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Objectives: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist–led quality improvement and research that resulted in improved patient outcomes is provided. Data sources: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical-Care Nurses, and National Association of Clinical Nurse Specialists. Study selection: Not applicable. Data extraction: Not applicable. Data synthesis: Not applicable. Conclusions: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system. [ABSTRACT FROM AUTHOR]

Healthcare organizations have prioritized patient safety and quality improvement efforts to reduce central line-associated bloodstream infections (CLABSIs). Implementation of central venous catheter (CVC) insertion and maintenance bundles have significantly reduced infection rates. Nevertheless, CLABSIs continue to be a significant cause of mortality and morbidity in hospitals, and further efforts are necessary to improve CVC care practices. A hospital-wide committee at a tertiary care pediatric hospital identified gaps in our CVC maintenance practices resulting from CVC contamination events from a patient's body fluids. A lack of published literature on the topic resulted in the need to create an institutional clinical practice guideline (CPG) to develop guidance to mitigate potential CLASBIs from CVC contamination. Utilization of the CVC CPG in all inpatient units and other reduction strategies resulted in a steady decline in our CLABSI rates, particularly in those related to CVC contamination events. Case reports illustrate the effectiveness of the CPG. [ABSTRACT FROM AUTHOR]

The clinical nurse specialist (CNS), one of the 4 advanced practice registered nurse (APRN) categories, has a unique role to play in contributing to high-quality patient care and system-level change across multiple health care settings. CNS practice requires advanced knowledge and skills, including specialty expertise, the ability to integrate new knowledge and innovation into the system of care, the ability to consult and collaborate with all health professions, and the mentoring of nursing staff to support and fully implement that new knowledge. The purpose of this article was to describe the role of the CNS, explain the background of the CNS role as it relates to APRN practice, provide current CNS workforce statistics, and share opportunities for hospitals and health systems to strategically use CNSs to advance patient and organizational goals. [ABSTRACT FROM AUTHOR]

Objective: Acute funisitis (AF) is most commonly associated with acute chorioamnionitis (AC) and ascending infection. The significance of cases of AF without associated AC or isolated funisitis (IF) is unknown. Our objective was to evaluate clinical and pathologic features of IF and to determine its significance.Study Design: This was a retrospective review of placentas of patients delivering at our institution from 1997 to 2017. Placentas with the diagnosis of IF comprised the study population and placentas without either AF or AC served as controls.Results: There were 156 cases and 181 controls identified. Maternal age, gestational age, birthweight and mode of delivery were similar in both groups. 132 (84.6%) of cases of IF had meconium, with 62 (47.0%) having meconium only in the membranes, 36 (27.3%) in the membranes and cord and 34 (25.6%) in the membranes and cord with associated myonecrosis. 72 (38.7%) of controls had microscopically identified meconium, with only one (1.4%) showing meconium in the cord. None had myonecrosis (p < .001). There was also a significantly higher rate of intrauterine fetal demise (IUFD) in the IF group (p = .027). but the rate of suspected Intrauterine growth restriction (IUGR) was significantly greater in the controls (p = .014).Conclusion: IF is highly associated with the presence of meconium discharge and meconium-associated myonecrosis of umbilical vessels. The inflammation in IF may be the result of damage to the muscle fibers of the cord due to meconium but additional studies are necessary to understand the significance of these findings. [ABSTRACT FROM AUTHOR]

We discuss the benefits that a collaborative research network, a group of faculty from different institutions who jointly conduct a research project, can have on undergraduate research (UR) by enhancing the diversity and significance of projects and by improving student motivation and breadth of learning. The main example used is the Ecological Research as Education Network (EREN), founded in 2010 to enhance undergraduate research in ecology at primarily undergraduate institutions (PUIs) by (1) providing networking and collaborative research opportunities for both faculty and students and (2) developing free educational resources. EREN comprises about 280 ecology faculty and staff nationally and has facilitated development of nine continental-scale, collaborative research projects. Project leaders design a research project that can be conducted by faculty and students at just about any college. Faculty and their students carry out the data collection at their home institution and submit it to the publicly available project database. Then participants (and even non-participants) can avail themselves of the large, multi-year, continent-wide data set. Substantial benefits have been reported for programs, faculty, and students. Undergraduate research programs are broadened and faculty benefit because they gain insights and laboratory techniques from colleagues in other institutions and fields, thereby expanding the diversity of potential undergraduate research projects and resulting in more broadly trained undergraduates. The research projects themselves have become educational resources incorporated into courses at all levels, as well as independent research projects. Because data collection happens nationwide, college faculty and students at small colleges are now able to investigate large-scale ecological questions. Preliminary assessments have shown significant improvements for some student-learning outcomes, including thinking across scales, use of best practices in data management, and describing scientific collaboration techniques. Students demonstrate increased motivation and retention through participation in a nationwide, authentic research project with publication-quality data, becoming part of a community of scholars and gaining a sense of belonging and responsibility. Despite challenges with coordination and communication, students are exposed to a wider range of techniques and subfields of ecology than they would be without this network. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to investigate the characteristics under which ultramarathon-associated visual impairment occurs and to seek to identify its physiological basis and risk factors. Methods Through an online questionnaire, distributed worldwide, we obtained information from 173 self-identified ultramarathon runners who had experienced visual impairment during an ultramarathon. We attempted to characterize this vision impairment—its symptoms, duration, and the conditions under which it occurs. Select characteristics were compared with a reference group of 412 registrants of the 161-km Western States Endurance Run. Results Ultramarathon-associated visual impairment was typically characterized as painless clouding of vision that resolved either during (13.5%) or after racing within a median of 3.5 hours (range 0 to 48 hours) upon cessation of running. The mean (±SD) distance at which vision impairment occurred was 73 ± 40 km, and the 161-km distance was the most frequent race distance (46.8%) in which visual impairment occurred. Visual impairment was often recurrent, with respondents reporting having it develop during a median of 2 races. Respondents with a history of refractive surgery had more episodes than those without such history (median 3.5 vs 2 episodes, P = .010). Compared with the reference group, runners with visual impairment were nearly twice as likely (23.7% vs 12.1%, P < .001) to have had refractive surgery. Conclusions Ultramarathon-associated visual impairment typically presents as a painless clouding of vision that is self-limited but tends to recur in certain runners. Risk appears higher among those with a history of refractive surgery, which is relevant for ultramarathon runners who are considering, or who have a history of, refractive surgery. [ABSTRACT FROM AUTHOR]

Several oat processors in the United States and Canada operate under what is referred to as a Purity Protocol for the provision of gluten-free oats. This term is derived from a Health Canada position statement that indicated that pure oats, which they defined as oats that are harvested, transported, stored, processed, and manufactured under good manufacturing practices (GMPs) to minimize the presence of gluten, can safely be consumed by some persons with celiac disease. While proprietary definitions of the appropriate GMPs have been used in industry for many years, no independent definition of the requirements to make a Purity Protocol claim has been published. This paper provides a consensus definition of the Purity Protocol requirements based on input from the four largest Purity Protocol oat processors in North America. This definition provides transparency to gluten-free consumers and allows for auditing of a Purity Protocol claim. [ABSTRACT FROM AUTHOR]

Objectives: This study’s primary objective was to determine the sensitivity, specificity, and accuracy of fully quantitative stress perfusion cardiac magnetic resonance (CMR) versus a reference standard of quantitative coronary angiography. We hypothesized that fully quantitative analysis of stress perfusion CMR would have high diagnostic accuracy for identifying significant coronary artery stenosis and exceed the accuracy of semiquantitative measures of perfusion and qualitative interpretation. Background: Relatively few studies apply fully quantitative CMR perfusion measures to patients with coronary disease and comparisons to semiquantitative and qualitative methods are limited. Methods: Dual bolus dipyridamole stress perfusion CMR exams were performed in 67 patients with clinical indications for assessment of myocardial ischemia. Stress perfusion images alone were analyzed with a fully quantitative perfusion (QP) method and 3 semiquantitative methods including contrast enhancement ratio, upslope index, and upslope integral. Comprehensive exams (cine imaging, stress/rest perfusion, late gadolinium enhancement) were analyzed qualitatively with 2 methods including the Duke algorithm and standard clinical interpretation. A 70% or greater stenosis by quantitative coronary angiography was considered abnormal. Results: The optimum diagnostic threshold for QP determined by receiver-operating characteristic curve occurred when endocardial flow decreased to <50% of mean epicardial flow, which yielded a sensitivity of 87% and specificity of 93%. The area under the curve for QP was 92%, which was superior to semiquantitative methods: contrast enhancement ratio: 78%; upslope index: 82%; and upslope integral: 75% (p = 0.011, p = 0.019, p = 0.004 vs. QP, respectively). Area under the curve for QP was also superior to qualitative methods: Duke algorithm: 70%; and clinical interpretation: 78% (p < 0.001 and p < 0.001 vs. QP, respectively). Conclusions: Fully quantitative stress perfusion CMR has high diagnostic accuracy for detecting obstructive coronary artery disease. QP outperforms semiquantitative measures of perfusion and qualitative methods that incorporate a combination of cine, perfusion, and late gadolinium enhancement imaging. These findings suggest a potential clinical role for quantitative stress perfusion CMR. [Copyright &y& Elsevier]

Learning objectives are a critical step in the creation and implementation of a radiology curriculum. Their use is mandated by the Liaison Committee on Medical Education, the Accreditation Council on Graduate Medical Education, and the Accreditation Council on Continuing Medical Education, but more importantly they can have a significant beneficial impact on quality of radiology education programs. Learning objectives guide student learning, help clarify our teaching goals, and simplify learner testing and evaluation. This article will review the components of a proper learning objective and provide a simple, straightforward approach to writing them effectively. [Copyright &y& Elsevier]

Despite years of constructive discourse about documentation theory, the complex nature of identity, approaches to ethnicity, and the role of the archivist in light of postmodernism, the call for archivists to collect the documentary heritage of minorities and other historically marginalized groups remains largely unanswered. With the exception of a relatively few specialized institutions and dedicated programs, the identification and preservation of Latino archives are not keeping pace with the nation's fastest growing and increasingly geographically dispersed population. This paper presents two related initiatives, developed in dialogue over the past seven years. It outlines operational practices related to identification of collections in private hands, outreach, trust, and long-term relationships. The paper then provides a practical model and insights for overcoming the day-to-day challenges of identifying and preserving the documentary heritage of the Latino experience and challenges others to undertake such projects. [ABSTRACT FROM AUTHOR]

We present a case of twin Hispanic male infants fed with cow's milk formula who presented at 3 weeks of life with nonbilious, nonbloody vomiting and diarrhea. Laboratory evaluation revealed leukocytosis, acidosis, and methemoglobinemia. Sepsis evaluation was negative. Although they recovered quickly with i.v. fluids, symptoms recurred again with ingestion of soy formula. An underlying diagnosis was sought that could explain their symptoms. [ABSTRACT FROM AUTHOR]

This article presents a case report of a 13-year-old boy who presented to the Emergency Department with abdominal pain and vomiting. He had a known history of recurrent swelling but no previous abdominal episodes. A computed tomography scan revealed small bowel intussusception and he was scheduled for surgery. The patient had a history of multiple episodes of swelling of extremities, face, and genitalia. The Allergy Consult Service was consulted for perioperative management of his angioedema. [ABSTRACT FROM AUTHOR]

The article offers information on Chiari malformations, structural defects of the hindrain. It notes that this condition involves the cerebellum, ventricles, spine and cerebrospinal fluid (CSF) flow. It discusses the characteristics of Chiari malformation types through their signs, treatment and prescribed diagnostic imaging techniques. A case for each type is also provided.

Abstract: Background: Retrospective studies have suggested that routine use of a preformed silo for infants with gastroschisis may be associated with improved outcomes. We performed a prospective multicenter randomized controlled trial to test this hypothesis. Methods: Eligible infants were randomized to (1) routine bedside placement of a preformed Silastic spring-loaded silo, with gradual reduction and elective abdominal wall closure, or (2) primary closure. Results: There were 27 infants in each group. There was no significant difference between groups with respect to age, weight, sex, Apgar scores, prenatal diagnosis, or mode of delivery. The total number of days on the ventilator was lower in the spring-loaded silo group, although it did not reach statistical significance (3.2 vs 5.3, P = .07). There was no significant difference between groups with respect to length of time on total parenteral nutrition, length of stay, or incidence of sepsis and necrotizing enterocolitis. Conclusion: Routine use of a preformed silo was associated with similar outcomes to primary closure for infants with gastroschisis but with a strong trend toward fewer days on the ventilator. Use of a preformed silo has the advantage of permitting definitive abdominal wall closure in a more elective setting. [Copyright &y& Elsevier]

Nursing literature is replete with articles addressing issues and ideas pertinent to nursing administration and leadership. This selected compilation presents 41 annotated references to current articles representing some of the hottest topics affecting nursing leadership and administration. References to topics, including leadership, nurse retention and satisfaction, staffing issues, change, nursing research, finance, patient care, and communication, embody the contents of this annotated bibliography, presented for busy nurse leaders and administrators in emergency centers. Many of the articles are available online in full-text format for rapid access. [ABSTRACT FROM AUTHOR]

Objectives: The goals of this study were to investigate whether depression is associated with cellular immunity in ambulatory patients and to identify neuroendocrine and behavioral pathways that might account for this relationship.Methods: We studied 32 women who met Diagnostic and Statistical Manual of Mental Disorder, fourth edition, criteria for major depressive disorder and 32 healthy female control subjects. The groups were matched for age and ethnicity. None were taking medication, and all were free of disease involving the immune system.Results: Depressed subjects had reduced proliferative responses to the mitogens concanavalin A and phytohemagglutinin compared with control subjects. Natural killer cell activity was reduced among older depressed subjects but enhanced among younger depressed subjects. Although depression was associated with elevated circulating levels of norepinephrine and estradiol, these hormones could not account for the immunologic differences between depressed and control subjects. Depression was also associated with greater tobacco and caffeine consumption, less physical activity, and poorer sleep quality. Mediational analyses were consistent with physical activity acting as a pathway through which depression was associated with reduced lymphocyte proliferation.Conclusions: Ambulatory patients with mild to moderately severe depression exhibit reduced mitogen-stimulated lymphocyte proliferative responses and altered natural killer cell cytotoxicity. The relationship between depression and proliferative responses may be mediated by physical activity. [ABSTRACT FROM AUTHOR]

Objective: To describe the relationships between cardiovascular and natural killer (NK) cell number changes on acute psychological stress in women.Method: Data from eight different studies were analyzed. A total of 128 healthy female subjects, 85 younger (18-45 years) and 43 older (49-87 years), had been subjected to a speech stressor (N = 80) or a mental effort stressor (N = 48), mental arithmetic, or the Stroop test. Correlations between changes in NK cell numbers, systolic (SBP) and diastolic (DBP) blood pressure, and heart rate (HR) were computed. Meta-analysis programs were used to study correlations across studies and to examine whether correlations differed with stressors or age.Results: In all studies, significant increases over baseline were observed for each variable. Across studies, the mean weighted r between changes in HR, DBP, and SBP was medium (rw = .25) to large (rw = .64). A medium to large average correlation between HR and NK changes (rw = .37) was observed, whereas average correlations of changes in NK cell numbers with blood pressure changes were small to medium (rw < or = .23). Correlations between changes in NK cell numbers and cardiovascular variables were homogeneous across studies, whereas mutual correlations between cardiovascular variables were heterogeneous. One moderator variable showed itself: correlations between HR and DBP reactions were larger in studies with older than younger subjects.Conclusion: NK cell changes and HR responses induced by acute stress in women are regulated, to some extent, by the same mechanisms. Neither the type of stressor nor age seem to be very important when considering correlations between NK cell and cardiovascular changes. This study integrates information about NK cell and cardiovascular responses in women that can be used as reference material in future studies. [ABSTRACT FROM AUTHOR]

Background. Correction of significant tricuspid regurgitation (TR) at the time of continuous-flow (CF) left ventricular assist device (LVAD) implantation has been shown to be beneficial in several recently published studies. The most common technique is ring annuloplasty followed by valve replacement. Our center has primarily used the De Vega annuloplasty, and the durability of this repair is the focus of this study. Methods. This was a retrospective review of 35 consecutive patients who underwent CF LVAD implantation and De Vega tricuspid valve annuloplasty (TVA) for severe TR and were alive at 1 year. Echocardiograms were obtained preoperatively, intraoperatively, at discharge, and at 1 year after operation. Results. The TR in 32 of 35 patients (91.4%, group A) improved from severe preoperatively to insignificant at the time of discharge after De Vega TVA, and 3 patients (8.6%, group B) had moderate residual TR. At 1-year follow-up, 29 of 32 (90.6%) patients in group A had insignificant TR, 2 (6.3%) had moderate TR, and 1 (3.1%) had severe TR. In group B, 2 of 3 patients had no progression of their moderate TR at 1 year and 1 had severe TR. Overall, 2 of 35 (5.7%) patients had severe TR at 1 year after De Vega TVA and LVAD implantation. Conclusions. We conclude from this consecutive cohort of patients undergoing CF LVAD implantation and De Vega TVA that this technique is very durable at 1 year and has the advantages of a shorter operative time relative to ring annuloplasty and decreased cost because a prosthetic implant is not used. [ABSTRACT FROM AUTHOR]