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Purpose: In rural America, the road to obtaining a liver transplant (LTX) often starts at the primary care provider's (PCP's) office. Patients with end-stage liver disease (ESLD) in rural communities experience lower rates of wait-listing and higher mortality. This study identifies issues related to the knowledge and perceptions of ESLD and LTX referral among PCPs in rural Kentucky (KY)., Methods: The study protocol involved relying upon a semistructured outline to explore the knowledge, attitude, and perceptions of PCPs toward ESLD and LTX referral among PCPs in rural KY. Inductive thematic analysis was utilized to identify, analyze, and report themes., Findings: From the focus group interviews, three themes were identified: medical culture, gaps in knowledge, and bias against those with self-induced causes of ESLD. Each theme illuminated barriers to referral for transplant evaluation., Conclusions: Knowledge gaps, attitudes in medical culture, and biases surrounding ESLD and LTX referral exist in community medicine practice. This highlights the importance of education, resources, and facilitation of LTX referral processes for PCPs., (© 2024 National Rural Health Association.)

Older adults' engagement in age-friendly community (AFC) initiatives is considered an essential element of community transformation. However, research on older adults' experiences of engaging in AFC initiatives remains nascent. Based on qualitative interviews with 23 older adult participants from 15 AFC initiatives across four states in the United States (U.S.), our reflexive thematic analysisidentified three themes regarding what participants value from their engagement: (a) social contribution; (b) social connectedness and integration; and (c) staying active and personal growth. Exploring older adults' interest in contributing to, connecting with, and growing in their community can inform recruitment and retention in AFC initiatives.

Purpose: To assess pharmacists' mental well-being, perceptions of safety, and willingness to administer vaccines before and during the COVID-19 pandemic. Methods: An electronic survey was administered to a convenient sample of practicing pharmacists working in Alabama, Tennessee and Texas. The 33-item survey examined pharmacists' beliefs about the pandemic's impact on their mental well-being, their perceptions of safety in vaccine administration, and their willingness to vaccinate. Responses were assessed on a 5-point Likert scale, ranging from strongly disagree (1) to strongly agree (5). A recruitment email with the survey link was sent to pharmacists, with periodic reminders over a 4-week period. Descriptive statistics and bivariate analyses were utilized to evaluate survey responses. Results: A total of 387 responses were analyzed, with an estimated response rate of 3.93%. Most respondents were women (65%) and had at least 6 to 10 years of practice experience (28%). Overall, participants felt that the pandemic worsened their mental well-being, with women reporting a more negative mental well-being compared with men ( P < .001). They reported having less time during workflow to apply personal protective equipment (PPE) ( P = .0074) compared to before the pandemic. They also reported a decrease in willingness to vaccinate adult patients during the pandemic ( P < .0001), and that concern about contracting COVID-19 prevented them from giving vaccinations ( P < .0001). Conclusions: Pharmacists felt their mental well-being and willingness to vaccinate patients suffered as a result of the COVID-19 pandemic. Future research and initiatives that focus on improving vaccination rates should also consider pharmacists' concerns and well-being., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Pain in hospitalised children is common, yet inadequately treated. Electronic medical records (EMRs) can improve care quality and outcomes during hospitalisation. Little is known about how clinicians use EMRs in caring for children with pain. This national cross-sectional survey examined the perceptions of clinician-EMR users about current and potential use of EMRs in children's pain care. One hundred and ninety-four clinicians responded ( n = 81, 74% nurses; n = 21, 19% doctors; n = 7, 6% other); most used Epic ( n = 53/109, 49%) or Cerner ( n = 42/109, 38%). Most ( n = 84/113, 74%) agreed EMRs supported their initiation of pharmacological pain interventions. Fewer agreed EMRs supported initiation of physical ( n = 49/113, 43%) or psychological interventions ( n = 41/111, 37%). Forty-four percent reported their EMR had prompt reminders for pain care. Prompts were perceived as useful ( n = 40/51, 78%). Most agreed EMRs supported pain care provision ( n = 94/110, 85%) and documentation ( n = 99/111, 89%). Only 39% ( n = 40/102) agreed EMRs improved pain treatment, and 31% ( n = 32/103) agreed EMRs improved how they involve children and families in pain care. Findings provide recommendations for EMR designs that support clinicians' understanding of the multidimensionality of children's pain and drive comprehensive assessments and treatments. This contribution will inform future translational research on harnessing technology to support child and family partnerships in care., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Diabetic bladder dysfunction (DBD) is driven in part by inflammation which dysregulates prostaglandin release in the bladder. Precise inflammatory mechanisms responsible for such dysregulation have been elusive. Since prostaglandins impact bladder contractility, elucidating these mechanisms may yield potential therapeutic targets for DBD. In female Type 1 diabetic Akita mice, inflammation mediated by the nucleotide-binding domain, leucine-rich-containing family, pyrin domain-containing-3 (NLRP3) inflammasome is responsible for DBD. Here, we utilized female Akita mice crossbred with NLRP3 knock-out mice to determine how NLRP3-driven inflammation impacts prostaglandin release within the bladder and prostaglandin-mediated bladder contractions., Methods: Akita mice were crossbred with NLRP3-⁣/- mice to yield four groups of non-diabetics and diabetics with and without the NLRP3 gene. Females were aged to 30 weeks when Akitas typically exhibit DBD. Urothelia and detrusors were stretched ex vivo to release prostaglandins. Prostaglandin E2 (PGE2) and prostaglandin F2α (PGF2α) were quantified using enzyme linked immunosorbent assays (ELISA). In separate samples, ex vivo contractile force to PGE2 and PGF2α +/- the prostaglandin F (FP) receptor antagonist, AL8810, was measured. FP receptor protein expression was determined via western blotting., Results: Stretch-induced PGE2 release increases in urothelia but decreases in detrusors of diabetics. However, PGE2-mediated bladder contractions are not impacted. Conversely, diabetics show no changes in PGF2α release, but PGF2α-mediated contractions increase significantly. This is likely due to signaling through the FP receptors as FP receptor antagonism prevents this increase and diabetics demonstrate a four-fold increase in FP receptor proteins. Without NLRP3-mediated inflammation, changes in prostaglandin release, contractility, and receptor expression do not occur., Conclusion: NLRP3-dependent inflammation dysregulates prostaglandin release and prostaglandin-mediated bladder contractions in diabetic female Akita mice via FP receptor upregulation., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s). Published by IMR Press.)

Objective: Studies demonstrate that heart transplantation can be performed safely in septuagenarians. We evaluate the outcomes of septuagenarians undergoing heart transplantation after the US heart allocation change in 2018., Methods: The United Network for Organ Sharing registry was used to identify heart transplant recipients aged 70 years or more between 2010 and 2021. Primary outcomes were 90-day and 1-year mortality. Kaplan-Meier, multivariable Cox proportional hazards, and accelerated failure time models were used for unadjusted and risk-adjusted analyses., Results: A total of 27,403 patients underwent heart transplantation, with 1059 (3.9%) aged 70 years or more. Patients aged 70 years or more increased from 3.7% before 2018 to 4.5% after 2018 (P = .003). Patients aged 70 years or more before 2018 had comparable 90-day and 1-year survivals relative to patients aged less than 70 years (90 days: 93.8% vs 94.2%, log-rank P = .650; 1 year: 89.4% vs 91.1%, log-rank P = .130). After 2018, septuagenarians had lower 90-day and 1-year survivals (90 days: 91.4% vs 95.0%, log-rank P = .021; 1 year: 86.5% vs 90.9%, log-rank P = .018). Risk-adjusted analysis showed comparable 90-day mortality (hazard ratio, 1.29; 0.94-1.76, P = .110) but worse 1-year mortality (hazard ratio, 1.32; 1.03-1.68, P = .028) before policy change. After policy change, both 90-day and 1-year mortalities were higher (90 days: HR, 1.99; 1.23-3.22, P = .005; 1 year: hazard ratio, 1.71; 1.14-2.56, P = .010). An accelerated failure time model showed comparable 90-day (0.42; 0.16-1.44; P = .088) and 1-year (0.48; 0.18-1.26; P = .133) survival postallocation change., Conclusions: Septuagenarians comprise a greater proportion of heart transplant recipients after the allocation change, and their post-transplant outcomes relative to younger recipients have worsened., Competing Interests: Conflict of Interest Statement Dr Tedford reports no direct conflicts of interest related to this article, but reports general disclosures to include consulting relationships with Medtronic, Abbott, Acorai, Aria CV Inc, Acceleron/Merck, Alleviant, CareDx, Cytokinetics, Itamar, Edwards LifeSciences, Eidos Therapeutics, Lexicon Pharmaceuticals, and Gradient. Dr Tedford is the national Principal Investigator for the RIGHT-FLOW clinical trial (Edwards), serves on the steering committee for Merck, Edwards, and Abbott, and a research advisory board for Abiomed, and performs hemodynamic core laboratory work for Merck. Dr Kilic reports consulting and speaking relationships with Abbott, Abiomed, LivaNova, and 3ive. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Micro-credentials (MCs) and digital badges (DBs) have gained popularity in recent years as a means to supplement traditional degrees and certifications. MCs and DBs can play a significant role in supporting student-centered learning by offering personalized and flexible learning pathways, emphasizing real-world relevance and practical skills, and fostering a culture of continuous learning and growth. However, barriers currently exist within health professions education, including pharmacy education, that could limit the full adoption and implementation of MCs and DBs. Research on the use of MCs and DBs in Doctor of Pharmacy degree programs is sparse. In this integrative review, literature on the use of MCs and DBs in health professions education is reviewed, and perspectives on the benefits, issues, and potential future uses within Doctor of Pharmacy degree programs are presented., 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 American Association of Colleges of Pharmacy. Published by Elsevier Inc. All rights reserved.)

Abstract: Studies from multiple countries report that most hospitalized children, especially the youngest and sickest, experience pain that is often severe yet inadequately treated. Evidence suggests this can lead to immediate and lifelong consequences affecting children, families, and communities. Partnership and shared decision-making by children, families, and clinicians is the ideal pediatric healthcare model and can improve care quality and safety, including pain care. A growing evidence base demonstrates that inpatient portals (electronic personal health record applications linked to hospital electronic medical or health records) can improve child and family engagement, outcomes, and satisfaction during hospitalization. This study examined the perspectives of caregivers of hospitalized children and of hospitalized youth about using an inpatient portal to support their engagement in pain care while in hospital. A qualitative descriptive study design was used and 20 participants (15 caregivers and 5 youth) with various painful conditions in one pediatric hospital participated in semistructured interviews. The authors applied a reflexive content analysis to the data and developed 3 broad categories: (1) connecting and sharing knowledge about pain, (2) user-centred designs, and (3) preserving roles. These findings outlined caregiver and youth recommendations for portal configurations that deeply engage and empower children and families in pain care through multidirectional knowledge sharing, supporting caregiver and clinicians' roles without burdening, or replacing human interaction implicit in family-centered pain care. Further research should measure the impact of portals on pain-related outcomes and explore the perspectives of clinicians., (Copyright © 2023 International Association for the Study of Pain.)

The development of new therapies against SARS-CoV-2 is required to extend the toolkit of intervention strategies to combat the global pandemic. In this study, hyperimmune plasma from sheep immunised with whole spike SARS-CoV-2 recombinant protein has been used to generate candidate products. In addition to purified IgG, we have refined candidate therapies by removing non-specific IgG via affinity binding along with fragmentation to eliminate the Fc region to create F(ab') 2 fragments. These preparations were evaluated for in vitro activity and demonstrated to be strongly neutralising against a range of SARS-CoV-2 strains, including Omicron B2.2. In addition, their protection against disease manifestations and viral loads were assessed using a hamster SARS-CoV-2 infection model. Results demonstrated protective effects of both IgG and F(ab') 2 , with the latter requiring sequential dosing to maintain in vivo activity due to rapid clearance from the circulation., (© 2023. Springer Nature Limited.)

Abstract: Most hospitalized children experience pain that is often inadequately assessed and undertreated. Exposure to undertreated childhood pain is associated with negative short-term and long-term outcomes and can detrimentally affect families, health services, and communities. Adopting electronic medical records (EMRs) in pediatric hospitals is a promising mechanism to transform care. As part of a larger program of research, this study examined the perspectives of pediatric clinical pain experts about how to capitalize on EMR designs to drive optimal family-centered pain care. A qualitative descriptive study design was used and 14 nursing and medical experts from 5 countries (United States, Canada, United Kingdom, Australia, and Qatar) were interviewed online using Zoom for Healthcare. We applied a reflexive content analysis to the data and constructed 4 broad categories: "capturing the pain story," "working with user-friendly systems," "patient and family engagement and shared decision making," and "augmenting pain knowledge and awareness." These findings outline expert recommendations for EMR designs that facilitate broad biopsychosocial pain assessments and multimodal treatments, and customized functionality that safeguards high-risk practices without overwhelming clinicians. Future research should study the use of patient-controlled and family-controlled interactive bedside technology to and their potential to promote shared decision making and optimize pain care outcomes., (Copyright © 2023 International Association for the Study of Pain.)

Although the significance of a positive social classroom climate in face-to-face learning has been established, its role within online and technology-enhanced learning environments is unclear. The central aim of this systematic review was to synthesize the findings of empirical studies which have examined any aspect of the social classroom climate in online and technology-enhanced learning environments in primary and secondary schools. Appropriate search terms were entered into ACM Digital Library, Web of Science, Scopus, and ERIC in November 2021. Articles were included if they were relevant for the aim, reported primary data, sampled primary/secondary school students and/or teachers, and were published in journals, conference proceedings, or book chapters in English. Furthermore, articles were excluded if they focused on the development/testing of measurement tools. The thematic narrative synthesis includes 29 articles, comprising of qualitative, quantitative, and mixed-method studies. A quality assessment checklist was completed for all. The findings encompass examinations of the social classroom climate in online learning before and during the Covid-19 pandemic, in blended learning environments and a comparison between them. Furthermore, associations between the online social classroom climate and academic variables is explored, as is the fostering thereof through synchronous/asynchronous discussion groups and social media. We discuss the theoretical framing of the studies, the impact of a positive classroom climate in online and technology-enhanced learning environments on students, as well as practical approaches and new opportunities in leveraging technologies. Based on the findings and the studies' limitations we outline implications and future research, such as the need to consider students' voices and diversity, technology perspectives, a transdiciplinary approach and the reconceptualization of boundaries., Competing Interests: Conflicts of InterestNone., (© The Author(s) 2023.)

Aim: To systematically identify, explore and synthesise qualitative data related to mental health consumer and health professional experiences of diagnostic overshadowing., Background: Mental health consumers experience significantly high rates of physical illness, poorer health outcomes and are more likely to die prematurely of physical illnesses than the general population. Diagnostic overshadowing is a complex and life-threatening phenomenon that occurs when physical symptoms reported by mental health consumers are misattributed to mental disorders by health professionals. This typically occurs in general healthcare settings., Methods: Drawing on JBI methodology for systematic reviews, four scholarly databases and grey literature was searched, followed by eligibility screening and quality assessment using JBI QARI frameworks, resulting in six studies for inclusion. Findings were synthesised using meta-aggregation. The PRISMA checklist was adhered to throughout this process., Findings: Five synthesised findings emerged. Three from the health professional experience: working in ill-suited healthcare systems, missing the complete diagnostic picture, and misunderstanding the lived experience of mental illness. Two from the mental health consumer experience: not knowing if the cause is physical or mental, and surviving and ill-suited health care system., Conclusions: Diagnostic overshadowing is a multidimensional experience of interconnecting factors including systematic healthcare system issues, health professionals limited mental health knowledge and skills, stigmatic attitudes and mental health consumers miscommunicating their physical healthcare needs. Further research is needed to make diagnostic overshadowing visible and mitigate against this phenomenon that deprives mental health consumers of equitable access to quality healthcare., Relevance to Clinical Practice: Those who govern healthcare systems have an obligation to recognise and address the unique needs of mental health consumers who seek help for physical illnesses to ensure they receive quality and safe care. Forming collaborative partnerships with mental health consumers in the development of knowledge translation initiatives targeting healthcare policy, practice and education are urgently required., (© 2021 John Wiley & Sons Ltd.)

Community planning around housing needs of older adults is, at present, very understudied. This study stemmed from a practical need to determine the housing preferences of residents as part of an Age Friendly Community initiative. Data presented in this paper focus on the quantitative component of a sequential mixed methods study examining attitudes and preferences about housing. This first phase of this project involved data collected from 1,514 residents aged 30+ using a researcher-devised survey of 43 items. There was little difference in housing preferences between older and younger respondents or among those with varying financial means. Analysis revealed the most important housing considerations were safety in home, affordability, privacy, proximity to services frequently used, and accessibility. An unexpected finding was that almost half of older respondents expressed a willingness to share a home with a roommate. There were also differences in preferences on home environment based on current marital status. Data suggests that city planners and property developers should prioritize these preferences when planning for the housing-related needs of older residents. Future research should examine the interpretation of housing preferences, such as qualitative exploration of what it means for housing to be "safe" or 'affordable.'

Purpose: Recent changes in the market for left ventricular assist devices have resulted in the HeartMate 3 (HM3) being the only commercially-available device. This study evaluates the outcomes of patients with a HM3 waitlisted for and undergoing orthotopic heart transplantation (OHT)., Methods: Patients waitlisted for isolated OHT with a HM3 or undergoing OHT after bridge-to-transplant (BTT) with a HM3 between 2015 and 2021 were identified from the UNOS registry and included in this study. Propensity matching was used to compare outcomes of BTT-HM3 versus primary OHT., Results: A total of 1321 patients supported with a HM3 underwent OHT during our study period. Unadjusted 30-day, 90-day, and 1-year survival following OHT in the BTT-HM3 cohort was 96.5%, 94.4%, and 90.7%, respectively. In propensity-matched analysis, 1103 BTT-HM3 patients were compared with 1103 primary OHT patients. Rates of post-OHT stroke were higher in the BTT-HM3 group (4.4% vs. 2.0%, p = .001). The BTT-HM3 group had lower 30-day survival (96.2% vs. 97.4%, p = .033) although 90-day (94.2% vs. 95.3%, p = .103) and 1-year survival (90.4% vs. 91.7%, p = .216) were comparable. A total of 1251 patients were supported with a HM3 at the time of OHT listing during the study period. At the time of this analysis, 60 (4.5%) remained on the waitlist, 991 (75.0%) underwent OHT, and 119 (9.0%) died or clinically deteriorated with waitlist removal., Conclusions: The HM3 is a viable method for BTT with acceptable waitlist outcomes. Although 1-year survival is comparable to primary OHT, early outcomes are worse, suggesting that refinement of patient selection and perioperative management is prudent to optimizing outcomes., (© 2022 Wiley Periodicals LLC.)

Background: Early right heart failure (RHF) remains a major source of morbidity and mortality after left ventricular assist device (LVAD) implantation, yet efforts to predict early RHF have proven only modestly successful. Pharmacologic unloading of the left ventricle may be a risk stratification approach allowing for assessment of right ventricular and hemodynamic reserve., Methods: We performed a multicenter, retrospective analysis of patients who had undergone continuous-flow LVAD implantation from October 2011 to April 2020. Only those who underwent vasodilator testing with nitroprusside during their preimplant right heart catheterization were included (n = 70). Multivariable logistic regression was used to determine independent predictors of early RHF as defined by Mechanical Circulatory Support-Academic Research Consortium., Results: Twenty-seven patients experienced post-LVAD early RHF (39%). Baseline clinical characteristics were similar between patients with and without RHF. Patients without RHF, however, achieved higher peak stroke volume index (SVI) (30.1 ± 8.8 vs 21.7 ± 7.4 mL/m 2 ; p < 0.001; AUC: 0.78; optimal cut-point: 22.1 mL/m 2 ) during nitroprusside administration. Multivariable analysis revealed that peak SVI was significantly associated with early RHF, demonstrating a 16% increase in risk of early RHF per 1 ml/m 2 decrease in SVI. A follow up cohort of 10 consecutive patients from July 2020 to October 2021 resulted in all patients being categorized appropriately in regards to early RHF versus no RHF according to peak SVI., Conclusion: Peak SVI with nitroprusside administration was independently associated with post-LVAD early RHF while resting hemodynamics were not. Vasodilator testing may prove to be a strong risk stratification tool when assessing LVAD candidacy though additional prospective validation is needed., Competing Interests: Financial disclosures No grants, contracts, or other financial support was received for this manuscript., (Copyright © 2022 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective: This review will evaluate the experiences of health care professionals in the intensive care unit when families participate in clinician handovers., Introduction: Families of patients admitted to the intensive care unit report stress and anxiety. Family participation in multidisciplinary rounds in the intensive care unit may improve patient and family outcomes. However, health care professionals have different attitudes toward family participation. Furthermore, there is limited understanding of the barriers, facilitators, and other outcomes of family participation in clinician handovers for the patient, family, and health care professionals., Inclusion Criteria: The review will consider studies involving health care professionals (eg, nurses, physicians, allied health professionals) and any type of family participation, from bedside presence to participation in decision-making. Clinician handovers may be multidisciplinary ward rounds or nursing handovers. Settings may be the adult, pediatric, or neonatal intensive care unit in rural or metropolitan regions in any country. Studies in other clinical contexts will be excluded., Methods: Databases to be searched include CINAHL, MEDLINE, Scopus, PsycINFO, Embase, Emcare, Web of Science, and ProQuest Central. The search will be limited to articles written in English from 2000 to the present. Two independent reviewers will screen titles and abstracts, assess the full text of selected citations for inclusion, and assess methodological quality. A data extraction tool will be used, and findings will be assigned a level of credibility. Meta-aggregation will be used to synthesize findings. Disagreements between reviewers will be discussed to reach consensus; a third reviewer will be consulted if necessary., Systematic Review Registration Number: PROSPERO CRD42020223011., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 JBI.)

Antibodies against SARS-CoV-2 are important to generate protective immunity, with convalescent plasma one of the first therapies approved. An alternative source of polyclonal antibodies suitable for upscaling would be more amendable to regulatory approval and widespread use. In this study, sheep were immunised with SARS-CoV-2 whole spike protein or one of the subunit proteins: S1 and S2. Once substantial antibody titres were generated, plasma was collected and samples pooled for each antigen. Non-specific antibodies were removed via affinity-purification to yield candidate products for testing in a hamster model of SARS-CoV-2 infection. Affinity-purified polyclonal antibodies to whole spike, S1 and S2 proteins were evaluated for in vitro for neutralising activity against SARS-CoV-2 Wuhan-like virus (Australia/VIC01/2020) and a recent variant of concern, B.1.1.529 BA.1 (Omicron), antibody-binding, complement fixation and phagocytosis assays were also performed. All antibody preparations demonstrated an effect against SARS-CoV-2 disease in the hamster model of challenge, with those raised against the S2 subunit providing the most promise. A rapid, cost-effective therapy for COVID-19 was developed which provides a source of highly active immunoglobulin specific to SARS-CoV-2 with multi-functional activity., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Coronary artery pseudoaneurysms are extremely rare and most often occur after trauma or endovascular procedures [Aoki 2008; Kar 2017]. Delay in diagnosis or treatment may lead to coronary thrombosis with resultant ischemia or hemorrhage subsequent tamponade. Here, we present the case of a 66-year-old female who developed a coronary artery pseudoaneurysm of a non-grafted vessel three weeks after coronary artery bypass grafting. To avoid re-sternotomy, the pseudoaneurysm was successfully managed with a covered coronary stent and mini-left anterior thoracotomy to evacuate the hemopericardium and relieve tamponade.

Objective: The objective of this review is to identify, appraise, and synthesize available qualitative evidence related to diagnostic overshadowing in mental health consumers who present with clinical manifestations of physical illness., Introduction: A lived experience of mental illness is associated with compromised physical health and decreased life expectancy. Mental health consumers face greater barriers to accessing treatment for physical illnesses and are less likely to receive appropriate physical care than those without mental illness. Physical illnesses may go underdiagnosed and undertreated in mental health consumers because clinicians tend to focus on the mental illness to the exclusion of other health problems, a phenomenon called diagnostic overshadowing. This systematic review will combine the experiences of mental health consumers and health care professionals to gain deeper understanding of diagnostic overshadowing., Inclusion Criteria: This review will consider qualitative studies that include the experiences of diagnostic overshadowing in mental health consumers and/or the health care professionals who treat them. Studies conducted in any health care facility or service offering care for physical illnesses will be considered., Methods: MEDLINE, CINAHL, PsycINFO, and Scopus will be searched along with sources of gray literature. Studies in English published from 2004 onward will be considered. Retrieval of full-text studies, assessment of methodological quality, and data extraction will be performed independently by two reviewers. Findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach. A ConQual Summary of Findings will be presented., Systematic Review Registration Number: PROSPERO CRD42020186418., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 JBI.)

Background: Digital capability, that is the ability to live, work, participate and thrive in a digital world, is imperative for nurses because increasingly nurses' work and patient outcomes are influenced by technology., Aim: To evaluate and synthesise the evidence regarding the development of digital capability in nurses and the strategies that support effective integration of digital skills into the workplace., Design: Whittemore and Knafl's methodology, following the preferred reporting items for systematic reviews (PRISMA) guidelines., Data Sources: CINAHL, Embase, PsychINFO, Medline (Ovid) and PubMed databases were searched for articles published in English from 2008-2019. Search terms included; digital capabil*, digital literacy, informatics, nursing informatics, health informatics, nurs*, knowledge, knowledge integration, competency, continuing education, nursing skills, workplace and work environment., Review Methods: A total of 35 studies were retrieved for quality assessment by two reviewers using standardised critical appraisal instruments from the Joanna Briggs Institute (JBI-MAStARI and JBI-QARI). Minimum essential criteria and scores were agreed prior to appraisal., Results: The 17 studies included comprised quantitative (n = 7), qualitative (n = 8) and mixed methods (n = 2). Integration of digital capability in nurses' workplaces is dependent on user proficiency and competence (theme 1). Nurses use technology to access data at the point of care, specifically accessing evidence to guide care (theme 2a) as well as accessing the medical records (theme 2b). Nurses have several concerns related to the use of technology at point of care (theme 3), some of which can be resolved through investment for implementation (theme 4)., Conclusions: There are key attributes of digitally proficient nurses. Nurses with these attributes are more inclined to use digital technology in their work. Involvement of the nurses as end users in the development of digital systems to ensure they are fit for purpose, alongside investment in professional development opportunities for nurses to develop digital capability, should be prioritised., (© 2020 John Wiley & Sons Ltd.)

Background: Breast reconstruction in patients with a high body mass index (BMI) (≥30 kg/m) is technically challenging and is associated with increased postoperative complications. The optimal reconstructive approach for these patients remains to be determined. This study compared outcomes of prepectoral and dual-plane reconstruction in high-BMI patients to determine whether there was an association between postoperative complications and the plane of reconstruction., Methods: High-BMI patients who underwent immediate dual-plane or prepectoral expander/implant reconstruction were included in this retrospective study. Patients were stratified by reconstructive approach (dual-plane or prepectoral), and postoperative complications were compared between the groups. Multivariate logistic regression analysis was performed to determine whether the plane of reconstruction was an independent predictor of any complication after adjusting for potential confounding differences in patient variables between the groups., Results: Of 133 patients, 65 (128 breasts) underwent dual-plane and 68 (129 breasts) underwent prepectoral reconstruction. Rates of seroma (13.3 percent versus 3.1 percent), surgical-site infection (9.4 percent versus 2.3 percent), capsular contracture (7.0 percent versus 0.8 percent), and any complication (25.8 percent versus 14.7 percent) were significantly higher in patients who had dual-plane versus prepectoral reconstruction (p < 0.05). Multivariate logistic regression identified dual-plane, diabetes, neoadjuvant radiotherapy, and adjuvant chemotherapy as significant, independent predictors of any complication (p < 0.05). Dual-plane reconstruction increased the odds of any complication by 3-fold compared with the prepectoral plane., Conclusion: Compared with the dual-plane approach, the prepectoral approach appears to be associated with a lower risk of postoperative complications following immediate expander/implant breast reconstruction and may be a better reconstructive option in high-BMI patients., Clinical Question/level of Evidence: Therapeutic, III.

The rapid uptake of technology is changing the way health professionals provide care to patients and communities. While this presents opportunities to improve, enhance, and positively transform care and treatment, graduates must have the requisite knowledge, skills, and attitudes to make effective use of the technology and data available to them. This research explored nursing students' self-reported digital literacy levels. We undertook a student survey at one university in Australia, utilizing the validated Self-Assessment Nursing Informatics Competencies Scale-SF30 instrument. Overall, 90% of students rated their basic computer knowledge and skills as at least "competent" including performing basic troubleshooting, using the Internet, and conducting online literature searches. However, only 55% of students considered their overall applied computer skills as at least "competent," which included using applications for diagnostic coding and to extract data from clinical data sets. Students have digital literacy in everyday settings; however, their ability to translate this into practice is limited, restricting their access to and use of digital tools in the workplace. Our findings provide the opportunity to address practice issues related to digital literacy and to embed appropriate content in curricula to enable the delivery of improved patient care and the appropriate use of data in various settings., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

This essay examines the reception of Kodachrome sheet film, a color transparency material intended for professional use, in American commercial photography. This film was a large-format version of the original Kodachrome, which was first introduced in 1935 as a 16 mm color movie film for amateur use. Kodachrome was the first fully successful single-base, continuous-tone, full-color film invented and manufactured in America, a major technological advance in color reproduction. The sheet version of Kodachrome, known as Kodachrome Professional, was released in late 1938, then taken off the market in favor of Ektachrome in June 1951. Though not as steeped in popular acclaim or nostalgia as 35 mm Kodachrome slide film-which was available from 1936 until 2009-Kodachrome sheet film played a central role in facilitating and encouraging the use of color photographs in print media and in consumer advertising, helping to pave the way for the ubiquity of color photographs in today's world.

Background: Oxygen-evolving photoautotrophic organisms, like cyanobacteria, protect their photosynthetic machinery by a number of regulatory mechanisms, including alternative electron transfer pathways. Despite the importance in modulating the electron flux distribution between the photosystems, alternative electron transfer routes may compete with the solar-driven production of CO 2 -derived target chemicals in biotechnological systems under development. This work focused on engineered cyanobacterial Synechocystis sp. PCC 6803 strains, to explore possibilities to rescue excited electrons that would normally be lost to molecular oxygen by an alternative acceptor flavodiiron protein Flv1/3-an enzyme that is natively associated with transfer of electrons from PSI to O 2 , as part of an acclimation strategy towards varying environmental conditions., Results: The effects of Flv1/3 inactivation by flv3 deletion were studied in respect to three alternative end-products, sucrose, polyhydroxybutyrate and glycogen, while the photosynthetic gas fluxes were monitored by Membrane Inlet Mass Spectrometry (MIMS) to acquire information on cellular carbon uptake, and the production and consumption of O 2 . The results demonstrated that a significant proportion of the excited electrons derived from photosynthetic water cleavage was lost to molecular oxygen via Flv1/3 in cells grown under high CO 2 , especially under high light intensities. In flv3 deletion strains these electrons could be re-routed to increase the relative metabolic flux towards the monitored target products, but the carbon distribution and the overall efficiency were determined by the light conditions and the genetic composition of the respective pathways. At the same time, the total photosynthetic capacity of the Δflv3 strains was systematically reduced, and accompanied by upregulation of oxidative glycolytic metabolism in respect to controls with the native Flv1/3 background., Conclusions: The observed metabolic changes and respective production profiles were proposedly linked with the lack of Flv1/3-mediated electron transfer, and the associated decrease in the intracellular ATP/NADPH ratio, which is bound to affect the metabolic carbon partitioning in the flv3-deficient cells. While the deletion of flv3 could offer a strategy for enhancing the photosynthetic production of desired chemicals in cyanobacteria under specified conditions, the engineered target pathways have to be carefully selected to align with the intracellular redox balance of the cells.

Background: In recognising the capability and rights of children to express their experiences, 'draw, write and tell' (DWT) has emerged as a participatory qualitative research method. DWT enables children to communicate their experiences by drawing, writing words and telling the story of their pictures in response to interview questions., Aim: To discuss the challenges and benefits of using DWT to explore children's experiences of pain., Discussion: Aspects that affect the quality of data in DWT include the materials used and the influences of the primary caregiver. Experience suggests that if trust between the child and researcher has been established, the duration of the interview is unimportant., Conclusion: While many methods of analysis can be used with data gathered using DWT, it is important to ensure children's perspectives are represented accurately. Furthermore, children's capacity as active participants in research should be reflected., Implications for Practice: Future studies could examine the potential of using drawings to share information in adult and paediatric clinical settings., Competing Interests: None declared, (©2018 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Background: Body mass index has been shown to be a predictor of outcomes after subpectoral expander/implant reconstruction, with every unit increase in body mass index increasing the risk of complications by approximately 6 percent. The effect of body mass index on complications after prepectoral reconstruction has not yet been evaluated and is the purpose of this study., Methods: A total of 366 reconstructed breasts from 197 patients were stratified into five body mass index groups (normal; overweight; and class I, class II, and class III, obese) and postoperative complications were compared across the groups. Additional analyses were performed using broad classifications of body mass index into nonobese and obese in addition to normal, overweight, and obese. Body mass index as an independent predictor of complications was assessed using multivariate logistic regression analysis., Results: Complication rates did not differ significantly across body mass index groups when using the broad classifications. With five-group stratification, significantly higher rates of return to operating room, expander/implant loss, skin necrosis, wound dehiscence, and overall complications were seen in class II and/or class III obese versus overweight patients. However, on multivariate logistic regression analyses, body mass index, as a continuous variable, did not independently predict any complication. Diabetes and smoking emerged as significant predictors of any complication, indicating that these factors, rather than body mass index, were driving the increased rates of complications seen in the high-body mass index groups., Conclusion: Body mass index alone is not a predictor of outcomes after prepectoral expander/implant breast reconstruction and should not be used to estimate risk of postoperative complications or exclude patients for prepectoral reconstruction., Clinical Question/level of Evidence: Risk, II.

This exploratory netnographic study is among the first to investigate military video blogs (milvlogs) posted by Iraq and Afghanistan veterans who self-published stories on military-related trauma to YouTube. Studies have shown that self-published milvlogs provide benefits such as education, social support, and self-management of chronic physical and psychological illness. The aim of this study was to explore combat veterans' milvlogs and to determine themes that emerged across the videos. We transcribed and analyzed content from 17 milvlogs. Our analysis yielded seven themes: motivation, loss, managing symptoms, help-seeking, guilt and shame, suicide, and connecting to other veterans. We concluded that veterans were initially drawn to vlogging to connect to others. Vlogging also served as a medium for combat veterans to tell their stories, position these stories against others' experiences, and engage in outreach and advocacy. Finally, milvlogs may provide an easily accessible resource for developing preventive and/or mental health treatment/support links.

Firearms are a significant risk factor in suicide and older adults are disproportionately impacted in suicide by this means. This study investigated the impact of Counseling on Access to Lethal Means (CALM) training with geriatric case managers at an Area Agency on Aging. A concurrent mixed methods approach was used to explore 1) geriatric case managers' attitudes, beliefs, and behavioral intentions about counseling on access to lethal means following CALM training, and 2) perceived barriers to assessing for suicidality and counseling clients on access to firearms. The CALM evaluation data was collected immediately posttest at CALM training, at three-month follow up. Results indicated that 38% of respondents reported they had, since CALM training, discussed reducing access to lethal means with clients and/or families. At three-month follow up, data showed that most beliefs, attitudes, and behavioral intentions about counseling clients and families on this topic increased. Focus group findings indicated that training had a positive effect on participants' attitudes, beliefs, and behavioral intentions about counseling on access to lethal means.The findings of the present study offer additional evidence and implication for trainings of this type.

Indubitably, the challenges facing health-care social workers are becoming increasingly complex. Whilst these problematic professional circumstances compound the need for self-compassion among health-care social workers, few studies, if any, have explicitly examined self-compassion among this practitioner group. This cross-sectional study explored self-compassion among a sample of practitioners (N = 138) in one southeastern state. Results indicate that health-care social workers in this sample engage in self-compassion only moderately. Further, occupational and demographic/life characteristics (e.g., age, years practicing social work, average hours worked per week, health status, and relationship status, among others) are able to predict self-compassion scores. After a terse review of relevant literature, this paper will explicate findings from this study, discuss relevant points derived from said findings, and identify salient implication for health-care social work praxis.

Purpose: Pain management within emergency departments (ED) remains challenging. Given that unrelieved pain in children is linked to a number of negative physiological and psychological consequences, optimal management of children's pain is paramount. Many studies exploring children's pain have adopted quantitative methods or sought the perspectives of adults. Compared to adults, studies examining children's views on pain and pain management are limited. This study aimed to explore children's pain experiences, their perception of pain management and expectations of the role of the nurse., Design: This was a qualitative descriptive study using an inductive approach., Methods: Fifteen children, aged 4-8 years who presented to the ED of an Australian tertiary pediatric hospital in acute pain participated. Data were collected using draw, write, and tell (DWT) technique and analyzed using thematic analysis., Results: Three themes emerged (1) "Security," (2) "My pain" with subthemes: "The pain feelings" and "My sad/happy feelings," (3) "Comfort and relief" with subthemes: "Taking my mind off it," "Resting" and "Hospital things." When in pain children needed to feel secure. Parents and nurses were important in fostering a secure environment for children. Children were capable of describing their pain and identified nonpharmacological strategies to help their pain., Practice Implications: Children as young as 4 years old can provide detailed accounts of their pain, which extends beyond physical dimensions to include visual, auditory, and sensory features. Nurses need to listen, be honest, and develop trust with children to be helpful. Nonpharmacological pain-relieving strategies can be implemented by parents and nurses in collaboration with the child. Fostering a secure environment is essential., (© 2018 Wiley Periodicals, Inc.)

Background: Animation deformity is a direct consequence of subpectoral implant placement for breast reconstruction following mastectomy. Current treatment options ameliorate but do not address the source of the problem. Moving the implant from subpectoral to prepectoral has the potential to eliminate animation deformity., Objectives: Describe the technique and outcomes of prepectoral revision reconstruction in over 100 cases and discuss patient selection criteria for a successful outcome., Methods: Patients who presented with animation deformity following two-stage implant reconstruction were included in this retrospective study. Revision surgery involved removal of the existing implant via the previous incision site along the inframammary fold, suturing of the pectoralis major muscle back to the chest wall, creation of a prepectoral pocket for the new implant, use of acellular dermal matrix to reinforce the prepectoral pocket and completely cover the implant, and fat grafting to enhance soft tissue. Patients were evaluated for resolution of animation deformity and occurrence of complications during follow up., Results: Fifty-seven patients (102 breasts) underwent prepectoral revision reconstruction with complete resolution of animation deformity. Complications occurred in 4 breasts (3.9%) and included seroma (2 breasts), skin necrosis (3 breasts), and wound dehiscence (1 breast). All 4 breasts with complications had their implants removed and replaced. There were no incidences of infection or clinically significant capsular contracture in this series., Conclusions: Revision reconstruction with prepectoral implant placement and complete coverage with acellular dermal matrix resolves animation deformity and results in aesthetically pleasing soft breasts. Patient selection is critical for the success of this technique.

Background: In many countries, aseptic procedures are undertaken by nurses in the general ward setting, but variation in practice has been reported, and evidence indicates that the principles underpinning aseptic technique are not well understood., Methods: A survey was conducted, employing a brief, purpose-designed, self-reported questionnaire., Results: The response rate was 72%. Of those responding, 65% of nurses described aseptic technique in terms of the procedure used to undertake it, and 46% understood the principles of asepsis. The related concepts of cleanliness and sterilization were frequently confused with one another. Additionally, 72% reported that they not had received training for at least 5 years; 92% were confident of their ability to apply aseptic technique; and 90% reported that they had not been reassessed since their initial training. Qualitative analysis confirmed a lack of clarity about the meaning of aseptic technique., Conclusion: Nurses' understanding of aseptic technique and the concepts of sterility and cleanliness is inadequate, a finding in line with results of previous studies. This knowledge gap potentially places patients at risk. Nurses' understanding of the principles of asepsis could be improved. Further studies should establish the generalizability of the study findings. Possible improvements include renewed emphasis during initial nurse education, greater opportunity for updating knowledge and skills post-qualification, and audit of practice., (Copyright © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Neutrophils promote experimental abdominal aortic aneurysm (AAA) formation via a mechanism that is independent from MMPs (matrix metalloproteinases). Recently, we reported a dominant role of IL (interleukin)-1β in the formation of murine experimental AAAs. Here, the hypothesis that IL-1β-induced neutrophil extracellular trap formation (NETosis) promotes AAA was tested., Approach and Results: NETs were identified through colocalized staining of neutrophil, Cit-H3 (citrullinated histone H3), and DNA, using immunohistochemistry. NETs were detected in human AAAs and were colocalized with IL-1β. In vitro, IL-1RA attenuated IL-1β-induced NETosis in human neutrophils. Mechanistically, IL-1β treatment of isolated neutrophils induced nuclear localization of ceramide synthase 6 and synthesis of C16-ceramide, which was inhibited by IL-1RA or fumonisin B1, an inhibitor of ceramide synthesis. Furthermore, IL-1RA or fumonisin B1 attenuated IL1-β-induced NETosis. In an experimental model of murine AAA, NETs were detected at a very early stage-day 3 of aneurysm induction. IL-1β-knockout mice demonstrated significantly lower infiltration of neutrophils to aorta and were protected from AAA. Adoptive transfer of wild-type neutrophils promoted AAA formation in IL-1β-knockout mice. Moreover, treatment of wild-type mice with Cl-amidine, an inhibitor NETosis, significantly attenuated AAA formation, whereas, treatment with deoxyribonuclease, a DNA digesting enzyme, had no effect on AAA formation., Conclusions: Altogether, the results suggest a dominant role of IL-1β-induced NETosis in AAA formation., (© 2018 American Heart Association, Inc.)

Context: Intervention fidelity is a critical component of behavioral research that has received inadequate attention in palliative care studies. With increasing focus on the need for palliative care models that can be widely disseminated and delivered by non-specialists, rigorous yet pragmatic strategies for training interventionists and maintaining intervention fidelity are needed., Objectives: (1) Describe components of a plan for interventionist training and monitoring and maintaining intervention fidelity as part of a primary palliative care trial (CONNECT) and (2) present data about perceived training effectiveness and delivery of key intervention content., Methods: Post-training evaluations, visit checklists, and visit audio-recordings., Results: Data were collected from June, 2016 through April, 2017. We include procedures for (1) identification, training and certification of oncology nurses as CONNECT interventionists; (2) monitoring intervention delivery; and (3) maintaining intervention quality. All nurses (N = 14) felt prepared to deliver key competencies after a 3-day in-person training. As assessed via visit checklists, interventionists delivered an average of 94% (SD 13%) of key content for first intervention visits and 85% (SD 14%) for subsequent visits. As assessed via audio-recordings, interventionists delivered an average of 85% (SD 8%) of key content for initial visits and 85% (SD 12%) for subsequent visits., Conclusion: We present a 3-part strategy for training interventionists and monitoring and maintaining intervention delivery in a primary palliative care trial. Training was effective in having nurses feel prepared to deliver primary palliative care skills. As assessed via nursing checklists and visit audio-recordings, intervention fidelity was high.

Eight software applications are compared for their performance in estimating the octanol-water partition coefficient (K ow ), melting point, vapor pressure and water solubility for a dataset of polychlorinated biphenyls, polybrominated diphenyl ethers, polychlorinated dibenzodioxins, and polycyclic aromatic hydrocarbons. The predicted property values are compared against a curated dataset of measured property values compiled from the scientific literature with careful consideration given to the analytical methods used for property measurements of these hydrophobic chemicals. The variability in the predicted values from different calculators generally increases for higher values of K ow and melting point and for lower values of water solubility and vapor pressure. For each property, no individual calculator outperforms the others for all four of the chemical classes included in the analysis. Because calculator performance varies based on chemical class and property value, the geometric mean and the median of the calculated values from multiple calculators that use different estimation algorithms are recommended as more reliable estimates of the property value than the value from any single calculator., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Prosthetic breast reconstruction in the setting of radiotherapy is associated with poor outcomes. Until recently, prosthetic breast reconstruction was predominantly performed by placing the prosthesis in a subpectoral space. Placement of the prosthesis in a prepectoral space is currently emerging as a simpler, alternative approach to subpectoral placement. The impact of postmastectomy radiotherapy (PMRT) on prepectoral reconstruction has not yet been specifically assessed. This study compared the outcomes of patients who underwent immediate, direct-to-implant, or 2-staged, prepectoral breast reconstruction followed by PMRT with those from patients who did not receive PMRT., Methods: Patients with well-perfused skin flaps and without contraindications, including uncontrolled diabetes-mellitus, previous irradiation, and current tobacco use, were offered the prepectoral approach. Following implant or expander placement, patients underwent planned or unplanned radiotherapy. Complications after each stage of reconstruction were recorded., Results: Thirty-three patients underwent 52 breast reconstructions via the prepectoral approach. Sixty-five percentage of the breasts were irradiated, including 21% after expander and 44% after implant placement. Patients were followed for a mean of 25.1 ± 6.4 months. Complication rate in irradiated breasts was 5.9% (1 incidence of seroma and 1 incidence of wound dehiscence followed by expander removal) and 0% in nonirradiated breasts. Capsular contracture rate was 0% in both irradiated and nonirradiated breasts., Conclusions: Immediate implant-based prepectoral breast reconstruction followed by PMRT appears to be well tolerated, with no excess risk of adverse outcomes, at least in the short term. Longer follow-up is needed to better understand the risk of PMRT in prepectorally reconstructed breasts.

Despite growing interest in self-care, few studies have explicitly examined the self-care practices of healthcare social workers. This exploratory study investigated self-care among practitioners (N = 138) in one southeastern state. Overall, data suggest that healthcare social workers only moderately engaged in self-care. Additionally, analyses revealed significant differences in self-care practices by financial stability, overall health, and licensure status, respectively. Interestingly, perceived health status and current financial situation were significant predictors for overall self-care practices. After a brief review of the literature, this narrative will explicate findings, elucidate discussion points, identify salient implications, and conclude with areas for future research.

Caregiver research often focuses on negative health outcomes, yet little is known about the self-care practices of caregivers. The present study investigates self-care practices among family caregivers and the relationships between personal self-care, perceived stress, and other health variables. Data were collected from informal caregivers through self-administered Internet and paper surveys that included the Medical Outcomes Study Short Form 36-item Health Survey, Perceived Stress Scale, and Self-Care Practices Scale. Personal self-care was most strongly associated with emotional well-being, pain, perceived stress, and general health. The relevance of study findings to strengthening family caregiver programs and future research is discussed.

Despite the use of mentoring programs in fields such as business, career training, and youth development, little is known about how mentoring can be used to train and support new foster parents. This paper describes how Concept Mapping was used with current foster parents to develop a conceptual framework suitable to plan a foster parent mentor program. A secondary aim of this study was to explore priority differences in the conceptualization by self-reported gender (foster mothers vs. foster fathers). Participant data was collected via three qualitative brainstorming sessions, and analyzed using non-metric multidimensional scaling and hierarchical cluster analysis. Findings indicate that foster parents participating in this study conceptualized effective mentor programs via a seven cluster solution. Study results also showed no significant differences in cluster ratings by gender. Implications for practice and program planning are identified, as well as areas for future research., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Pain is a universal and complex phenomenon that is personal, subjective and specific. Despite growing knowledge in pediatric pain, management of children's pain remains sub-optimal and is linked to negative behavioral and physiological consequences later in life. As there is no synthesis of these studies, it was timely to undertake a systematic review., Objectives: To identify, evaluate and synthesize the existing qualitative evidence on children's experiences of acute pain, including pain management, within a healthcare facility., Inclusion Criteria Types of Participants: Children aged four to 18 years (inclusive) attending a healthcare facility who experienced acute pain associated with any injury, medical condition or treatment., Phenomena of Interest: Children's experiences and perceptions of their acute pain, pain management and expectations of others in managing their pain. Studies on children's experiences of pain in the postoperative context were excluded as a systematic review exploring this phenomenon had previously been published. Studies reporting on children's experiences of chronic pain were also excluded., Context: Any healthcare facility including general practitioners' surgeries, hospitals, emergency departments and outpatient clinics., Types of Studies: Qualitative studies including phenomenology, grounded theory, ethnography, action research and feminist research designs., Search Strategy: Using a three-step search strategy, databases were searched in December 2015 to identify both published and unpublished articles from 2000 to 2015. Studies published in languages other than English were excluded., Methodological Quality: All studies that met the inclusion criteria were assessed by at least two independent reviewers for methodological quality using a standardized critical appraisal tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI)., Data Extraction: Data were extracted from the papers included in the review using standardized data extraction tool from JBI-QARI., Data Synthesis: Findings were pooled using JBI-QARI. Findings were rated according to their level of credibility and categorized based on similarity in meaning and then were subjected to a meta-synthesis., Results: Four studies were included in this review. Two meta-syntheses were generated from five categories based on 21 findings: first, children can express their pain experiences in terms of cause, location, meaning and quality. Children's pain experiences include both physical and psychological dimensions. Children's pain experiences are influenced by their previous pain experiences, pain expectations and sociocultural factors. Second, children use a range of cognitive/behavioral and sensory/physical self-soothing strategies not only to help manage their pain, but also rely on the actions and presence of others as helpers when they are in pain., Conclusion: Children's pain is a multi-dimensional complex phenomenon relying upon a multi-modal approach to management. Children as young as four years are capable of articulating their pain in terms of location, intensity and depth. The way children perceive, express and respond to pain is shaped by sociocultural factors, previous pain experiences and their expectations of pain. Children, parents and healthcare professionals play an important role in managing children's pain experiences.

Implant-based breast reconstruction is currently performed with placement of the implant in a subpectoral pocket beneath the pectoralis major muscle, by means of the dual-plane approach. Although the safety and breast aesthetics of this approach are well recognized, it is not without concerns. Animation deformities and accompanying patient discomfort, which are direct consequences of muscle elevation, can be severe in some patients. Moving the implant prepectorally may eliminate these concerns. For a successful prepectoral approach, the authors advocate use of their bioengineered breast concept, which was detailed in a previous publication. In this report, the authors discuss the rationale for prepectoral implant reconstruction, its indications/contraindications, and preliminary results from over 350 reconstructions., Clinical Question/level of Evidence: Therapeutic, IV.

Across the globe, wild bees are threatened by ongoing natural habitat loss, risking the maintenance of plant biodiversity and agricultural production. Despite the ecological and economic importance of wild bees and the fact that several species are now managed for pollination services worldwide, little is known about how land use and beekeeping practices jointly influence gene flow. Using stingless bees as a model system, containing wild and managed species that are presumed to be particularly susceptible to habitat degradation, here we examine the main drivers of tropical bee gene flow. We employ a novel landscape genetic approach to analyse data from 135 populations of 17 stingless bee species distributed across diverse tropical biomes within the Americas. Our work has important methodological implications, as we illustrate how a maximum-likelihood approach can be applied in a meta-analysis framework to account for multiple factors, and weight estimates by sample size. In contrast to previously held beliefs, gene flow was not related to body size or deforestation, and isolation by geographic distance (IBD) was significantly affected by management, with managed species exhibiting a weaker IBD than wild ones. Our study thus reveals the critical importance of beekeeping practices in shaping the patterns of genetic differentiation across bee species. Additionally, our results show that many stingless bee species maintain high gene flow across heterogeneous landscapes. We suggest that future efforts to preserve wild tropical bees should focus on regulating beekeeping practices to maintain natural gene flow and enhancing pollinator-friendly habitats, prioritizing species showing a limited dispersal ability., (© 2016 John Wiley & Sons Ltd.)

The regeneration of disturbed forest is an essential part of tropical forest ecology, both with respect to natural disturbance regimes and large-scale human-mediated logging, grazing, and agriculture. Pioneer tree species are critical for facilitating the transition from deforested land to secondary forest because they stabilize terrain and enhance connectivity between forest fragments by increasing matrix permeability and initiating disperser community assembly. Despite the ecological importance of early successional species, little is known about their ability to maintain gene flow across deforested landscapes. Utilizing highly polymorphic microsatellite markers, we examined patterns of genetic diversity and differentiation for the pioneer understory tree Miconia affinis across the Isthmus of Panama. Furthermore, we investigated the impact of geographic distance, forest cover, and elevation on genetic differentiation among populations using circuit theory and regression modeling within a landscape genetics framework. We report marked differences in historical and contemporary migration rates and moderately high levels of genetic differentiation in M. affinis populations across the Isthmus of Panama. Genetic differentiation increased significantly with elevation and geographic distance among populations; however, we did not find that forest cover enhanced or reduced genetic differentiation in the study region. Overall, our results reveal strong dispersal for M. affinis across human-altered landscapes, highlighting the potential use of this species for reforestation in tropical regions. Additionally, this study demonstrates the importance of considering topography when designing programs aimed at conserving genetic diversity within degraded tropical landscapes.

Background and Aims: Global pollinator declines and continued habitat fragmentation highlight the critical need to understand reproduction and gene flow across plant populations. Plant size, conspecific density and local kinship (i.e. neighbourhood genetic relatedness) have been proposed as important mechanisms influencing the reproductive success of flowering plants, but have rarely been simultaneously investigated., Methods: We conducted this study on a continuous population of the understorey tree Miconia affinis in the Forest Dynamics Plot on Barro Colorado Island in central Panama. We used spatial, reproductive and population genetic data to investigate the effects of tree size, conspecific neighbourhood density and local kinship on maternal and paternal reproductive success. We used a Bayesian framework to simultaneously model the effects of our explanatory variables on the mean and variance of maternal viable seed set and siring success., Key Results: Our results reveal that large trees had lower proportions of viable seeds in their fruits but sired more seeds. We documented differential effects of neighbourhood density and local kinship on both maternal and paternal reproductive components. Trees in more dense neighbourhoods produced on average more viable seeds, although this positive density effect was influenced by variance-inflation with increasing local kinship. Neighbourhood density did not have significant effects on siring success., Conclusions: This study is one of the first to reveal an interaction among tree size, conspecific density and local kinship as critical factors differentially influencing maternal and paternal reproductive success. We show that both maternal and paternal reproductive success should be evaluated to determine the population-level and individual traits most essential for plant reproduction. In addition to conserving large trees, we suggest the inclusion of small trees and the conservation of dense patches with low kinship as potential strategies for strengthening the reproductive status of tropical trees., (© The Author 2015. Published by Oxford University Press on behalf of the Annals of Botany Company. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Global trends in pollinator-dependent crops have raised awareness of the need to support managed and wild bee populations to ensure sustainable crop production. Provision of sufficient forage resources is a key element for promoting bee populations within human impacted landscapes, particularly those in agricultural lands where demand for pollination service is high and land use and management practices have reduced available flowering resources. Recent government incentives in North America and Europe support the planting of wildflowers to benefit pollinators; surprisingly, in North America there has been almost no rigorous testing of the performance of wildflower mixes, or their ability to support wild bee abundance and diversity. We tested different wildflower mixes in a spatially replicated, multiyear study in three regions of North America where production of pollinator-dependent crops is high: Florida, Michigan, and California. In each region, we quantified flowering among wildflower mixes composed of annual and perennial species, and with high and low relative diversity. We measured the abundance and species richness of wild bees, honey bees, and syrphid flies at each mix over two seasons. In each region, some but not all wildflower mixes provided significantly greater floral display area than unmanaged weedy control plots. Mixes also attracted greater abundance and richness of wild bees, although the identity of best mixes varied among regions. By partitioning floral display size from mix identity we show the importance of display size for attracting abundant and diverse wild bees. Season-long monitoring also revealed that designing mixes to provide continuous bloom throughout the growing season is critical to supporting the greatest pollinator species richness. Contrary to expectation, perennials bloomed in their first season, and complementarity in attraction of pollinators among annuals and perennials suggests that inclusion of functionally diverse species may provide the greatest benefit. Wildflower mixes may be particularly important for providing resources for some taxa, such as bumble bees, which are known to be in decline in several regions of North America. No mix consistently attained the full diversity that was planted. Further study is needed on how to achieve the desired floral display and diversity from seed mixes.