS: Medical records of patients with an AGV M4 implantation between December 1, 2012 and December 31, 2013 were reviewed. The main outcome measure was surgical failure, defined as either (1) IOP<5 mm Hg or >21 mm Hg and/or <20% reduction of IOP at last follow-up visit, (2) a reoperation for glaucoma, and/or (3) loss of light perception. RESULTS: Seventy-five eyes of 73 patients were included. Postoperative IOP at all follow-up visits significantly decreased from a baseline IOP of 31.2 mm Hg (P<0.01). However, IOP increased significantly at 3 months (20.4 mm Hg), 6 months (19.3 mm Hg), and 12 months (20.3 mm Hg) compared with 1 month (13.8 mm Hg) postoperatively (P<0.05). At 6 months and 1 year, the cumulative probability of failure was 32% and 72%, respectively. CONCLUSIONS: The AGV M4 effectively reduced IOP in the first postoperative month, but IOP steadily increased thereafter. Consequently, failure rates were high after 1 year of follow-up.

Re-examining the risk for switch from unipolar to bipolar major depressive disorder in youth with ADHD: a long term prospective longitudinal controlled study.

BACKGROUND: Recent studies have identified subthreshold forms of bipolar (BP)-I disorder and deficits in emotional regulation as risk factors for bipolar disorder in youth. The primary aim of this study was to investigate whether emotional dysregulation and subthreshold forms of BP-I disorder increase the risk for BP switches in ADHD youth with non-bipolar MDD. METHODS: We used data from two large controlled longitudinal family studies of boys and girls with and without ADHD. Subjects (N=522) were followed prospectively and blindly over an average follow up period of 11.4 years. Comparisons were made between ADHD youth with unipolar major depression (MDD) who did (N=24) and did not (N=79) switch to BP-I disorder at follow-up. RESULTS: The rate of conversion to BP-I disorder at follow up was higher in MDD subjects with subthreshold BP-I disorder at baseline compared to those without (57% vs. 21%; OR=9.57, 95% CI=1.62-56.56, p=0.013) and in MDD subjects with deficient emotional self-regulation (OR=3.54, 95% CI=1.08-11.60, p=0.037). LIMITATIONS: The sample was largely Caucasian, so these results may not generalize to minority groups. The sample of youth with SED was small, which limited the statistical power for some analyses. CONCLUSIONS: Switches from unipolar MDD to BP-I disorder in children with ADHD and MDD were predicted by baseline subthreshold BP-I disorder symptoms and baseline deficits in emotional regulation. More work is needed to assess whether these risk factors are operant outside the context of ADHD.

Examining the clinical correlates of autism spectrum disorder in youth by ascertainment source.

To examine whether presentation of autism spectrum disorder (ASD) and associated patterns of psychiatric comorbidity and dysfunction vary by referral source. ASD youth referred to a specialized ambulatory program for ASD (N = 143) were compared to ASD youth referred to a general child psychiatry clinic (N = 217). More ASD clinic youth met criteria for a more robust form of ASD (autistic disorder); more youth referred to the psychiatry clinic met criteria for broader spectrum ASD (pervasive developmental disorder not otherwise specified). General psychiatry clinic youth with ASD suffered from a greater burden of psychopathologies and higher levels of dysfunction. The presentation of ASD in psychiatrically referred youth differs between general and ASD-specialized clinics, though both referral populations have high levels of comorbidity and dysfunction.

Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: a controlled study.

While symptoms of deficient emotional self-regulation (DESR) such as low frustration tolerance, temper outbursts, emotional impulsivity, and mood lability are commonly associated with attention deficit hyperactivity disorder (ADHD), little is known about their nature. The main aim of this post hoc study was to examine the correlates of DESR in a large sample of adults with and without ADHD. Subjects were 206 adults with ADHD and 123 adults without ADHD from a family study of ADHD. Emotional impulsivity was operationalized using items from the Barkley Current Behavior Scale. Subjects were comprehensively assessed for psychiatric comorbidity using structured diagnostic interview methodology. We used the Quality of Life, Enjoyment, and Satisfaction Questionnaire-Short Form (QLES-Q-SF) and Social Adjustment Scale-Self-report (SAS-SR) to assess quality of life and psychosocial functioning. DESR was more common among ADHD compared with non-ADHD adults, and 55% of adults with ADHD reported extreme DESR of greater severity than 95% of control subjects. The association of ADHD and DESR was not entirely accounted for by either current or lifetime comorbid disorders. DESR was also associated with significant functional impairment as evaluated by the QLES-Q-SF and SAS-SR, and with reduced marital status, as well as higher risk for traffic accidents and arrests. DESR adversely impacts quality of life in adults with ADHD. More work is needed to further evaluate DESR in clinical and investigational studies of subjects with ADHD.