by Tetsuya Akaishi, Toshiyuki Takahashi, Kazuo Fujihara, Tatsuro Misu, Shunji Mugikura, Michiaki Abe, Tadashi Ishii, Masashi Aoki, Ichiro NakashimaIntroduction
Progressive brain atrophy, development of T1-hypointense areas, and T2-fluid-attenuated inversion recovery (FLAIR)-hyperintense lesion formation in multiple sclerosis (MS) are popular volumetric data that are often utilized as clinical outcomes. However, the exact clinical interpretation of these volumetric data has not yet been fully established.Methods
We enrolled 42 consecutive patients with MS who fulfilled the revised McDonald criteria of 2010. They were followed-up for more than 3 years from onset, and cross-sectional brain volumetry was performed. Patients with no brain lesions were excluded in advance from this study. For the brain volumetric data, we evaluated several parameters including age-adjusted gray-matter volume atrophy, age-adjusted white-matter volume atrophy, and T2-FLAIR lesion volume. The numbers of T1-hypointense and T2-FLAIR-hyperintense areas were also measured along the same timeline. The clinical data pertaining to disease duration, expanded disability status scale (EDSS), and MS severity score (MSSS) at the timing of volumetry were collected.Results
Among the 42 patients with MS and brain lesions, the number of T1-hypointensity (rho = 0.51, p Conclusion
Numbers of T1-hypointensities and brain atrophy equally indicated the current neurological disability in MS. The number of T1-hypointensities divided by FLAIR lesion volume represented the clinical severity. The size or number of FLAIR lesions reflected earlier relapses but was not a good indicator of neurological disability or clinical severity.
by Dieunel Derilus, Filipa Godoy-Vitorino, Hebe Rosado, Edgardo Agosto, Maria Gloria Dominguez-Bello, Humberto CavallinBacteria found in operating rooms (ORs) might be clinically relevant since they could pose a threat to patients. In addition, C-sections operations are performed in ORs that provide the first environment and bacterial exposure to the sterile newborns that are extracted directly from the uterus to the OR air. Considering that at least one third of neonates in the US are born via C-section delivery (and more than 50% of all deliveries in some countries), understanding the distribution of bacterial diversity in ORs is critical to better understanding the contribution of the OR microbiota to C-section- associated inflammatory diseases. Here, we mapped the bacteria contained in an OR after a procedure was performed; we sampled grids of 60x60 cm across walls and wall-adjacent floors and sequenced the V4 region of 16S rRNA gene from 260 samples. The results indicate that bacterial communities changed significantly (ANOSIM, p-value
by Janine Barden-O’Fallon, Jennifer Mason, Emmanuel Tluway, Gideon Kwesigabo, Egidius KamanyiIn a context of high rates of HIV prevalence, concerns over hormonal contraceptive use and the potential for increased risk of HIV acquisition have led to increased attention to counseling messages, particularly for users of the injectable. However, the consequence of adding additional HIV risk messages to family planning counseling sessions was not well understood. This evaluation assessed the effect of providing revised injectable and HIV risk counseling messages on contraceptive knowledge and behavior during a three month pilot intervention. The pilot intervention was conducted September-November 2018 with all eligible family planning clients in ten healthcare facilities located in the Iringa and Njombe regions of Tanzania. Data collection for the evaluation occurred November-December 2018 and included 471 client exit interviews, 26 healthcare provider interviews, and the extraction of service statistics for 12 months prior to the intervention and three months of the intervention. Univariate and bivariate analyses were used to assess quantitative interview data. Thematic qualitative assessment was used to assess qualitative interview data from healthcare providers. Interrupted time series analysis was used to assess changes in the trend of contraceptive uptake. Results indicate that the counseling messages did not cause a decrease in the uptake of injectables (Depo-Provera): 97 percent of interviewed clients received Depo-Provera at their visit; sixty percent reported an intention to use condoms for dual protection. The analysis of service statistics showed no statistical difference in the trend of Depo-Provera uptake between the pre-intervention and intervention periods (p = 0.116). Overall knowledge of counseling messages by clients was good; however only 64.8% of women correctly responded that women at risk of getting HIV can use any method of family planning. Providers’ knowledge of the messages was high, though it appears that not all messages were consistently provided during the counseling sessions. The findings from this evaluation provide evidence that complex HIV counseling messages can be implemented in family planning programs in Tanzania, and potentially in other countries that are considering how to better integrate HIV risk messages into family planning counseling.
by Tzu-Chun Chung, Tzu-Shan Chen, Yao-Chun Hsu, Feng-Chen Kao, Yuan-Kun Tu, Pao-Hsin LiuBackground/objective
Osteoarthritis typically develops after surgery for traumatic fractures of the acetabulum and may result in total hip arthroplasty (THA). We conducted a population-based retrospective study to investigate the incidence of THA after treatment of acetabular, pelvic, and combined acetabular and pelvic fractures with open reduction-internal fixation surgery compared with that in the control group.Design
A retrospective population-based cohort study.Setting
Data were gathered from the Taiwan National Health Insurance Research Database.Participants
We enrolled 3041 patients with acetabular fractures, 5618 with pelvic fractures, and 733 with combined pelvic and acetabular fractures between January 1, 1997, and December 31, 2013, totaling 9392 individuals. The control group comprised 664,349 individuals. Study participants were followed up for the occurrence of THA until death or the end of the study period.Results
The THA rates after surgical intervention were 17.82%, 7.28%, and 18.01% in patients with acetabular, pelvic, and combined acetabular and pelvic fractures, respectively. Moreover, they were significantly higher for the acetabular fracture, pelvic fracture, and combined-fracture groups (adjusted hazard ratios [aHRs] = 58.42, 21.68, and 62.04, respectively) than for the control group (p p Conclusion
The incidence rates of THA after surgical intervention in the pelvic fracture, acetabular fracture, and combined-fracture groups were significantly higher than that of the control group.
by Christophe Béné, Jessica Fanzo, Steven D. Prager, Harold A. Achicanoy, Brendan R. Mapes, Patricia Alvarez Toro, Camila Bonilla CedrezAt present, our ability to comprehend the dynamics of food systems and the consequences of their rapid ‘transformations’ is limited. In this paper, we propose to address this gap by exploring the interactions between the sustainability of food systems and a set of key drivers at the global scale. For this we compile a metric of 12 key drivers of food system from a globally-representative set of low, middle, and high-income countries and analyze the relationships between these drivers and a composite index that integrates the four key dimensions of food system sustainability, namely: food security & nutrition, environment, social, and economic dimensions. The two metrics highlight the important data gap that characterizes national systems’ statistics—in particular in relation to transformation, transport, retail and distribution. Spearman correlations and Principal Component Analysis are then used to explore associations between levels of sustainability and drivers. With the exception of one economic driver (trade flows in merchandise and services), the majority of the statistically significant correlations found between food system sustainability and drivers appear to be negative. The fact that most of these negative drivers are closely related to the global demographic transition that is currently affecting the world population highlights the magnitude of the challenges ahead. This analysis is the first one that provides quantitative evidence at the global scale about correlations between the four dimensions of sustainability of our food systems and specific drivers.
by Christian Kirchnawy, Fiona Hager, Veronica Osorio Piniella, Mathias Jeschko, Michael Washüttl, Johannes Mertl, Aurelie Mathieu-Huart, Christophe RoussellePlastic toys mouthed by children may be a source of exposure to endocrine active substances. The purpose of this study was to measure hormonal activity of substances leaching from toys and to identify potential endocrine disruptors causing that activity. For this purpose, migration experiments of toys were conducted in saliva simulants. The CALUX® assays were used to detect (anti-) estrogenic and (anti-) androgenic activity of 18 toys. Chemical trace analysis–namely, GC-MS and HPLC-MS- was used to identify which compounds may be responsible for endocrine activity in the sample migrates. Nine out of 18 tested toys showed significant estrogenic activity. For two samples, the detected estrogenic activity could be well explained by detecting the known endocrine active substance bisphenol A (BPA). For all identified substances, including BPA, a risk assessment for human health was performed by comparing the exposure dose, calculated based on the determined substance concentration, to toxicological reference values. Using worst-case scenarios, the exposure to BPA by mouthing of the two estrogen active, BPA-containing toys could be above the temporary TDI that EFSA has calculated. This demonstrates that some toys could significantly contribute to the total exposure to BPA of babies and infants. For seven out of nine estrogen active samples, the source of the estrogen activity could not be explained by analysis for 41 known or suspected endocrine active substances in plastic, indicating that the estrogen activities were caused by currently unknown endocrine active substances, or by endocrine active substances that would currently not be suspected in toys.
by Ahmed M. Alzahrani, Ahmed Hakami, Ahmad AlHadi, Mohammed A. Batais, Abdullah A. Alrasheed, Turky H. AlmigbalThere is a growing body of research that shows a significant association between mindfulness and mental health. However, studies on Saudi populations are still in their infancy. Mindfulness is a personal tendency to focus on the present time in a non-judgmental manner, including the interior and exterior experience of feelings and events. The first aim of this study is to examine the relationship between mindfulness, stress, depression, and academic performance in a sample of medical students from King Saud University. The second aim is to explore the potential moderation effects of mindfulness on the impact of stress on academic performance and depression in the study population. This cross-sectional study examined 289 medical students who were selected by a stratified random sampling technique and completed validated online questionnaires measuring mindfulness, stress, and depression. The data were analyzed using SAS version 9.2, and R software was used for graphs. Correlation analysis showed that mindfulness is inversely associated with depression and stress, but not with academic performance. Furthermore, multiple logistic regression showed that mindfulness can predict both depression and stress. We also found that two subscales of mindfulness can moderate the relation between stress and depression: non-judging of inner experience and describing. The findings suggest that a higher mindfulness score is associated with lower depression and stress levels and could buffer against depression in a stressful environment. There is a need for further research to investigate the relation of mindfulness with positive psychological outcomes, as well as experimental trials to examine the efficacy of mindfulness training on improving mental wellbeing in our community.
Japan is now a super‐aged society, and the older population is estimated to reach 39.9% in 2060 (Cabinet Office, 2016). Long‐term care insurance was launched in 2000 to support the older population in community‐settings. Presently, many parents in their 80s who are receiving pensions are supporting their single children in their 50s who have experienced social withdrawal and been unemployed since their youth. This situation, commonly called the ‘8050 issue’, is increasing in Japan (Ministry of Health, Labour, and Welfare, 2019).
To explore nursing students’ subjective experience of emotions during first‐year clinical placements, strategies used to manage their emotions, and socialisation to emotion management.
Emotion regulation is a key source of stress for early career and student nurses. Clinical placement experiences can elicit strong emotions in nursing students; however, they may be unprepared for the challenge of regulating their emotions in real‐world practice. How nursing students learn to manage their emotions in the clinical setting, whether they receive support for this, and how they are socialised to manage their emotions during placements, are not well known.
An exploratory qualitative study.
Semi‐structured interviews (n=19) were conducted with first year nursing students, exploring their experiences of emotion management during clinical placement. Interview transcripts were analysed using conventional qualitative content analysis. Reporting adheres to the COREQ Checklist.
Interactions with patients and staff often elicited negative feelings. Structured guidance for emotion management by supervising staff was scarce. Students used informal self‐reflection and interpretation to guide emotion management.
In the absence of strategic socialisation and formal support for effective emotion management, students used emotional labour strategies that can negatively impact on well‐being. A focus on adequately preparing nursing students for emotion work is a necessary component of classroom and clinical learning environments. Structured debriefing during clinical placements may provide a relevant context to discuss emotions arising during clinical work, and to learn emotion management strategies.
Emotional competence, a fundamental ability for registered nurses and students, supports personal health maintenance and strengthens professional practice. Students are exposed to clinical environments and interpersonal encounters that evoke strong emotions. They need situated learning strategies and formal support to develop knowledge and strengthen capability for emotion management, as this is essential for promoting professional development and patient care.
What use are words at a time like this? I am writing this on 27th March as the world is plunging further into the coronavirus crisis. Like many worldwide, I am in virtual ‘lockdown’ in Australia while the exponential spread of the virus continues. At a follow‐up tele‐consult with my medical consultant recently, he said that he was apprehensive about the ‘calm before the storm’ that our health services face. He was deadly serious.
Personal resilience has been conceptualised in many different ways; however, a common definition is that resilience is the ability to cope successfully despite adverse circumstances (Henshall, 2020). Historically, the term ‘resilience’ encompasses both physiological and psychological aspects and the latter is personal to individuals, with some people having more developed strategies for personal resilience than others. Understandings of resilience vary between populations, contexts and cultures (McDonald et al., 2012), with resilience being viewed in some cases as an inherent personality trait and in others as a dynamic process existing on a continuum between resilience and vulnerability.
Anecdotal reports from across the country highlight the fact that nurses are facing major challenges in moving new evidence‐based practice (EBP) initiatives into the electronic health record (EHR).
The purpose of this study was to: (a) learn current processes for embedding EBP into EHRs, (b) uncover facilitators and barriers associated with rapid movement of new evidence‐based nursing practices into the EHR and (c) identify strategies and processes that have been successfully implemented in healthcare organizations across the nation.
A qualitative study design was utilized. Purposive sampling was used to recruit nurses from across the country (N = 29). Nine focus group sessions were conducted. Semistructured interview questions were developed. Focus groups were conducted by video and audio conferencing. Using an inductive approach, each transcript was read and initial codes were generated resulting in major themes and subthemes.
Five major themes were identified: (a) barriers to advancing EBP secondary to the EHR, (b) organizational structure and governing processes of the EHR, (c) current processes for prioritization of EHR changes, (d) impact on ability of clinicians to implement EBP and (e) wait times and delays.
Delays in moving new EBP practice changes into the EHR are significant. These delays are sources of frustration and job dissatisfaction. Our results underscore the importance of a priori planning for anticipated changes and building expected delays into the timeline for EBP projects. Moreover, nurse executives must advocate for greater representation of nursing within informatics technology governance structures and additional resources to hire nurse informaticians.
To identify training strategies and determine how registered health and social care practitioners change their practice post Mental Capacity Act training.
Narrative literature review
Seventeen databases were searched up to December 2019; CINAHL, Social Care Online, PubMed, Social Policy and Practice, Discover, Medline, Science Direct, Ovid, PsycINFO, ASSIA, Social Services Abstracts, Science Direct, Academic Search Premier, Web of Science, British Nursing Index, DH‐Data, King’s Fund Library Catalogue.
Empirical studies of any design investigating Mental Capacity Act training were searched and screened. Data were extracted to a bespoke spreadsheet and quality assessed. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses, (PRISMA).
Of 162 papers identified, 16 were included comprising qualitative, quantitative and mixed methods studies. Trainees valued interactive training with close alignment to practice. Training did not lead to demonstrable practice change. Barriers in the context and cultures of care environments were identified.
To facilitate application of Mental Capacity Act legislation, identified barriers should be addressed. Future training should be interactive, scenario‐based and relevant to trainees’ practice.
The Mental Capacity Act is widely misunderstood and implementation poor. Training is proposed as a solution, but the nature of training that will positively affect practice remains unknown. This review aims to address this gap in the evidence base. Interactive training, using scenarios that reflect practice complexities, has the most positive impact. Cultural norms in care environments may impede application of this legislation.
The review has international relevance as there is a global imperative to adhere to the United Nations Convention on the Rights of Persons with Disabilities. The review will inform training design and delivery to ensure that people with impaired capacity to make decisions are given the best opportunity to act autonomously.
To investigate the relationship between symptom burden, medication adherence, and spiritual well‐being in patients with chronic obstructive pulmonary disease (COPD).
The relationship between spirituality and medication adherence has been investigated in different chronic conditions. However, the relationship between symptom burden, medication adherence, and spiritual well‐being in patients with COPD has not been explored.
A descriptive correlational study design was adopted.
A total of 112 patients with COPD were included in the study. Data were collected using the COPD Assessment Test (CAT), the Adherence to Refills and Medications Scale‐7 (ARMS‐7), and the Functional Assessment of Chronic Illness Therapy‐Spiritual Well‐Being Scale (FACIT‐Sp). The data were analyzed using descriptive and correlational statistics. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) Checklist was used.
The CAT score was significantly higher in patients on long‐term oxygen therapy and those who had more than three comorbid conditions (p < 0.05). The mean score of ARMS‐7 was significantly associated with age (p < 0.05). Current smokers had higher ARMS‐7 and lower FACIT‐Sp scores (p < 0.001). The FACIT‐Sp score was negatively and moderately associated with the CAT and ARMS‐7 scores (p < 0.001).
This study concluded that individuals with higher spiritual well‐being had lower symptom burden and higher medication adherence. The need for long‐term oxygen therapy and a high number of comorbid conditions were associated with increased symptom burden. Current smokers had lower spiritual well‐being and medication adherence.
Spiritual well‐being should be evaluated when assessing symptom burden and medication adherence in clinical practice. In addition, further studies examining the causal relationship between symptom burden, spiritual well‐being, and medication adherence in different populations are warranted.
The aim of this study was to examine the knowledge, perceptions and factors influencing pain assessment and management practices among Australian emergency nurses.
Pain is the most commonly reported symptom in patients presenting to the emergency department, with over half rating their pain as moderate to severe. Patients unable to communicate, such as critically ill intubated patients, are at greater risk of inadequate pain management.
This cross‐sectional exploratory study used survey methodology to explore knowledge, perceptions and factors influencing pain management practices among Australian emergency nurses.
Australian emergency nurses were invited to complete an online survey comprising 91‐items. The response rate was 450 of 1,488 (30.2%). STROBE guidelines were used in reporting this study.
Variations in level of acute pain management knowledge, especially in older, cognitively impaired or mechanically ventilated patients were identified. Poor interprofessional communication, workload and staffing negatively impacted on nurses’ intention to administer analgesia. For intubated patients, validated observation pain assessment instruments were rarely used, although respondents recognised the importance of pain management in critically ill patients.
Emergency nurses recognise the importance of pain relief. The ability to nurse‐initiate analgesia, education and training in pain management education is variable. Little education is provided on assessing and managing acute pain in elderly, cognitively impaired or mechanically ventilated patients. Use of validated pain assessment instruments to assess pain in critically ill patients is poor.
While pain management is the responsibility of all healthcare professionals, in the emergency department, it is a core role of emergency nursing. This study highlights the variation in ability to nurse‐initiate analgesia, level of acute pain knowledge, education and training, and use of validated pain assessment instruments to guide pain management in critically ill intubated patients.
To investigate the effects on the quality of care of the Patient Report Informing Self‐Management Support (PRISMS) form compared with usual care among patients with Chronic Obstructive Pulmonary Disease (COPD) consulting a COPD nurse in primary health care.
Patients with COPD experience symptoms affecting their everyday lives and there is a need for interventions in self‐management support. The delivery of chronic care in an organized, structured, and planned manner can lead to more productive relationships between professionals and patients.
A multicentre randomised controlled trial with a post‐test design, according to the CONSORT checklist, in one intervention group (n=94) and one control group (n=108).
In addition to usual care, the intervention group (n=94) completed the PRISMS form to indicate areas where they wanted self‐management support before the consultation with the COPD nurse. This form comprises 17 items that patients with COPD commonly experience as problems. The control group received usual care (n=108). The primary outcome was patients’ satisfaction with quality of care, assessed using the Quality from the Patient’s Perspective (QPP) questionnaire. Means and (SD) are presented where applicable. Differences between the intervention and control group were analysed with Student’s t‐test for independent groups for interval data, and the Mann‐Whitney U‐test for ordinal data.
Participants in the intervention group were more satisfied with the QPP domains “personal attention”, regarding both “Perceived reality” (p=0.021) and “Subjective Importance” (p=0.012). The PRISMS form revealed “Shortness of breath” as the most commonly experienced problem and the issue most desired to discuss.
The PRISMS form improved patient satisfaction with quality of care regarding personal attention, which is an important factor in patient participation and improving relationships and communication.
The PRISMS form can be a useful tool in improving person‐centred care when delivering self‐management support.
To explore older inpatients’ experiences and perceptions of delirium and non‐pharmacological delirium prevention strategies (NDPS).
Delirium is a distressing and serious complication in hospitalised older adults. NDPS (supporting nutrition, mobility and cognitive participation) have strong supporting evidence. Few studies have explored older inpatients’ perspectives of these strategies. This information may assist staff to better support patient participation in NDPS.
Qualitative study using an interpretive descriptive (ID) methodological approach to explore older patient’s experience of delirium and NDPS.
Structured interviews of inpatients aged over 65 years across 6 medical and surgical wards explored patients’ experiences and perceptions of delirium and prevention activities related to nutrition, mobility and cognition; and barriers and enablers to participation. Reporting used COREQ.
Twenty‐three participants were included (12 male, 11 reported delirium experience). Participants reported a range of physiological, emotional and psychological responses to delirium, hearing about delirium was different to experiencing it. Most participants were aware of the benefits of maintaining nutrition and hydration, physical activity and cognitive engagement in hospital. Barriers included poor symptom control, inflexible routines and inconsistent communication, while enablers included access to equipment, family involvement, staff encouragement and individual goals. These were organised into themes: outlook, feeling well enough, hospital environment, feeling informed and listened to, and support networks.
A more patient centred approach to delirium prevention requires consideration of older people’s values, needs, preferences and fit within the hospital environment and routines. Feeling informed, listened to and receiving support from staff and family carers can improve older inpatients’ engagement in NPDS to prevent delirium in hospital.
Nurses are ideally placed to improve patient participation in NDPS through holistic assessment and care, addressing symptoms, providing clear information about delirium and delirium prevention, and facilitating family carer support and patient interactions.
Amelanotic melanoma (AM) of the heel is a very rare subtype of malignant melanoma in which the tumour cells, unlike other types of melanoma, are characterised by little or no melanin pigmentation. AM resembles many benign dermatological complications that often lead to late diagnosis of lesions, poor prognosis, and occasionally misdiagnosis at an early stage of the disease. We report a case of a 73‐year‐old man with a heel ulcer who was admitted to Al‐Zahra Hospital (Isfahan, Iran). Chronic osteomyelitis was considered the primary diagnosis, and several courses of antibiotics were prescribed for the patient. The ulcer failed to improve after 9 months' of therapy, and because of an increase in the size of the ulcer and the growth of two tumours in the right heel, a biopsy of the lesion was conducted. The pathology report confirmed invasive AM. The present report emphasises the necessity to biopsy all skin lesions, even with low clinical significance, to avoid wrong subsequent treatments, prevent a delay in diagnosis, reduce misdiagnosis, and improve the survival rate of patients.
The aim of this study is to evaluate the clinical and economic burden of wound care in the Tropics via a 5‐year institutional population health review. Within our data analysis, wounds are broadly classified into neuro‐ischaemic ulcers (NIUs), venous leg ulcers (VLUs), pressure injuries (PIs), and surgical site infections (SSIs). Between 2013 and 2017, there were a total of 56 583 wound‐related inpatient admissions for 41 461 patients, with a 95.1% increase in wound episodes per 1000 inpatient admissions over this period (142 and 277 wound episodes per 1000 inpatient admissions in 2013 and 2017, respectively). In 2017, the average length of stay for each wound episode was 17.7 days, which was 2.4 times that of an average acute admission at our institution. The average gross charge per wound episode was USD $12 967. Among the 12 218 patients with 16 674 wound episodes in 2017, 71.5% were more than 65 years of age with an average Charlson Comorbidity Index (CCI) of 7.2. Half (51.9%) were moderately or severely frail, while 41.3% had two or more wound‐related admission episodes. In 2017, within our healthcare cluster, the gross healthcare costs for all inpatient wound episodes stand at USD $216 million within hospital care and USD $596 000 within primary care. Most NIU patients (97.2%) had diabetes and they had the most comorbidities (average CCI 8.4) and were the frailest group of patients (44.9% severely frail). The majority of the VLU disease burden was at the specialist outpatient setting, with the average 1‐year VLU recurrence rate at 52.5% and median time between healing and recurrence at 9.5 months. PI patients were the oldest (86.5% more than 65 years‐old), constituted the largest cohort of patients with 3874 patients at an incidence of 64.6 per 1000 admissions in 2017, and have a 1‐year all‐cause mortality rate of 14.3%. For SSI patients, there was a 125% increase of 14.2 SSI wound episodes per 1000 inpatient admissions in 2013 to 32.0 in 2017, and a 413% increase in wound‐related 30‐day re‐admissions, from 40 in 2013 (4.1% of all surgeries) to 205 (8.3% of all surgeries) in 2017. The estimated gross healthcare cost per patient ranges from USD $15789–17 761 across the wound categories. Similar to global data, there is a significant and rising trend in the clinical and economic burden of wound care in Tropics.