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Background/purpose: Oral squamous cell carcinoma (OSCC) is a common malignancy often associated with poor prognosis due to chemoresistance. In this study, we investigated whether arecoline, a major alkaloid in betel nuts, can stimulate aldo-keto reductase family 1 member B10 (AKR1B10) levels in OSCC, promoting cancer stemness and leading to resistance to cisplatin (CDDP)-based chemotherapy., Materials and Methods: Gain- and Loss- of AKR1B10 functions were analyzed using WB and q-PCR of OSCC cells. Stemness, epithelial mesenchymal transition (EMT) markers, and CDDP drug resistance in overexpressed AKR1B10 were also identified., Results: Upregulated AKR1B10 in OSCC significantly increased cell motility and aggregation. The results also showed that the canonical TGF-β1-Smad3 pathway was involved in arecoline-induced AKR1B10 expression, further increasing cancer stemness with CDDP resistance via the Snail-dependent EMT pathway. Moreover, oleanolic acid (OA) and ROS/RNS (reactive oxygen/nitrogen species) inhibitors effectively reversed AKR1B10-induced CDDP-resistance., Conclusion: Arecoline-induced ROS/RNS to hyper-activate AKR1B10 in tumor sphere cells via the TGF-β1-Smad3 pathway. Furthermore, AKR1B10 enhanced CDDP resistance in OSCC cells via EMT-inducing markers. Finally, Finally, OA may efficiently target CDDP resistance, reverse stemness in OSCC cells, and have the potential as a novel anticancer drug., Competing Interests: The authors have stated that there are no conflicts of interest related to this study., (© 2024 Association for Dental Sciences of the Republic of China. Publishing services by Elsevier B.Vé.)

Purpose: The impact of obesity on mortality risk in patients undergoing hemodialysis (HD) remains uncertain due to conflicting findings across obesity measurement methods. This study aimed to assess the obesity measurements influence mortality risk in HD populations., Methods: Systematic review and meta-analysis were conducted following PRISMA guidelines, registered on PROSPERO (CRD42023429943). Relevant observational studies analyzing mortality risk using obesity measurements in adult HD patients up to March 27, 2023 were included from multiple databases, including EMBASE, MEDLINE (OVID), and CINAHL (EBSCO). Pooled analyses with a random-effects model were performed using RevMan 5.4., Results: Twenty-three studies involving 381,580 subjects were reviewed. A meta-analysis of 15 studies in event-based analysis showed contrasting results between anthropometry and body composition analysis in predicting all-cause mortality. Obese patients indicated by body mass index (BMI) had a lower mortality risk than non-obese patients (RR = 0.73, 95% CI: 0.70-0.76, p < 0.001). In contrast, abdominal obesity measured by waist circumference (WC) or waist-to-hip ratio (WHR) increased mortality risk (RR = 1.35, 95% CI: 1.01-1.80, p = 0.04). Studies using bioelectrical impedance analysis (BIA) demonstrated an increased mortality risk for obese patients (RR = 1.22, 95% CI: 1.05-1.41, p = 0.009)., Conclusions: Obese patients undergoing HD exhibit different mortality risks depending on the methods of obesity measurement. The observed 'obesity paradox' in patients on HD, where lower mortality is seen with obesity measured by BMI, may reflect BMI's limitations in differentiating fat mass. More studies with other anthropometry and body composition analysis are needed to clarify this phenomenon., Competing Interests: Declarations. Conflict of interest: The authors have no competing interest to declare both of financial interest or non-financial interest. Ethical approval: An ethics statement is not applicable for this study, since it is based on published literature., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Tulisokibart is a tumor necrosis factor-like cytokine 1A (TL1A) monoclonal antibody in development for the treatment of moderately to severely active ulcerative colitis. A genetic-based diagnostic test was designed to identify patients with an increased likelihood of response., Methods: We randomly assigned patients with glucocorticoid dependence or failure of conventional or advanced therapies for ulcerative colitis to receive intravenous tulisokibart (1000 mg on day 1 and 500 mg at weeks 2, 6, and 10) or placebo. Cohort 1 included patients regardless of status with respect to the test for likelihood of response. Cohort 2 included only patients with a positive test for likelihood of response. The primary analysis was performed in cohort 1; the primary end point was clinical remission at week 12. Patients with a positive test for likelihood of response from cohorts 1 and 2 were combined in prespecified analyses., Results: In cohort 1, a total of 135 patients underwent randomization. A significantly higher percentage of patients who received tulisokibart had clinical remission than those who received placebo (26% vs. 1%; difference, 25 percentage points; 95% confidence interval [CI], 14 to 37; P<0.001). In cohort 2, a total of 43 patients underwent randomization. A total of 75 patients with a positive test for likelihood of response underwent randomization across both cohorts. Among patients with a positive test for likelihood of response (cohorts 1 and 2 combined), clinical remission occurred in a higher percentage of patients who received tulisokibart than in those who received placebo (32% vs. 11%; difference, 21 percentage points; 95% CI, 2 to 38; P = 0.02). Among all the enrolled patients, the incidence of adverse events was similar in the tulisokibart and placebo groups; most adverse events were mild to moderate in severity., Conclusions: In this short-term trial, tulisokibart was more effective than placebo in inducing clinical remission in patients with moderately to severely active ulcerative colitis. (Funded by Prometheus Biosciences, a subsidiary of Merck; ARTEMIS-UC ClinicalTrials.gov number, NCT04996797.)., (Copyright © 2024 Massachusetts Medical Society.)

Background: The rapid development of digital technology impacts all aspects, including nursing education. Nursing programs are tasked with equipping graduates with both clinical skills and digital competence. However, inconsistencies in the conceptual understanding of digital competence in nursing literature, underscore the need to refine the concept., Design: This study involved two phases including a modified Delphi approach and psychometric testing. In Phase 1, the panel of experts in nursing was invited to evaluate the theoretical framework, domain, and item of assessment checklist. In Phase 2, the psychometric properties of the assessment checklist were tested using a quantitative survey., Setting: The study was conducted in Taiwan, Indonesia, and Vietnam., Participant: Participants included 12 nursing experts from Taiwan, Indonesia, and Vietnam during the development phase and 417 nursing students from these countries in the validation phase., Methods: Phase 1 utilized a modified Delphi approach establishing a theoretical framework and assessment checklist. Experts provided feedback on a Likert scale, aiming for consensus. Phase 2 involved a quantitative survey where graduate nursing students rated the DCAC. The analysis process following the recommendation of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)., Results: The theoretical framework defined digital competence across four domains. In the first Delphi round, all items were rated above the consensus threshold. After two rounds, the CVI ranged from .8 to 1.0, suggesting strong agreement among experts. The second phase revealed high discriminant validity among survey items, with Cronbach's alpha indicating high internal consistency. The refined 22-item DCAC showed improved fit indices, confirming the assessment checklist's structure., Conclusion: The developed 22-item DCAC is a valid and reliable tool for measuring digital competence among nursing students. Integration of digital competence into nursing education is essential for preparing students to excel in the healthcare environment., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Miaofen Yen, PhD, RN, FAAN reports financial support was provided by National Science and Technology Council. Other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Aim: This study aims to elicit graduate entry nursing students' views on factors that enable and constrain their learning engagement., Background: Learning engagement has been associated with student retention/attrition and the achievement of learning confidence and success. While all students are subject to challenges that affect their learning engagement, those experienced by international students who are learning in a foreign and unfamiliar context are of particular concern to academics. An understanding of international graduate entry nursing students' perspectives on factors that enable and constrain their engagement can inform development of learning and teaching strategies that are more responsive to the needs of this group of students and can support their learning achievement., Design: A qualitative descriptive design conducted in one Australian multi campus university School of Nursing. Participants included first and second-year international students enrolled in a graduate entry Master of Nursing course., Methods: Data, including demographic information, was collected via a theoretically informed online survey consisting of a Likert scale and open- ended questions. This study reports participant responses to open ended questions included in the survey. A thematic analysis was used to interpret findings., Findings: Analysis identified participants' perspectives on factors that influenced their learning engagement in four theme areas: 1) Availability of study support resources, 2) Opportunities for social interaction, 3) Opportunities to build a sense of belonging, and 4) Constraints on development of a sense of engagement. Opportunities for social engagement emerged as a dominant finding across all themes., Conclusion: This research, which focused on international students' perspectives on learning engagement, contributed to existing knowledge on student engagement in higher education graduate entry nursing courses. Opportunities for social interaction within and beyond formal course learning experiences were valued by students and identified as key to their learning engagement. These findings have implications for academics and student support services who together, can influence the context of students learning to better meet their engagement needs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Frailty is highly prevalent in hospitalized older patients and may increase the risk of adverse health outcomes. Understanding the experiences of older patients and the management strategies they use to recover from frailty is crucial to developing appropriate interventions., Purpose: This study was designed to explore the frailty experiences of older adults and the management strategies they use to recover from frailty., Methods: Using purposive sampling, semistructured, face-to-face interviews were conducted with 16 older patients with frailty. Data were analyzed using content analysis., Results: The experiences of participants were classified into three phases, including the (a) individual sensing phase, (b) daily-living-threatening phase, and (c) acclimatization and acceptance phase. When experiencing frailty, the participants developed management strategies to facilitate recovery, which manifested in three phases: (a) making flexible adjustments to the daily routine, (b) using adequate support systems, and (c) adopting positive thinking., Conclusions/implications for Practice: The results indicate that familial support and positive thinking are important management strategies for successful recovery in frail individuals. Older patients require adequate support systems. Positive thinking was also found to be an effective management strategy for recovery. Healthcare professionals should not only focus on providing supportive resources but also provide support to older patients to facilitate their adoption of positive thinking to face life changes brought on by frailty., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.)

Periapical radiography is a routine radiographic procedure performed by dentists on a daily basis. It can be taken with two techniques, the paralleling technique (P tech) and the bisecting angle technique (B tech). This systematic review aimed to identify the relevant literature, compare the use of P and B techs across various dental specialties, and determine the most appropriate technique to be used for different purposes in taking periapical radiographs. In January 2023, we searched PubMed, Web of Science, Scopus, and Google Scholar to identify the studies that compared the two radiographic techniques. The search string was: (paralleling AND ("bisecting angle" OR "bisected angle")). Manual reference tracing was also performed to identify the studies potentially missed. After screening, 26 studies were included for the qualitative review. The 26 included studies were published between 1976 and 2021. Ten of the studies were about general dentistry (dental radiology in general applications), whereas another ten studies were related to endodontics, such as working length estimation. Most studies advocated the use of the P tech for general, endodontics, implantology, and other indications. B tech was advocated for patients with a low palatal height. More future studies are needed to evaluate their performance in different scenarios with standardized equipment and radiographic positioning.

Aims: To determine factors associated with poor sleep quality among patients with pre-dialysis chronic kidney disease., Design: This is a systematic review study guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements and checklist., Data Sources: Empirical evidence was sought in major electronic databases, including Embase, MEDLINE, CINAHL and Airiti library from March to September 2022., Review Methods: Studies investigating factors associated with poor sleep quality among adult patients with chronic kidney disease were included. Study participants who received renal replacement therapy and had sleep disorders and serious illnesses such as cancer were excluded. Of the 526 studies that resulted from the search after removing duplicate articles, 20 studies were assessed for quality by using Joanna Briggs Institute and Newcastle-Ottawa Scale by two doctorial prepared nursing scientists., Results: A total of 20 studies were included in this review. The prevalence of poor sleep quality in these studies ranged from 11% to 97.5%. Demographics (older age and female), physiological conditions (higher body mass index, higher hip circumferences, higher systolic blood pressure, poor cardiovascular function, dyspnoea, pain, cramps, itchiness or moderate to extreme pruritus, lower fasting plasma glucose, electrolyte imbalance, higher total cholesterol and gastrointestinal symptoms), depression, smoking, arousal-related and cognitive arousal behaviours were associated with poor sleep quality., Conclusion: Poor sleep quality was prevalent and influenced kidney function, increased mortality as well as decreased quality of life in patients with pre-dialysis chronic kidney disease. This review synthesizes factors associated with poor sleep quality. Managing these factors can mitigate and prevent poor sleep quality., Impact: Healthcare providers, especially nurses, can assess the risk factors of poor sleep quality and reinforce patients' self-management. Future research should elucidate the assessment and management of risk factors and transfer these into widespread use in the routine care of patients with chronic kidney disease., (© 2023 John Wiley & Sons Ltd.)

Hypertension is a leading modifiable risk factor for cerebral small vessel disease. Our laboratory has shown that endothelium-dependent dilation in cerebral parenchymal arterioles (PAs) is dependent on transient receptor potential vanilloid 4 (TRPV4) activation, and this pathway is impaired in hypertension. This impaired dilation is associated with cognitive deficits and neuroinflammation. Epidemiological evidence suggests that women with midlife hypertension have an increased dementia risk that does not exist in age-matched men, though the mechanisms responsible for this are unclear. This study aimed to determine the sex differences in young, hypertensive mice to serve as a foundation for future determination of sex differences at midlife. We tested the hypothesis that young hypertensive female mice would be protected from the impaired TRPV4-mediated PA dilation and cognitive dysfunction observed in male mice. Angiotensin II (ANG II)-filled osmotic minipumps (800 ng/kg/min, 4 wk) were implanted in 16- to 19-wk-old male C56BL/6 mice. Age-matched female mice received either 800 ng/kg/min or 1,200 ng/kg/min ANG II. Sham-operated mice served as controls. Systolic blood pressure was elevated in ANG II-treated male mice and in 1,200 ng ANG II-treated female mice versus sex-matched shams. PA dilation in response to the TRPV4 agonist GSK1016790A (10 -9 -10 -5 M) was impaired in hypertensive male mice, which was associated with cognitive dysfunction and neuroinflammation, reproducing our previous findings. Hypertensive female mice exhibited normal TRPV4-mediated PA dilation and were cognitively intact. Female mice also showed fewer signs of neuroinflammation than male mice. Determining the sex differences in cerebrovascular health in hypertension is critical for developing effective therapeutic strategies for women. NEW & NOTEWORTHY Vascular dementia is a significant public health concern, and the effect of biological sex on dementia development is not well understood. TRPV4 channels are essential regulators of cerebral parenchymal arteriolar function and cognition. Hypertension impairs TRPV4-mediated dilation and memory in male rodents. Data presented here suggest female sex protects against impaired TRPV4 dilation and cognitive dysfunction during hypertension. These data advance our understanding of the influence of biological sex on cerebrovascular health in hypertension.

Lack of time, lack of access to equipment, and environmental constraints are generally perceived as barriers to regular physical activity. Moreover, insufficient activity is known to promote sedentary behavior, which is a factor in many chronic diseases, negatively affects mental health, and reduces quality of life. Exercise snacks, defined as short and efficient bursts of exercise, are convenient and easy to implement, reduce sedentary time, increase physical activity, and promote the development of good exercise habits. Previous studies have found exercise snacks to be safe and feasible for the elderly, promoting physical function and reducing the incidence of falls and metabolic diseases. Exercise snacks have also been found to be effective in healthy adults as well as in patients with obesity and diabetes, helping decrease blood sugar and promoting cardiorespiratory fitness. Depending on the participant's age and tolerance, exercise snack patterns may be extended and distinguished into two forms: 10-minute bouts of gentle intermittent exercise twice a day and 60-second bouts of vigorous exercise 3 to 8 times a day. The main considerations for exercise snacks include: multi-joint exercise is better than single-joint exercise, lower body exercise is better than upper body exercise, and dynamic and rapid movement that pushes away from the ground promotes osteogenesis and helps prevent osteoporosis and fractures. Exercise snacks may be applied in healthcare practice and related research to promote health and improve quality of life for all.

Most individuals who experience aphasia after a stroke recover to some extent, with the majority of gains taking place in the first year. The nature and time course of this recovery process is only partially understood, especially its dependence on lesion location and extent, which are the most important determinants of outcome. The aim of this study was to provide a comprehensive description of patterns of recovery from aphasia in the first year after stroke. We recruited 334 patients with acute left hemisphere supratentorial ischaemic or haemorrhagic stroke and evaluated their speech and language function within 5 days using the Quick Aphasia Battery (QAB). At this initial time point, 218 patients presented with aphasia. Individuals with aphasia were followed longitudinally, with follow-up evaluations of speech and language at 1 month, 3 months, and 1 year post-stroke, wherever possible. Lesions were manually delineated based on acute clinical MRI or CT imaging. Patients with and without aphasia were divided into 13 groups of individuals with similar, commonly occurring patterns of brain damage. Trajectories of recovery were then investigated as a function of group (i.e. lesion location and extent) and speech/language domain (overall language function, word comprehension, sentence comprehension, word finding, grammatical construction, phonological encoding, speech motor programming, speech motor execution, and reading). We found that aphasia is dynamic, multidimensional, and gradated, with little explanatory role for aphasia subtypes or binary concepts such as fluency. Patients with circumscribed frontal lesions recovered well, consistent with some previous observations. More surprisingly, most patients with larger frontal lesions extending into the parietal or temporal lobes also recovered well, as did patients with relatively circumscribed temporal, temporoparietal, or parietal lesions. Persistent moderate or severe deficits were common only in patients with extensive damage throughout the middle cerebral artery distribution or extensive temporoparietal damage. There were striking differences between speech/language domains in their rates of recovery and relationships to overall language function, suggesting that specific domains differ in the extent to which they are redundantly represented throughout the language network, as opposed to depending on specialized cortical substrates. Our findings have an immediate clinical application in that they will enable clinicians to estimate the likely course of recovery for individual patients, as well as the uncertainty of these predictions, based on acutely observable neurological factors., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background/purpose: Little is known regarding the outcomes and distinguishing characteristics of lawsuits related to endodontic procedures. This study used a verdict-based data from United States of America to analyze the factors associated with endodontic malpractice lawsuits and mitigate the risk of litigation., Materials and Methods: The LexisNexis legal database was used to search for endodontic malpractice cases from January 1, 2000 to December 31, 2021 using the terms "medical malpractice" and (I) "endodontist" (II) "endodontics" (III) "root canal" (IV) "dental pulp." Each case was reviewed for reported medical characteristics and litigation outcomes., Results: A total of 650 cases were initially identified, and 97 cases were included in the final analysis. Eighty-four (86.6%) of the 97 defendants were general practitioners; 42 cases favored the plaintiff, 53 (54.6%) favored the defendant, 1 was partial win/loss, and 1 was settled. The annual case mean was 4.41 ± 2.17 (Mean ± SD). The major allegations favored for the patients involving paresthesia, root perforation, rubber dam not use, wrong tooth therapy, and infections. Plaintiffs who claimed with post-procedural reasons had a significantly higher winning rate than non-post-procedural reasons (P < 0.05)., Conclusion: In the present study, 54.6% of endodontic litigation favored the dentists in the US. The authors recommend that general practitioners refer complicated cases to endodontists and treat carefully to avoid paresthesia, canal perforation and infections. Clinicians should always diagnose and treat correctly, shared decision making with the patient, use rubber dam routinely, and timely management to prevent malpractice claims., Competing Interests: The authors have no conflicts of interest relevant to this article., (© 2022 Association for Dental Sciences of the Republic of China. Publishing services by Elsevier B.V.)

Aims: To synthesize and evaluate the psychometric properties of self-report instruments that measure patient dignity., Design: A psychometric systematic review., Data Sources: A comprehensive search of studies published from inception until February 17, 2022, was performed using PubMed, Embase, CINAHL, Web of Science, and Scopus., Review Methods: The methodological quality of the psychometric studies was evaluated following the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines., Results: Eleven self-report instruments that evaluate dignity were identified. For most instruments, psychometric properties, including reliability, cross-cultural validity, responsiveness, and measurement error, had not been adequately examined. The Patient Dignity Inventory (PDI), the Jacelon's Attributed Dignity Scale (JADS), and the Inpatient Dignity Scale (IPDS) had acceptable content validity, structure validity, and internal consistency to measure dignity among adult patients under palliative care, community-dwelling older adults, and inpatients receiving daily care., Conclusion: The PDI, the JADS, and the IPDS are recommended for future clinical practice and research to measure dignity among adult patients under palliative care, community-dwelling older adults, and inpatients receiving daily care. Early identification of patients' dignity-related problems in nursing care can prevent negative health outcomes and help develop a timely intervention to promote patients' health and recovery., Impact: Given that the psychometric properties of the existing self-report dignity instruments have not been systematically assessed, the present review utilized comprehensive methods according to COSMIN to evaluate and determine the most appropriate measure for research and practice. The PDI, the JADS, and the IPDS demonstrated satisfactory psychometric properties and are, thus, recommended for clinical and research applications. Nursing professionals can employ these instruments to assess and promptly identify dignity issues among both young and older adults in hospitals and communities., (© 2022 John Wiley & Sons Ltd.)

Using the helping relationships from significant others (HRSO) scale assists patients, such as those with chronic kidney disease (CKD), in adopting a healthy lifestyle to decelerate disease progression, complications, and mortality. To study the efficacy of the scale, we recruited a convenience sample ( n = 250) of patients with CKD from a nephrology clinic in southern Taiwan. Principal axis factor analysis and a promax rotation revealed a 15-item, three-factor explanation of 68.44 % of the total variance. The confirmatory factor analysis showed a good fit. The Composite reliability was .91, .89, and .92 in the same factors. Cronbach's alpha was .90 for the 15-item scale, with the 3 subscales ranging from .86 to .91. The split reliability was .73. The HRSO is a valid and reliable scale to measure significant others' support of patients with CKD in maintaining a healthy lifestyle.

Background: Nursing students with master degrees have the strong potential to serve as future leaders in medical teams. Implementing a well-developed and integrated educational program for nursing leadership at the master's level can strengthen the leadership of advanced practice nurses and promote a positive nursing practice environment., Purpose: To develop a leadership integrated educational program for master's nursing students and conduct a preliminary evaluation of the effectiveness of this program in cultivating leadership competencies in these students., Methods: Phase 1: A modified Delphi survey conducted on 14 experts with clinical or academic backgrounds was used to identify the teaching objectives and strategies of the leadership integrated educational program. Phase 2: These teaching objectives and strategies were embedded into nine compulsory courses within a current training program for master's nursing students at a national university. The core elements of the leadership integrated educational program were incorporated into each compulsory course. The objectives of each compulsory course directly reflected the objectives of the integrated program. The leadership integrated educational program was implemented for one academic year, and its effectiveness was evaluated using a quasi-experimental test with a single group pre- and post-test design. A self-developed, 10-item "Master Nursing Student's Leadership Competence Scale" covering four core elements was applied to measure the self-reported leadership competencies of the participants. A paired sample t-test was applied to analyze the differences in leadership competencies between pre- and post-intervention., Results: A consensus on the teaching objectives and strategies of the leadership integrated educational program was achieved in the first round of the Delphi survey. The overarching teaching objective of the leadership integrated educational program was to "lead the healthcare team with the leadership and competencies, and demonstrate the advanced nursing practice skills for improving quality of care." In addition, the four core elements under the overarching goal, i.e., personal characteristics, leading people, business management, and vision building, were proposed. Forty-eight master's nursing students participated in this study. The results showed the average total score of leadership competency was 42.33 ± 12.16 (potential range: 10 - 70), indicating that the participants had a middle level of leadership competency prior to program participation. After participating in the Leadership Integrated Educational Program for one academic year, the average total score for leadership competency increased to 51.27 ± 9.74, indicating that the participants still had a middle level of leadership competency. Nevertheless, the 8.94 increase in the post-intervention score was statistically significant (p < .01). Moreover, the scores for each subscale (personal characteristics, leading people, business management, and vision building) had all increased significantly increased from 13.52 to 15.71, 12.65 to 15.35, 8.15 to 10.31, and 8.02 to 9.90, respectively (p < .01)., Conclusions / Implications for Practice: This study offers proactive recommendations for reforming master's degree programs in nursing. The proposed multidisciplinary-expert-informed leadership integrated educational program may be used to strengthen leadership competencies in this student population. Furthermore, the findings provide a benchmark for developing an effective nursing leadership integrated educational program that may be incorporated into domestic master's degree programs.

The IL-17 family of cytokines and receptors have central roles in host defence against infection and development of inflammatory diseases 1 . The compositions and structures of functional IL-17 family ligand-receptor signalling assemblies remain unclear. IL-17E (also known as IL-25) is a key regulator of type 2 immune responses and driver of inflammatory diseases, such as allergic asthma, and requires both IL-17 receptor A (IL-17RA) and IL-17RB to elicit functional responses 2 . Here we studied IL-25-IL-17RB binary and IL-25-IL-17RB-IL-17RA ternary complexes using a combination of cryo-electron microscopy, single-molecule imaging and cell-based signalling approaches. The IL-25-IL-17RB-IL-17RA ternary signalling assembly is a C2-symmetric complex in which the IL-25-IL-17RB homodimer is flanked by two 'wing-like' IL-17RA co-receptors through a 'tip-to-tip' geometry that is the key receptor-receptor interaction required for initiation of signal transduction. IL-25 interacts solely with IL-17RB to allosterically promote the formation of the IL-17RB-IL-17RA tip-to-tip interface. The resulting large separation between the receptors at the membrane-proximal level may reflect proximity constraints imposed by the intracellular domains for signalling. Cryo-electron microscopy structures of IL-17A-IL-17RA and IL-17A-IL-17RA-IL-17RC complexes reveal that this tip-to-tip architecture is a key organizing principle of the IL-17 receptor family. Furthermore, these studies reveal dual actions for IL-17RA sharing among IL-17 cytokine complexes, by either directly engaging IL-17 cytokines or alternatively functioning as a co-receptor., (© 2022. The Author(s).)

Objective: To highlight the general features of IQOS literature focusing on the chemical analysis of IQOS emissions., Data Sources: PubMed, Web of Science and Scopus databases were searched on 8 November 2021 using the terms 'heated tobacco product', 'heat-not-burn', 'IQOS' and 'tobacco heating system' with time restriction (2010-2021). The search yielded 5480 records., Study Selection: Relevant publications on topics related to IQOS assessment were retrieved (n=341). Two reviewers worked separately and reached agreement by consensus., Data Extraction: Data on author affiliation and funding, article type and date of publication were extracted. Publications were categorised depending on their focus and outcomes. Data on IQOS emissions from the chemical analysis category were extracted., Data Synthesis: Of the included publications, 25% were published by Philip Morris International (PMI) affiliates or PMI-funded studies. PMI-sponsored publications on emissions, toxicology assessments and health effects were comparable in number to those reported by independent research, in contrast to publications on IQOS use, market trends and regulation. Data on nicotine yield, carbonyl emissions, other mainstream emissions, secondhand emissions and IQOS waste were compared between data sources to highlight agreement or disagreement between PMI-sponsored and independent research., Conclusions: Our analysis showed agreement between the data sources on nicotine yield from IQOS under the same puffing conditions. Also, both sources agreed that IQOS emits significantly reduced levels of some emissions compared with combustible cigarettes. However, independent studies and examination of PMI's data showed significant increases in other emissions from and beyond the Food and Drug Administration's harmful and potentially harmful constituents list., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To evaluate the efficacy of MP-3 microperimeter biofeedback fixation training (MBFT) in vision rehabilitation of low-vision patients affected by macular disease with central vision loss., Methods: Seventeen eyes (7 age-related macular degeneration, 10 myopic maculopathy) of 17 patients were included in this prospective, interventional study. The preferred retinal locus was determined by comprehensive ophthalmoscopic fundus evaluation including fundus photography, autofluorescence, optical coherence tomography, and microperimetry. The rehabilitation consisted of three 10-min sessions per eye to be performed twice per week for 20 consecutive weeks using the MP-3 microperimeter. Best corrected visual acuity (BCVA), reading speed, mean central sensitivity, the percentages of fixation points within specified regions, bivariate contour ellipse area (BCEA) and the 25-item National Eye Institute visual function questionnaire (NEI-VFQ-25) were recorded pre- and post-training., Results: The final BCVA, reading speed and mean central sensitivity all showed significant improvements after rehabilitation (P <  0.0001, P = 0.0013, and P = 0.0002, respectively). The percentages of fixation points located within 2° and 4° diameter circles both significantly increased after training (P = 0.0008 and P = 0.0007, respectively). The BCEA encompassing 68.2, 95.4, 99.6% of fixation points were all significantly decreased after training (P = 0.0038, P = 0.0022, and P = 0.0021, respectively). The NEI-VFQ-25 scores were significantly increased at the end of the rehabilitation training (P <  0.0001)., Conclusion: Rehabilitation with MP-3 MBFT is a user-friendly therapeutic option for improving visual function, fixation stability, and quality of life in advanced macular disease., Trial Registration: The prospective study was registered with the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/ )., Trial Registration Number: ChiCTR2000029586 . Date of registration: 05/02/2020., (© 2022. The Author(s).)

Diabetes mellitus (DM) is a global public health concern. DM is importantly linked to the modern lifestyle. Lifestyle-based interventions currently represent a critical preventive and therapeutic approach for patients with DM. Increasing physical activity has proven multiple benefits to prevent this condition; however, there is still room for further progress in this field, especially in terms of the effect of exercise in patients with already established DM. This study intends to examine the economic relationship between physical activity and direct/indirect costs in patients with DM. We analyze a national representative sample ( n = 1496) of the general population of Spain, using available data from the National Health Survey of 2017 (NHS 2017). Our results show that 63.7% of the sample engaged in some degree of physical activity, being more frequent in men (67.5%), younger individuals (80.0%), and those with higher educational levels (69.7%). Conversely, lower levels of physical activity were associated with female sex, older subjects, and various comorbidities. Our study estimates that 2151 € per (51% in direct costs) patient may be saved if a minimum level of physical activity is implemented, primarily, due to a decrease in indirect costs (absenteeism and presenteeism). This study shows that physical activity will bring notable savings in terms of direct and indirect costs in patients with DM, particularly in some vulnerable groups.

Cytokines are powerful immune modulators that initiate signaling through receptor dimerization, but natural cytokines have structural limitations as therapeutics. We present a strategy to discover cytokine surrogate agonists by using modular ligands that exploit induced proximity and receptor dimer geometry as pharmacological metrics amenable to high-throughput screening. Using VHH and scFv to human interleukin-2/15, type-I interferon, and interleukin-10 receptors, we generated combinatorial matrices of single-chain bispecific ligands that exhibited diverse spectrums of functional activities, including potent inhibition of SARS-CoV-2 by surrogate interferons. Crystal structures of IL-2R:VHH complexes revealed that variation in receptor dimer geometries resulted in functionally diverse signaling outputs. This modular platform enabled engineering of surrogate ligands that compelled assembly of an IL-2R/IL-10R heterodimer, which does not naturally exist, that signaled through pSTAT5 on T and natural killer (NK) cells. This "cytokine med-chem" approach, rooted in principles of induced proximity, is generalizable for discovery of diversified agonists for many ligand-receptor systems., Competing Interests: Declaration of interests K.C.G., M.Y., J.R., and Q.L. are co-inventors on a provisional patent 63/306,882 based upon the technology described in this manuscript. K.C.G. is the founder of Synthekine Therapeutics., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To explore the relationship between walking activity and sleep quality among elderly., Design: A cross-sectional, correlation study with purposive sampling was conducted on participants with a walking habit but not regular moderate-intensity exercise., Methods: Data were collected by structured questionnaires, including the Walking Activity Questionnaire and the Pittsburgh Sleep Quality Index., Findings: The total walking time per week and frequency of walking per day were significant predictors of sleep quality., Conclusions: Walking can help older community-dwelling adults improve their sleep quality., Clinical Evidence: Walking more than once per day and total walking time per week ≥210 minutes were associated with good sleep quality.

Background: Healthy behaviors can slow the progression of chronic kidney disease. Professional healthcare providers deliver education, physical exercise programs, motivation consultations, and stage-tailored strategies for improving health behaviors, but their effectiveness reported mixed. The helping relationships of significant others based on the transtheoretical model have been shown to be beneficial in facilitating and practicing health-promoting behaviors. However, few studies have examined the effects of helping relationships on health-promoting behaviors among patients with chronic kidney disease., Objectives: The aim of this study was to examine the effects of the intervention strategies of significant others in their helping relationships with patients to advance stages of exercise and diet behaviors, and to improve health-promoting lifestyles., Design: A randomized controlled study., Settings: Two outpatient nephrology clinics in southern Taiwan., Participants: Sixty participants in each of the two groups., Methods: Patients were randomly assigned to either the intervention group (n = 60) whose significant others received strategies for helping relationships for 12 months, or the control group (n = 60). The Stage of Change of Exercise and Diet Behaviors, and Health Promoting Lifestyle Profile-II Chinese version were assessed at baseline and 3, 6, 9, and 12 months after receiving the helping relationship interventions tailored to stage of change from significant others., Results: Generalized estimating equation analyzes revealed that the intervention group, when compared to the control group, had significantly advanced stages of change in exercise and diet, and improvement in health-promoting lifestyle over time. Adult children and spouses were the most common significant others to help patients practice healthy behaviors, compared to previous studies where professional healthcare providers were the significant others., Conclusions: Individualized plans for healthy behaviors should take into consideration patients' readiness for adopting stage-tailored strategies of helping relationships of significant others to adhere to the health-promoting lifestyle. To promote a healthier lifestyle, significant others, such as spouses and adult children, should be included in treatment programs., Competing Interests: Declaration of Competing Interest No conflict of interest has been declared by the authors., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Aim: The aim of the study was to identify baccalaureate nursing leadership objectives and evaluate their effectiveness when embedded into an undergraduate nursing curriculum., Background: The objectives of nursing leadership competencies cannot be met in one semester but must be gradually developed over successive courses., Method: A list of learning objectives for leadership competence was generated and reviewed by 12 experts using the Delphi method. The consensuses objectives were embedded into a four-year nursing baccalaureate curriculum in Taiwan. Nursing students (N = 120) who participated in the courses evaluated the embedded objectives of leadership competency introduced in their undergraduate nursing program. Leadership competence was improved among students on nine items (t = 2.282 to 5.741, p = .001 to .030) of the Nursing Leadership Competence Assessment Scale for Undergraduate Nursing Students., Conclusion: The results can serve as a reference for universities seeking to promote nursing leadership education., Competing Interests: The authors have declared no conflict of interest., (Copyright © 2021 National League for Nursing.)

Background: The factors related to fluid intake adherence among patients undergoing hemodialysis have been explored in many studies. However, most of these were conducted in Western countries and have produced inconsistent results. A study of this issue in Indonesia, a tropical country with strong herbal medicine traditions, may show different results. In addition to demographic characteristics, self-efficacy is a standard measurement used in chronic care management activities such as hemodialysis treatment. Understanding the reasons behind patient nonadherence in Indonesia may help nurses better manage the fluid intake of patients., Purpose: This study was designed to determine the factors that predict patient adherence to fluid intake restrictions., Methods: A cross-sectional study was conducted on 153 patients undergoing hemodialysis at two hospitals. Intradialytic weight gain over a 1-month period was recorded to assess the participants' adherence to fluid intake restrictions. Intradialytic weight gains of more than 2 kg was considered to be nonadherent. A daily urine output and level of thirst were also recorded. The participants completed an adapted self-efficacy questionnaire, Swedish Fluid Intake Appraisal Inventory, and the data were analyzed together with demographic characteristic and clinical parameters using hierarchical multiple regression., Results: The results revealed that most of the respondents did not adequately adhere to fluid intake restrictions (59.5%). Intradialytic weight gain was shown to strongly correlate with self-efficacy (p < .05, β = -.201), gender (p < .05, β = -.179), educational background (p = .05, β = .159), and urine output (p < .05, β = -.168). Demographic characteristic explained 10.6% and self-efficacy explained 3.9% of the variance in fluid adherence., Conclusions/implications for Practice: Female participants with higher self-efficacy scores reported the lowest average level of intradialytic weight gain, indicating better adherence to fluid intake restrictions. Several demographic factors as well as self-efficacy were identified as potential predictors of fluid intake restriction adherence. Therefore, measuring self-efficacy periodically is a good initial step toward detecting those patients who are at higher risk of noncompliance with fluid intake restrictions., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.)

The dimeric ER Ca 2+ sensor STIM1 controls store-operated Ca 2+ entry (SOCE) through the regulated binding of its CRAC activation domain (CAD) to Orai channels in the plasma membrane. In resting cells, the STIM1 CC1 domain interacts with CAD to suppress SOCE, but the structural basis of this interaction is unclear. Using single-molecule Förster resonance energy transfer (smFRET) and protein crosslinking approaches, we show that CC1 interacts dynamically with CAD in a domain-swapped configuration with an orientation predicted to sequester its Orai-binding region adjacent to the ER membrane. Following ER Ca 2+ depletion and release from CAD, cysteine crosslinking indicates that the two CC1 domains become closely paired along their entire length in the active Orai-bound state. These findings provide a structural basis for the dual roles of CC1: sequestering CAD to suppress SOCE in resting cells and propelling it toward the plasma membrane to activate Orai and SOCE after store depletion., Competing Interests: Sv, RQ, UC, MW, MY, MK No competing interests declared, AB, RL Reviewing editor, eLife, (© 2021, van Dorp et al.)

Aim(s): To understand how nurse managers facilitate learning in clinical workplaces., Background: Meeting staff learning needs in the complex workplaces of contemporary health care is paramount to the delivery of safe patient care. Hospitals employ a range of strategies to address these needs. However, nurse managers' contribution to staff learning at the unit level is underexplored in contemporary literature., Method(s): A Gadamerian philosophical hermeneutic framework guided data collection and analysis. Thirteen nurse managers from two Australian hospitals each participated in two interviews and a period of observation., Findings: Nurse managers' learning facilitation practices were enacted with staff individually, within teams, and through artefacts, and were shaped by their identities, perspectives on staff learning, knowledge of staff performance, and motivations. Power was revealed as a uniquely enacted driver of their learning facilitation practices., Conclusion(s): This paper illuminates an aspect of nurse managers' practice that has been poorly acknowledged in contemporary nursing literature. Nurse managers' learning facilitation practices were found to be complex, fluid, and embedded in their everyday work routines., Implications for Nursing Management: Given current concerns about safety and quality in health care, this research opens up possibilities for definition and enrichment of nurse managers' practice as facilitators of learning., (© 2021 John Wiley & Sons Ltd.)

Background: Sodium restriction is difficult for most individuals with hypertension. Intention to limit sodium intake predicts behavior. Information on the determinants of intention to restrict sodium intake is limited., Objectives: The aims of this study were to identify (1) determinants of intention to restrict high-sodium food intake and (2) sources of sodium consumed by patients with hypertension in Indonesia., Methods: A cross-sectional study was conducted among adult patients with hypertension (n = 206) attending cardiac clinics. A researcher-developed and tested, self-administered questionnaire that included questions about sodium restriction and a high-sodium food inventory was distributed. The quantile regression method was used to identify determinants of intention to restrict dietary sodium., Results: The mean age of the patients with hypertension was 59 ± 10 years, and more than three-fourths were obese (n = 162, 78%). The determinants of intention to limit sodium intake included gender (β = 0.737, P = .036), attitude (β = -0.141, P = .050), and subjective norm (β = -0.283, P = .005). Men reported higher sodium consumption, while attitudes and subjective norm were negatively correlated with sodium intake. These determinants predicted 13.2% of the variance in intention to restrict dietary sodium. Subjects reported frequently consuming snacks (n = 82, 39.7%) and seasoning condiments (n = 65, 31.6%)., Conclusions: High-sodium snacks and condiments added while cooking were frequently consumed among patients with hypertension in Indonesia. Understanding the factors associated with intention to follow a low-sodium diet will assist nurses to design effective interventions that promote adherence to the low-sodium diet among those with hypertension., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Stimulant use has increased across the US, with concomitant opioid and methamphetamine use doubling between 2011 and 2017. Shifting patterns of polysubstance use have led to rising psychostimulant-involved deaths. While it is known that individuals who use methamphetamine require greater access to treatment, there is still little known about methamphetamine use and treatment among individuals who are already engaged in outpatient substance use treatment., Objectives: To characterize care-engaged individuals who use methamphetamine to guide harm reduction and treatment strategies., Methods: Retrospective cohort study of individuals at a large academic medical center in Massachusetts with ≥ 2 positive methamphetamine oral fluid toxicology tests between August 2019 and January 2020. We performed descriptive analysis of sociodemographic, medical, and drug use characteristics and a comparative analysis of injection methamphetamine use versus other routes of use., Results: Included were 71 individuals [56 male (80%), 66 non-Hispanic white (94%), median age 36 (IQR 30-42)]. Nearly all had opioid (94%) and stimulant use disorder (92%). Most had (93%) or were (83%) being treated with medications for opioid use disorder, but few received pharmacologic treatment for methamphetamine use disorder (24%). None received contingency management treatment. People who inject methamphetamine (68%) were more likely to have a history of overdose (91% vs. 70%; p = 0.02), have HCV (94% vs. 52%; p < 0.01), use fentanyl (93% vs. 65%; p = 0.02), and engage in sex work (19% vs. 0%; p = 0.03) compared to those who used via other routes. Both groups had prevalent homelessness (88% vs. 73%; p = 0.15), incarceration (81% vs. 64%; p = 0.11), depression (94% vs. 87%; p = 0.34), and bacteremia (27% vs. 22%; p = 0.63)., Conclusions: Individuals in our study had high prevalence of polysubstance use, particularly concomitant methamphetamine and opioid use. Individuals who were well connected to substance use treatment for their opioid use were still likely to be undertreated for their methamphetamine use disorder and would benefit from greater access to contingency management treatment, harm reduction resources, and resources to address adverse social determinants of health., (© 2021. The Author(s).)

Adherence to healthy behaviors is a protective factor in the disease progression of chronic kidney disease (CKD). Measuring adherence can lead to the recognition of unhealthy behaviors and the suggestion of programs to prevent poor health outcomes. An assessment measurement for patients with CKD not requiring dialysis was developed and psychometrically tested. A convenience sample ( n  = 330) of patients with CKD attending a nephrology clinic in southern Taiwan completed the 13-item Adherence to Healthy Behaviors Scale (AHBS). A principal axis factor analysis and a parallel analysis demonstrated a three-factor structure accounting for 47.16% of the total variance. Confirmatory factor analysis indicated a good model fit. The criterion-related validity was adequate ( r  = .51; p  < .000), with a Cronbach's alpha of .70; the test-retest reliability demonstrated good stability ( r  = .70; p  < .000). The AHBS is a valid, reliable instrument to assess adherence to healthy behaviors among patients with CKD.

ICP2 is a virulent bacteriophage (phage) that preys on Vibrio cholerae. ICP2 was first isolated from cholera patient stool samples. Some of these stools also contained ICP2-resistant isogenic V. cholerae strains harboring missense mutations in the trimeric outer membrane porin protein OmpU, identifying it as the ICP2 receptor. In this study, we identify the ICP2 proteins that mediate interactions with OmpU by selecting for ICP2 host range mutants within infant rabbits infected with a mixture of wild-type and OmpU mutant strains. ICP2 host range mutants that can now infect OmpU mutant strains have missense mutations in the putative tail fiber gene gp25 and the putative adhesin gene gp23 . Using site-specific mutagenesis, we show that single or double mutations in gp25 are sufficient to generate the host range mutant phenotype. However, at least one additional mutation in gp23 is required for robust plaque formation on specific OmpU mutants. Mutations in gp23 alone were insufficient to produce a host range mutant phenotype. All ICP2 host range mutants retained the ability to form plaques on wild-type V. cholerae cells. The strength of binding of host range mutants to V. cholerae correlated with plaque morphology, indicating that the selected mutations in gp25 and gp23 restore molecular interactions with the receptor. We propose that ICP2 host range mutants evolve by a two-step process. First, gp25 mutations are selected for their broad host range, albeit accompanied by low-level phage adsorption. Subsequent selection occurs for gp23 mutations that further increase productive binding to specific OmpU alleles, allowing for near-wild-type efficiencies of adsorption and subsequent phage multiplication. IMPORTANCE Concern over multidrug-resistant bacterial pathogens, including Vibrio cholerae, has led to renewed interest in phage biology and the potential for phage therapy. ICP2 is a genetically unique virulent phage isolated from cholera patient stool samples. It is also one of three phages in a prophylactic cocktail that have been shown to be effective in animal models of infection and the only one of the three that requires a protein receptor (OmpU). This study identifies an ICP2 tail fiber and a receptor binding protein and examines how ICP2 responds to the selective pressures of phage-resistant OmpU mutants. We found that this particular coevolutionary arms race presents fitness costs to both ICP2 and V. cholerae.

Introduction: Although Muslims constitute nearly one fourth of the global population, many non-Muslims are not familiar with Islam. To address this unique need from such a specific cultural context, the present study aimed to examine the spiritual needs and influencing factors of Indonesian Muslims with cancer. Method: A cross-sectional research design with 122 cancer patients was conducted by using the Bahasa-version Spiritual Needs Questionnaire. Results: The degree of spiritual needs was generally high. Religious needs were the strongest aspect, and "praying five times a day" was the highest scoring item. Gender ( p = .04), age ( p = .01), and duration of being diagnosed with cancer ( p = .01) were associated with spiritual needs. Female gender ( p = .005) and older age ( p < .001) were predictors of spiritual needs. Discussion: As expected to provide cultural-congruent spiritual interventions, nurses could meet Muslim patients' need to pray five times a day during hospitalization, thus help them manage and endure the illness.

Research on dietary and lifestyle modifications to decrease cardiovascular risk and slow disease progression has been limited to patients in the later stages of chronic kidney disease (CKD). Studies on the effectiveness of stage-of-change-tailored interventions on lifestyle modifications for individuals with early stage CKD are limited. Using random assignment, 60 patients with early stage CKD who received up to six tailored intervention visits over 30 months were compared to 60 usual care patients on physical indicators, lifestyle behaviors, and quality of life. Tailored interventions were consistent with the trans-theoretical Model of Change. Waist circumference, nutrition, and stress management improved over time in the intervention group. There was no difference or change in quality of life. To promote a healthier lifestyle, findings suggest that clinicians working with patients with CKD should consider patients' readiness to change their behaviors as well as implementation strategies tailored for different processes of change.

In this study, we investigated how the brain responds to task difficulty in linguistic and non-linguistic contexts. This is important for the interpretation of functional imaging studies of neuroplasticity in post-stroke aphasia, because of the inherent difficulty of matching or controlling task difficulty in studies with neurological populations. Twenty neurologically normal individuals were scanned with fMRI as they performed a linguistic task and a non-linguistic task, each of which had two levels of difficulty. Critically, the tasks were matched across domains (linguistic, non-linguistic) for accuracy and reaction time, such that the differences between the easy and difficult conditions were equivalent across domains. We found that non-linguistic demand modulated the same set of multiple demand (MD) regions that have been identified in many prior studies. In contrast, linguistic demand modulated MD regions to a much lesser extent, especially nodes belonging to the dorsal attention network. Linguistic demand modulated a subset of language regions, with the left inferior frontal gyrus most strongly modulated. The right hemisphere region homotopic to Broca's area was also modulated by linguistic but not non-linguistic demand. When linguistic demand was mapped relative to non-linguistic demand, we also observed domain by difficulty interactions in temporal language regions as well as a widespread bilateral semantic network. In sum, linguistic and non-linguistic demand have strikingly different neural correlates. These findings can be used to better interpret studies of patients recovering from aphasia. Some reported activations in these studies may reflect task performance differences, while others can be more confidently attributed to neuroplasticity., Competing Interests: Competing Interests: The authors declare that no competing interests exist.

Epitaxial CoFe 2 O 4 (CFO)/CoO bilayers were fabricated by pulsed laser deposition on flexible muscovite mica substrate. Samples with different CFO thicknesses were employed to study the phenomenon of exchange bias involving strongly anisotropic ferromagnet. Magnetic measurements exhibited great enhancement in the features of exchange bias. Raman and X-ray absorption spectroscopies indicated that a new phase emerged within the CFO layer because of the cation charge redistribution in CFO layer under bending, which in turn gave rise to anomalous hysteresis loops exhibited in the bent bilayers. These results provide a fundamental understanding about the mechanisms of exchange bias prevailing in these bilayers and call attention to the implementation of spintronic devices using flexible heterostructures such as the present CFO/CoO bilayers.

Microplastic particles and fibers are increasingly being detected in our surface and ground waters as well as within a wide range of aquatic species. Their presence in the environment is largely due to in situ generation from physical and chemical weathering of larger plastics, and thus has left environmental community concerned in the post-banned era of microbead use in personal care products through the passage of Microbead-Free Waters Act in the United States. To improve understanding of secondary microplastic formation, accelerated weathering has been conducted on four materials (high-density polyethylene, high impact polystyrene, nylon 6, and polypropylene) under ultraviolet radiation (equivalent to 44 days in full sun) in simulated seawater. Physical and chemical characterization of the plastics were completed following ultraviolet exposure. This simulated weathering generated microfibers from high-density polyethylene and nylon 6, while high impact polystyrene and polypropylene did not physically degrade. The techniques used were applied to sediment samples containing plastic pellets collected from Cox Creek in Port Comfort, TX (near a large plastics manufacturer), which were purified for analysis and were found to contain microplastics composed of polypropylene and polyethylene. These findings can be used to determine degradation pathways and plastic source tracking, which can facilitate risk assessment and environmental management., Competing Interests: Declaration of competing interest The authors whose names are listed immediately below certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Cryoablation of the posterior nasal nerve at the middle meatus has been shown to successfully treat nasal obstruction and symptoms of chronic rhinitis. Cryoablation of both the middle and inferior meatus has not yet been studied., Objectives: To evaluate the safety and feasibility of cryoablation of the posterior nasal nerve at both the middle and inferior meatus locations to treat chronic rhinitis., Methods: Participants underwent bilateral cryoablation of the posterior nasal nerve at both the middle meatus and inferior meatus and were assessed through 3 months post treatment. The primary endpoint is the change from baseline to 3-month follow-up in the reflective Total Nasal Symptom Score (rTNSS). Other assessments include additional patient-reported outcomes, physician assessment, and independent review and scoring of imaging., Results: Thirty participants were enrolled at 3 US centers. There was a significant improvement from baseline in the median rTNSS (-4.0, P  < .001) at 3 months. Statistically significant improvements from baseline ( P  < .001) were also observed with the Nasal Obstruction Symptom Score (NOSE), nasal symptom visual analog scale (VAS), Sino-Nasal Outcomes Score (SNOT-22), and mini Rhinoconjunctivitis Quality of Life Questionnaire (mini RQLQ). Clinical Global Impression - Improvement (CGI-I) indicated that 89.7% (26/29) of participants experienced improvement at 3 months. No serious adverse events were reported., Conclusion: Cryoablation at both the middle meatus and inferior meatus appears to be a safe and feasible option for treatment of chronic rhinitis. In this feasibility study, there is significant improvement in symptoms post treatment. Adverse events are minor and transient., (© The Author(s) 2020.)

A 47 year old woman presented to the emergency department for an intentional overdose of an over the counter cough suppressant. She had been seen multiple times over the last several months with the same presentation. Her work up revealed a significantly elevated chloride level (125 mmol/L, normal 98-107) as well as an anion gap of 1. She denied any other co-ingestions, including other over the counter medications or alcohol, and was otherwise asymptomatic. She was given fluids and supportive care. Ultimately, a significantly elevated bromide level was noted on a send out lab. She was diagnosed with chronic bromide toxicity (bromism) from recurrent over the counter Robitussin HBr use, which was the source of her hyperchloremia and decreased anion gap., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The ongoing new coronavirus disease (COVID-19) pandemic, which arose at the end of 2019, poses a severe challenge to world public health systems. Frontline medical staffs bear a great burden to provide health care services. The Taiwan government has taken rapid and decisive actions to reduce the risk of community transmission and campus cluster infection. Nursing education includes both classroom teaching and clinical practicum components. In preparing for their practicum, students must learn not only fundamental nursing care knowledge but also basic knowledge on emerging infectious diseases. All schools nationwide have complied with the Ministry of Education order to postpone the opening of the fall semester in response to the rapid evolution of the COVID-19 pandemic. Campus epidemic prevention measures were implemented through student counseling networks, and flexible teaching strategies, including online teaching and distance teaching, were implemented to protect the learning rights of students. This paper explores the strategies implemented in response to emerging infectious diseases in nursing education based on the core values of professional nursing. Examining the precautions taken at campuses and teaching strategies adopted in response to the COVID 19 pandemic may provide valuable insights that may be applied to the future development of nursing education.

The piezoresistive effect has shown a remarkable potential for mechanical sensor applications and been sought for its excellent performance. A great attention was paid to the giant piezoresistive effect and sensitivity delivered by silicon-based nanostructures. However, low thermal stability and complicated fabrication process hinder their practical applications. To overcome these issues and enhance the functionalities, we envision the substantial piezopotential in a zinc oxide (ZnO)/muscovite (mica) heteroepitaxy system based on theoretical consideration and realize it in practice. High piezoresistive effect with giant change of resistivity (-80 to 240%) and large gauge factor (>1000) are demonstrated through mechanical bending. The detailed features of heteroepitaxy, electrical transport, and strain are probed to understand the mechanism of such a giant resistivity change. In addition, a bending model is established to reveal the distribution of strain. Finally, we demonstrate a flex sensor featuring high sensitivity, optical transparency, and two-segment sensing with a great potential toward practical applications. Such an oxide heteroepitaxy exhibits excellent piezoresistive properties and mechanical flexibility. In the near future, the importance of flex sensors will emerge because of the precise control in the automation industries, and our results lead to a new design in the field of flex sensors.

The objective of international nursing education in Taiwan is to prepare nursing elites to improve the quality of global healthcare. Nurses are on the frontlines in terms of helping the public through increasingly frequent climate-change disasters, helping care for the rising populations of older adults and patients with chronic diseases, and dealing with the emergence of new infectious diseases. Advancing the knowledge and capabilities of global nursing elites is imperative. The main purpose of nursing education is to educate future nursing leaders. This paper describes the internationalization of nursing education in the Department of Nursing at National Cheng Kung University as well as the process of establishing the Asia-Pacific Nursing Education Alliance to highlight the international characteristics of nursing education, the related global social influence, and the pursuit of sustainable development goals.

The employment of flexible muscovite substrates has given us the feasibility of applying strain to heterostructures dynamically by mechanical bending. In this study, this novel approach is utilized to investigate strain effects on the exchange coupling in ferromagnetic Co and anti-ferromagnetic CoO (Co/CoO) bilayers. Two different Co/CoO bilayer heterostructures were grown on muscovite substrates by oxide molecular beam epitaxy, with the CoO layer being purely (111)- and (100)-oriented. The strain-dependent exchange coupling effect can only be observed on Co/CoO(100)/mica but not on Co/CoO(111)/mica. The origin of this phenomenon is attributed to the anisotropic spin re-orientation induced by mechanical bending. The strain-dependent magnetic anisotropy of the bilayers determined by anisotropic magnetoresistance measurements confirms this conjecture. This study elucidates the fundamental understanding of how magnetic exchange coupling can be tuned by externally applied strain via mechanical bending and, hence, provides a novel approach for implementing flexible spintronic devices.

We study the effects of the size of older cohorts on labor force participation and wages of older workers in the United States. We use panel data on states, treating the age structure of the population as endogenous, owing to migration. When older cohorts (50-59 or 60-69) are large relative to a young cohort (aged 16-24), the evidence fits the relative supply hypothesis. However, when older cohorts are large relative to 25- to 49-year-olds, the evidence points to a relative demand shift. Thus, we need a more nuanced view than simply whether the older cohort is large relative to the population: the cohort that they are large relative to matters.

Purpose Recovery from aphasia is thought to depend on neural plasticity, that is, functional reorganization of surviving brain regions such that they take on new or expanded roles in language processing. To make progress in characterizing the nature of this process, we need feasible, reliable, and valid methods for identifying language regions of the brain in individuals with aphasia. This article reviews 3 recent studies from our lab in which we have developed and validated several novel functional magnetic resonance imaging paradigms for language mapping in aphasia. Method In the 1st study, we investigated the reliability and validity of 4 language mapping paradigms in neurologically normal older adults. In the 2nd study, we developed a novel adaptive semantic matching paradigm and assessed its feasibility, reliability, and validity in individuals with and without aphasia. In the 3rd study, we developed and evaluated 2 additional adaptive paradigms-rhyme judgment and syllable counting-for mapping phonological encoding regions. Results We found that the adaptive semantic matching paradigm could be performed by most individuals with aphasia and yielded reliable and valid maps of core perisylvian language regions in each individual participant. The psychometric properties of this paradigm were superior to those of other commonly used paradigms such as narrative comprehension and picture naming. The adaptive rhyme judgment paradigm was capable of identifying fronto-parietal phonological encoding regions in individual participants. Conclusion Adaptive language mapping paradigms offer a promising approach for future research on the neural basis of recovery from aphasia. Presentation Video https://doi.org/10.23641/asha.10257584.

Background and Objectives: Hearing loss (HL) is a public health problem affecting older adults. HL is not only a health condition but also a complex, dynamic phenomenon related to disability. Previous studies identified associations between HL and undesirable outcomes; however, their correlation remains inconclusive. Hearing loss can have profound impact on daily life in the elderly, and an understanding of how HL contributes to disability is needed. A systematic review was conducted to comprehensively examine current evidence and determine the association between HL and disability regarding impairment, activity and participation in older adults., Research Design and Methods: The Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines were applied in this systematic review. Quality assessment was conducted using the Newcastle-Ottawa Scale for longitudinal studies and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for cross-sectional studies., Results: In this systematic review of 20 studies, HL was associated with mobility limitation, activity limitation and participation restriction. The severity of HL was associated with impaired mobility and physical performance, but the association was only found in persons with severe/major HL. HL was also associated with activities of daily living (ADL) dependency, however these findings were mainly based on cross-sectional studies., Discussion and Implications: HL is related to disability by impairment, activity limitations or participation restrictions in older adults. Future studies should include participation restrictions as a mediation factor to better understand this association. Consistent and accurate hearing measurements and hearing loss criteria are also required to determine the impact of HL on disability., (Copyright © 2019. Published by Elsevier B.V.)

Materials with high spin-polarization play an important role in the development of spintronics. Co-based Heusler compounds are a promising candidate for practical applications because of their high Curie temperature and tunable half-metallicity. However, it is a challenge to integrate Heusler compounds into thin film heterostructures because of the lack of control on crystallinity and chemical disorder, critical factors of novel behaviors. Here, muscovite is introduced as a growth substrate to fabricate epitaxial Co 2 MnGa films with mechanical flexibility. The feature of heteroepitaxy is evidenced by the results of X-ray diffraction and transmission electron microscopy. Moreover, high chemical ordering with superior properties is delivered according to the observation of large Hall conductivity (680 Ω -1 cm -1 ) and highly saturated magnetic moment (∼3.93 μ B /f.u.), matching well with bulk crystals. Furthermore, the excellence of magnetic and electrical properties is retained under the various mechanical bending conditions. Such a result suggests that the development of Co 2 MnGa/muscovite heteroepitaxy provides not only a pathway to the thin film heterostructure based on high-quality Heusler compounds but also a new aspect of spintronic applications on flexible substrates.

Purpose : To determine the repeatability and reproducibility of anterior segment optical coherence tomography (AS-OCT) and Scheimpflug photography for several measurements of corneal scars, including scar size, scar depth, and corneal thickness. Methods : A series of patients treated for fungal keratitis at a tertiary eye care center in South India were recalled two years after successful treatment. Eyes with corneal scars had a slit lamp examination performed by two ophthalmologists masked to the other's examination. For AS-OCT and Scheimpflug photography, each eye had two scans taken by one technician and a third scan taken by a separate technician. Scar measurements were subsequently assessed from AS-OCT images by three graders masked to each other's results. Repeatability and reproducibility were assessed by calculating the intra-class correlation coefficient (ICC) from mixed effects linear regression models. Results : Fifty eyes had all measurements taken. The corneal scar size, measured as the geometric mean of the two longest perpendicular meridians, ranged from 0.8 to 5.4 (mean 2.8 mm, 95%CI 2.6 to 3.1). Scar size measurements taken by two separate individuals were most reproducible when the border of the scar was traced from the OCT (ICC 0.90, 95%CI 0.86 to 0.94), and least repeatable when assessed from slit lamp examination (ICC 0.80, 95%CI 0.70 to 0.90). Conclusions : AS-OCT and Scheimpflug imaging of corneal scars produced measurements with acceptable reproducibility that could be useful as cornea-specific outcomes for clinical trials.

Purpose: The purpose of this study was to understand the influence of demographic and psychological factors on self-management behaviors and interdialytic weight gain (IDWG) as a fluid adherence marker among patients undergoing hemodialysis in Indonesia., Design: A quantitative correlational study., Method: A convenience sample of 145 patients undergoing hemodialysis was recruited from the dialysis units in two hospitals in Jakarta from September to December 2015. Questionnaires were used to examine self-management behaviors, depression, anxiety, and stress. Data for IDWG were obtained by subtracting the individual's predialysis weight from his or her postdialysis weight from the previous session. Hierarchical multiple linear regression identified the predictors of IDWG., Results: Self-advocacy was ranked the least performed self-management behavior, while medication adherence was ranked the most likely to be performed. Among the subscales of the Self-Management Behavior Indices, positive correlations were found between the communication dimension with all psychological factors (depression, anxiety, and stress), while self-advocacy had positive correlation with anxiety. Subjects gained a mean of 4.5% of their postdialysis weight, with over 50% exceeding the recommended 4% IDWG. Overall, 53.6% of the IDWG was explained by the weekly duration of hemodialysis, level of depression, communication, partnership in care, and self-advocacy., Conclusions: Self-management behaviors are potential predictors that can be modified by nephrology nurses in order to enhance clinical outcomes, with the specific outcome being IDWG. Self-management behaviors contribute to the promotion of appropriate IDWG. Depressed patients are less likely to adhere to weight gain restrictions., Clinical Relevance: Education combined with training in self-management behaviors-particularly communication, becoming a partner in care, and advocating for care-may improve adherence to IDWG guidelines among Indonesian hemodialysis patients. Interventions targeting depressed patients are needed., (© 2019 Sigma Theta Tau International.)

Objective: To determine whether there is a "dose-dependent" relationship between coronary atherosclerosis and the burden of exercise., Background: Recent data have suggested there may be negative consequences related to strenuous exercise. Previous studies evaluating the presence of coronary atherosclerosis as assessed by coronary calcium scores have been confounded by the presence of other cardiovascular risk factors. We aimed to assess whether there was a relationship between the burden of coronary calcium and the amount of running in a local cohort., Patients and Methods: Eighty-five runners were screened on the basis of an exercise questionnaire that was later used to determine the experimental groups from January 2016 through October 2016. Twenty-nine individuals were excluded from the study because of the presence of preexisting cardiovascular risk factors. Runners were divided into 3 categories: Group A comprised runners who had competed in at least 10 ultramarathons and/or Ironman competitions in 10 years. Group B included runners who had participated in more than 9 marathons over 10 years. Group C comprised runners who had competed in more than 9 shorter races over 10 years. Coronary artery calcium (CAC) scores were assessed by computed tomography. Statistical analysis was performed using chi-square analyses. Logistic regression models were used to assess the relationship between runner groups and calcium score greater than 100, calcium score percentile, and calcium score greater than 0., Results: There were no differences between groups A and B for CAC scores greater than 0 or greater than 100, and a similar percentage of group A and B athletes had scores greater than the 50th percentile. Groups A and B were combined for further analysis. Among those runners participating in extreme distance running (groups A and B), 73% of runners had CAC scores greater than 0 whereas only 21% of group C runners had CAC scores greater than 0 ( P =.0002). Moreover, 70% of group A + B athletes ranked above the 50th percentile of their age and sex as assessed by a national database (Hoff JA, Chomka EV, Krainik AJ, Daviglus M, Rich S, Kondos GT. Age and gender distributions of coronary artery calcium detected by electron beam tomography in 35,246 adults. Am J Cardiol . 2001;87(12):1335-1339), whereas only 19% of group C runners were ranked above the 50th percentile ( P =.0001). One-third of runners in group A + B had CAC scores greater than 100 as compared with only 12% of runners in group C ( P =.05). When controlling for age, sex, and number of years running, the study group was not a significant predictor of CAC greater than 100 ( P =.12). In contrast, group A + B was 10 times more likely than group C to have CAC scores in the 50th percentile or greater ( P =.02) and 8.8 times more likely to have a abnormal calcium score when controlling for covariates ( P =.03)., Conclusion: A significantly higher rate of coronary artery calcification existed in long-term marathon, ultramarathon, and extreme runners than in submarathon runners. Marathoners and ultramarathoners also had a higher incidence of calcification, as well as higher average plaque burden, as compared to a standard database. Marathoners and ultramarathoners also had above-average coronary calcium scores as compared to a national database.