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BACKGROUND: Patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) engage in low levels of activity, putting them at risk for relapse and future readmissions. There is little direction for health care providers regarding the parameters for safe exercise during an AECOPD that is effective for increasing activity tolerance before discharge from hospital, especially for patients with associated comorbid conditions.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common respiratory condition and the fourth leading cause of death in Canada. Optimal COPD management requires patients to participate in their care and physician knowledge of patients’ perceptions of their disease.

Dyspnea is a cardinal symptom of chronic obstructive pulmonary disease (COPD), and its severity and magnitude increases as the disease progresses, leading to significant disability and a negative effect on quality of life. Refractory dyspnea is a common and difficult symptom to treat in patients with advanced COPD. There are many questions concerning optimal management and, specifically, whether various therapies are effective in this setting. The present document was compiled to address these important clinical issues using an evidence-based systematic review process led by a representative interprofessional panel of experts.

Pulmonary rehabilitation (PR) participation is the standard of care for patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic despite bronchodilator therapies. However, there are questions about specific aspects of PR programming including optimal site of rehabilitation delivery, components of rehabilitation programming, duration of rehabilitation, target populations and timing of rehabilitation. The present document was compiled to specifically address these important clinical issues, using an evidence-based, systematic review process led by a representative interprofessional panel of experts.

Endemic tuberculosis (TB) was almost certainly present in Canadian aboriginal people (aboriginal Canadians denotes status Indians, Inuit, nonstatus Indians and metis as reported by Statistics Canada) before the Old World traders arrived. However, the social changes that resulted from contact with these traders created the conditions that converted endemic TB into epidemic TB. The incidence of TB varied inversely with the time interval from this cultural collision, which began on the east coast in the 16th century and ended in the Northern Territories in the 20th century. This relatively recent epidemic explains why the disease is more frequent in aboriginal children than in Canadian-born nonaboriginal people. Treatment plans must account for the socioeconomic conditions and cultural characteristics of the aboriginal people, especially healing models and language. Prevention includes bacillus Calmette-Guerin vaccination and chemoprophylaxis, and must account for community conditions, such as rates of suicide, which have exceeded the rate of TB. The control of TB requires a centralized program with specifically directed funding. It must include a program that works in partnership with aboriginal communities.

OBJECTIVES: To evaluate various aspects of the management of adult patients who present to the emergency department with acute exacerbations of asthma and who are discharged from the emergency department without hospital admission. Further, to compare the results with accepted management guidelines for the emergency department treatment of asthma.

The cardiopulmonary exercise test (CPET) is an important physiological investigation that can aid clinicians in their evaluation of exercise intolerance and dyspnea. Maximal oxygen consumption (V˙O2max) is the gold-standard measure of aerobic fitness and is determined by the variables that define oxygen delivery in the Fick equation (V˙O2 = cardiac output × arterial-venous O2 content difference). In healthy subjects, of the variables involved in oxygen delivery, it is the limitations of the cardiovascular system that are most responsible for limiting exercise, as ventilation and gas exchange are sufficient to maintain arterial O2 content up to peak exercise. Patients with lung disease can develop a pulmonary limitation to exercise which can contribute to exercise intolerance and dyspnea. In these patients, ventilation may be insufficient for metabolic demand, as demonstrated by an inadequate breathing reserve, expiratory flow limitation, dynamic hyperinflation, and/or retention of arterial CO2. Lung disease patients can also develop gas exchange impairments with exercise as demonstrated by an increased alveolar-to-arterial O2 pressure difference. CPET testing data, when combined with other clinical/investigation studies, can provide the clinician with an objective method to evaluate cardiopulmonary physiology and determination of exercise intolerance.

The Steep Ramp Anaerobic Test (SRAT) was developed as a clinical test of anaerobic leg muscle function for use in determining anaerobic power and in prescribing high-intensity interval exercise in patients with chronic heart failure and Chronic Obstructive Pulmonary Disease (COPD); however, neither the test-retest reliability nor the physiological qualities of this test have been reported. We therefore, assessed test-retest reliability of the SRAT and the physiological characteristics associated with the test in patients with COPD. 11 COPD patients (mean FEV1 43% predicted) performed a cardiopulmonary exercise test (CPET) on Day 1, and an SRAT and a 30-second Wingate anaerobic test (WAT) on each of Days 2 and 3. The SRAT showed a high degree of test-retest reliability (ICC=0.99; CV=3.8%, and bias 4.5 W, error −15.3–24.4 W). Power output on the SRAT was 157 W compared to 66 W on the CPET and 231 W on the WAT. Despite the differences in workload, patients exhibited similar metabolic and ventilatory responses between the three tests. Measures of ventilatory constraint correlated more strongly with the CPET than the WAT; however, physiological variables correlated more strongly with the WAT. The SRAT is a highly reliable test that better reflects physiological performance on a WAT power test despite a similar level of ventilatory constraint compared to CPET.

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.

Chronic obstructive pulmonary disease (COPD) is a common cause of disability and death in Canada. Moreover, morbidity and mortality from COPD continue to rise and the economic burden is enormous. The main goal of the Canadian Thoracic Society (CTS) Evidence-Based Guidelines is to optimize early diagnosis, prevention and management of COPD in Canada. Targeted spirometry is strongly recommended to expedite early diagnosis in smokers and exsmokers who develop respiratory symptoms, and who are at risk for COPD. Smoking cessation remains the single most effective intervention to reduce the risk of COPD and to slow its progression. Education, especially self-management plans, are key interventions in COPD. Therapy should be escalated in accordance with the increasing severity of symptoms and disability. Long acting anticholinergics and beta2-agonist inhalers should be prescribed for patients who remain symptomatic despite short-acting bronchodilator therapy. Inhaled steroids should not be used as first line therapy in COPD, but have a role in preventing exacerbations in patients with more advanced disease who suffer recurrent exacerbations. Management strategies consisting of combined modern pharmacotherapy and nonpharmacotherapeutic interventions (eg, pulmonary rehabilitation/exercise training) can effectively improve symptoms, activity levels, and quality of life, even in patients with severe COPD. Acute exacerbations of COPD cause significant morbidity and mortality and should be treated promptly with bronchodilators and a short course of oral steroids; antibiotics should be prescribed for purulent exacerbations. Patients with advanced COPD and respiratory failure require a comprehensive management plan that incorporates structured end-of-life care.

Variants of uncertain significance (VUS) are commonly identified in genetic testing. The rate at which a VUS is reclassified depends on multiple factors. However, as the amount of time it might take for a VUS to be reclassified varies, some patients with a VUS genetic testing result might have passed away before the VUS is reclassified. A VUS that is reclassified after the patient's death has clinical implications for the deceased patient's family members. The disclosure of reclassified VUS results for a deceased patient has complex legal and ethical implications. There are no established guidelines on how the reclassified VUS result for a deceased patient should be disclosed to at-risk relatives. An online survey was sent to members of the National Society of Genetic Counselors (NSGCs) to elicit practices and opinions regarding this issue. A total of 153 (4%) NSGC members completed the survey. Thirty-seven (24.2%) respondents reported having received a reclassified VUS for a deceased patient. Respondents were more likely to attempt disclosure if the variant was reclassified as pathogenic (93.5%) versus benign (76.5%), although the difference did not reach statistical significance (p = 0.06). Respondents more often reported the impact on family members (85.5%) than the decedent's right to privacy (15.0%) as extremely important when considering disclosure to family members. A legal mechanism to allow disclosure to relatives was supported by 70.6% of respondents and 97.4% felt the issue was important enough to pursue if such a process was in place. Only 9.8% of respondents supported a legal requirement of consent before disclosing to family members when a VUS is reclassified after the patient has passed away. Our results indicate that there is no consensus for how these results should be handled and a mechanism for disclosure of reclassified results to family members is supported., (© 2024 National Society of Genetic Counselors.)

Background: Improved survival rates for children with intestinal failure (IF) have resulted in an increased population of children receiving long-term parenteral nutrition (PN). Our objective was to determine burden on caregivers of children with IF receiving long-term PN., Methods: We performed a cross-sectional study of caregivers of children with IF receiving long-term PN in our intestinal rehabilitation program. A healthy comparison group matched on age of the child was enrolled. All participants completed standardized questionnaires, including the Parental Stress Index - Short Form (PSI-SF), Hospital Anxiety and Depression Scale (HADS), and PedsQL Family Impact Module (PedsQL FIM). Univariate analysis was completed using a Student t test and chi-square, with an alpha value of <0.05 considered significant., Results: Thirty-eight caregivers of children with IF and 29 caregivers of healthy children consented, with response rates of 89% and 96.5%, respectively. Our study demonstrated increased stress for caregivers compared with comparison parents (PSI-SF total score of 83 [SD = 26.8] vs 62.9 [SD = 13.5]; P < 0.01). Caregivers had increased anxiety (HADS anxiety score of 9.3 [SD = 4.8] vs 6.7 [SD = 3.2]; P = 0.02) and higher depression scores (HADS depression score of 6.3 [SD = 4.3] vs 4.1 [SD = 2.6]; P = 0.02) compared with the comparison group. Caregivers of children with IF demonstrated decreased health-related quality of life (HRQoL) (reduced PedsQL FIM total score of 50.6 [SD = 18.2] vs 84.1 [SD = 20.5]; P < 0.01)., Conclusions: Our results demonstrated significant burden of care in caregivers of children with IF receiving long-term PN, with elevated stress, anxiety, and depression and decreased HRQoL., (© 2022 American Society for Parenteral and Enteral Nutrition.)

Background: Children with intestinal failure (IF) receiving long-term parenteral nutrition (PN) require significant medical care, including high-risk procedures such as accessing a central venous catheter, with the majority provided by family caregivers in the home. This study sought to understand the experiences of family caregivers., Methods: This was a qualitative study of family caregivers of children with IF. Participants were recruited from an intestinal rehabilitation program to participate in virtual focus groups, which were recorded and transcribed. Thematic analysis was used to capture and describe experiences., Results: Thirteen caregivers providing care to 11 children participated in three virtual focus groups held between May and June 2020. Data analysis revealed five primary themes: (1) caregiving as a 24/7 commitment, (2) facing constant risk of death, (3) chronic illness creates difficult feelings and emotions, (4) effects on all aspects of family life, and (5) adapting and functioning as a family. The findings of this study pair well with the biopsychosocial model highlighting the need for multifaceted assessment and supports., Conclusion: The impact of caring for a child with IF receiving long-term PN is significant for caregivers and their families and has implications for all aspects of their lives. A better understanding of the impact on caregivers and their coping strategies lays the groundwork for the optimization of quality of life for caregivers and their family., (© 2022 American Society for Parenteral and Enteral Nutrition.)

Stigmatization of patients exists in nursing and results in less than optimal nursing care and poor patient outcomes. It is also a violation of our code of ethics. In order to eliminate stigmatization from nursing practice, it is necessary to understand how it develops. Two possible theoretical pathways are proposed to explain the development of stigmatization in nursing. These pathways are informed by a conceptual understanding of stigma and theories of professional socialization, professional formation, symbolic interactionism, and social cognitive theory. Re-labeling and role-taking and moral disengagement are proposed as two possible processes that may lead to stigmatization of patients. Both proposed pathways have implications on professional socialization, formation, and the development of professional identity. Devoting attention to and reframing normative behavioral expectations, eliminating labeling, developing empathy, focusing on relationships, and cultivating ethical comportment and moral maturity during nursing formation may reduce the stigmatization of patients by nurses., (© 2021 John Wiley & Sons Ltd.)

Workplace violence is a significant problem in healthcare. It was believed that in the context of patient violence nurses faced a moral dilemma regarding conflicting duties to self and patients. A qualitative study was conducted with nurses who experienced physical violence perpetrated by a patient. The aim was to examine the ethical decision-making process nurses used to determine the "right" course of action. Nurses did not perceive the conflict between these two duties as the primary dilemma they faced. They appreciated their patients' vulnerability and the power differential inherent in the RN-patient relationship and maintained that their primary responsibility was patient safety. Interpretation of the event was the primary dilemma they described. Patient violence was framed as a dichotomous experience: an expected part of the job or a crime. The middle space between these two choices was bounded by a fuzzy, porous, extremely difficult to interpret line. The dichotomous interpretation resulted in a perception of dichotomous responses: do nothing or file criminal charges. Violence in the context of the RN-patient relationship is a complex phenomenon involving a host of factors. We need to direct more attention to this complexity, to individualized responses to workplace violence, and to depolarizing this issue., (© 2021 John Wiley & Sons Ltd.)

Access to fresh and healthy food within a neighborhood has been identified as a social mechanism contributing to community health. Grounded in the understanding that challenges related to equity within a food system are both structural and systemic, our research demonstrates how systems thinking can further understandings of food system complexity. Within systems thinking, we provide an illustration of how system archetypes offer an analytic tool for examining complex community issues. We map semi-structured interview data from community stakeholders (N = 22) to the "Fixes that Fail" system archetype to illuminate systemic challenges, such as incarceration and poverty, that structure food system inequity in urban communities. Within our research, the "Fixes that Fail" archetype provided a narrative interpretive tool for unveiling complexity within the food system and interdependencies with racialized systems such as criminal justice and labor markets. This system archetype provided an accessible approach for generating narratives about systemic complexity, the production of inequity through racialized forces, and opportunities for transformation., (© 2021 Society for Community Research and Action.)

Issue Addressed: Utilisation of professional health care interpreting services improves the quality and safety of health care among patients with limited English proficiency. Health care interpreter service utilisation is inconsistent and suboptimal in Australia. Evidence of the impact of interpreter service use on patient outcomes and costs is limited. This study aimed to identify the proportion of hospitalised patients who received a health care interpreter during admission and describe the characteristics and outcomes for those requiring interpreter services., Methods: A retrospective cohort analysis of linked admitted patient data with internal interpreter audit data. This study included all inpatients in a health district-wide clinical audit of interpreter service use conducted between July 2016 and March 2018. The dataset comprised 74 patients (including 79 unique hospital stays and 90 episodes) from eight hospitals in one regional health district in New South Wales, Australia., Results: Interpreting services were utilised at least once for 54.4% (n = 43) of admissions. Females were more likely to receive an interpreter (65.1% vs 47.1%, P = .04). Age, preferred language, hospital, Diagnosis-Related Group partition and comorbidities were not associated with interpreter service utilisation. Differences in length of stay and cost associated with use of interpreter services were not statistically significant after casemix adjustment., Conclusions: Approximately half of those who required an interpreter received one during their hospital stay. Further investigation is needed to establish whether regular clinical audits contributed to this rate of utilisation, which is higher than reported elsewhere in the literature. SO WHAT?: A detailed understanding of regional interpreting service use with evidence from the literature provides compelling and contextual evidence for change, at the level at which the service is delivered. This supports meaningful action to increase utilisation, and improve the quality and safety of health care delivered to patients with limited English proficiency., (© 2020 Australian Health Promotion Association.)

Objectives: The aim of the study was to find evidence of SARS-CoV-2 infection in UK cats., Design: Tissue samples were tested for SARS-CoV-2 antigen using immunofluorescence and for viral RNA by in situ hybridisation. A set of 387 oropharyngeal swabs that had been submitted for routine respiratory pathogen testing was tested for SARS-CoV-2 RNA using reverse transcriptase quantitative PCR., Results: Lung tissue collected post-mortem from cat 1 tested positive for both SARS-CoV-2 nucleocapsid antigen and RNA. SARS-CoV-2 RNA was detected in an oropharyngeal swab collected from cat 2 that presented with rhinitis and conjunctivitis. High throughput sequencing of the viral genome revealed five single nucleotide polymorphisms (SNPs) compared to the nearest UK human SARS-CoV-2 sequence, and this human virus contained eight SNPs compared to the original Wuhan-Hu-1 reference sequence. An analysis of the viral genome of cat 2 together with nine other feline-derived SARS-CoV-2 sequences from around the world revealed no shared cat-specific mutations., Conclusions: These findings indicate that human-to-cat transmission of SARS-CoV-2 occurred during the COVID-19 pandemic in the UK, with the infected cats developing mild or severe respiratory disease. Given the ability of the new coronavirus to infect different species, it will be important to monitor for human-to-cat, cat-to-cat and cat-to-human transmission., (© 2021 The Authors. Veterinary Record published by John Wiley & Sons Ltd on behalf of British Veterinary Association.)

Objectives: The primary objective of this study was to compare the protection afforded by a standard face shield design with a new enhanced design in a controlled setting., Methods: This study was exempted from review by institutional review board waiver. A flexible fiberoptic endoscopy was placed through stellate openings in the standard face shield and the enhanced face shield. A series of simulated coughs were created with bursts of fluorescein dye through an atomizer tip placed within the test participant's mouth. Ultraviolet lighting illuminated the test area, and areas of dye splatter were noted., Results: Fluorescein dye is easily aerosolized along the lateral inferior aspect of a standard shield with significant contamination of the surrounds. The enhanced face shield maintained a barrier to the aerosolized dye., Discussion: Face shields, rather than face masks, should be considered a preferred alternative for the public and for health care professionals alike, as they address many of the personal protective equipment concerns especially during the COVID-19 pandemic. Otolaryngologists are at high risk from aerosol-generating procedures, such as flexible fiberoptic endoscopy, even when wearing personal protective equipment. Here we describe a uniquely designed face shield to be worn by the patient as another layer of protection for the environment and for medical personnel., Implications for Practice: During the course of a flexible fiberoptic endoscopy, medical personnel are safely isolated from potential infectious particles with a newly designed face shield.

Despite its lack of conceptual clarity and uniform definition, the term drug-seeking is used frequently by nurses from a variety of practice environments. The drugs patients are referred to as seeking are often pain medications. This is important because nursing has widely adopted a patient-centric definition of pain. Nursing also has a robust ethical code that places high value on human dignity and nurses' role in patient advocacy. A review of literature was conducted with the aims of describing whether/how the term drug-seeking has changed over time and to determine whether the use of the term in nursing literature is consistent with nursing values. Use of the term has shifted from objective counts of patient requests for medication to a confusing mixture of observable patient behavior and subjective interpretations of patient motivation. Its use is not consistent with nursing values. It is, in fact, a good illustration of stigmatization in nursing. Stigmatization is contrary to nursing values. Nurses in practice, research, education, authors, reviewers, and editors all have a role in ending this stigmatization., (© 2019 John Wiley & Sons Ltd.)

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Background: Metabolic syndrome (MSY) is associated with an increased risk of cardiovascular disease, type 2 diabetes, and recurrence in breast cancer survivors (BCS). MSY is 1.5 times more common in Hispanic women compared with non-Hispanic women. Although exercise mitigates MSY in BCS, to the best of the authors' knowledge, few studies to date have focused on minorities. This secondary analysis examined ethnicity as a moderator of the effects of a 16-week aerobic and resistance exercise intervention on MSY, sarcopenic obesity, and serum biomarkers in BCS., Methods: A total of 100 eligible BCS were randomized to exercise (50 BCS) or usual care (50 BCS). The exercise intervention promoted moderate to vigorous aerobic and resistance exercise 3 times a week for 16 weeks. MSY z scores, sarcopenic obesity, and serum biomarkers were measured at baseline, after the intervention, and at the 28-week follow-up (exercise group only). Linear mixed models adjusted for baseline values of the outcome, age, disease stage, adjuvant treatment, and recent physical activity were used to evaluate effect modification by ethnicity., Results: The study sample was 57% Hispanic BCS (HBCS) and 43% non-Hispanic BCS (NHBCS). HBCS were younger, of greater adiposity, and had been diagnosed with more advanced cancers compared with NHBCS (P<.001). Ethnicity was found to moderate the mean differences in exercise training on triglycerides (-36.4 mg/dL; 95% confidence interval [95% CI],-64.1 to -18.8 mg/dL), glucose (-8.6 mg/dL; 95% CI, -19.1 to -3.0 mg/dL), and C-reactive protein (-3.3 mg/L; 95% CI, -7.3 to -0.9 mg/L)., Conclusions: HBCS appear to have poorer metabolic profiles and therefore may derive relatively larger metabolic changes from exercise compared with NHBCS. Clinical exercise interventions may attenuate existing health disparities across diverse groups of BCS., (© 2018 American Cancer Society.)

Objective: To evaluate whether tocilizumab (TCZ) monotherapy is noninferior to treatment with TCZ plus methotrexate (MTX) for maintaining clinical responses in patients with rheumatoid arthritis (RA) in whom low disease activity is achieved with TCZ plus MTX., Methods: Patients with RA who experienced an inadequate response to MTX received MTX plus TCZ 162 mg subcutaneously. At 24 weeks, patients who achieved a Disease Activity Score in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR) of ≤3.2 were randomized to receive TCZ monotherapy or to continue treatment with TCZ plus MTX until week 52. The primary outcome measure was the comparison of the mean change in the DAS28-ESR from week 24 to week 40 between the TCZ monotherapy and TCZ plus MTX arms (noninferiority margin of 0.6). Secondary outcome measures included worsening of the DAS28-ESR by ≥1.2, achievement of a DAS28-ESR of <2.6 and ≤3.2, and safety and immunogenicity., Results: Among the 718 patients enrolled, 296 were randomized at week 24 to receive TCZ monotherapy (n = 147) or TCZ plus MTX (n = 147). The mean changes in the DAS28-ESR from week 24 to week 40 were 0.46 and 0.14 in the TCZ monotherapy arm and the TCZ plus MTX arm, respectively (weighted difference between the groups, 0.318 [95% confidence interval 0.045, 0.592]); discontinuing MTX in TCZ responders was noninferior to continuing MTX. Safety events were broadly similar between the randomized treatment groups; the most common serious adverse event was infection, which occurred in 2.1% of patients in the TCZ monotherapy group and 2.2% of patients receiving TCZ plus MTX., Conclusion: Patients with RA receiving TCZ plus MTX who achieve low disease activity can discontinue MTX without significant worsening of disease activity during the 16 weeks following MTX discontinuation., (© 2018 The Authors Arthritis & Rheumatology published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.)

Aims and Objectives: The purpose of this study was to explore the meaning of patient-nurse interaction for older women receiving care in healthcare settings., Background: Older women are often overlooked or misunderstood by the nurses caring for them. Some research exists on nurses' perception of their interaction with patients, yet few studies have described the meaning of such interaction from the patients' perspective., Methods: This was a pilot study using qualitative description as a methodology. Data were filtered through a lens of critical feminist theory to interpret interactions taking place in healthcare settings that are often characterised by paternalism. Seven women between the ages of 66 and 81 were interviewed using a semi-structured guide., Results: Participants had a distinctive perspective on the experience of caring. Their expressions include stories of being cared for themselves by nurses as well as historical recalls of being the one-caring for family members. In these combined stories, the contrast between the nurses who held caring in primacy and those who were distinctly uncaring sheds light on the importance of cultivating a moral ideal of caring and respect for personhood., Conclusion: A population of older women who potentially face disabling conditions must rely on direct, meaningful, interaction with nurses to successfully navigate the healthcare system. The findings suggest that these women did not have consistent access to such interaction., Implications for Practice: The gathering and interpretation of new narratives about patient-nurse interaction for older women could lead to a deeper understanding of power and civility as it impacts a caring relationship. Further research using a theoretical lens of critical feminism has implications for improving healthcare delivery for older women worldwide., (© 2017 John Wiley & Sons Ltd.)

Objective: Several competency models for training and practice in professional psychology have been proposed in the United States and Canada. Typically, the procedures used in developing and finalizing these models have involved both expert working groups and opportunities for input from interested parties. What has been missing, however, are empirical data to determine the degree to which the model reflects the views of members of the profession as a whole., Method: Using survey data from 466 licensed or registered psychologists (approximately half of whom completed one of two versions of the survey), we examined the degree to which psychologists, both those engaged primarily in practice and those involved in doctoral training, agreed with the competency framework developed by the Association of State and Provincial Psychology Boards' Practice Analysis Task Force (Rodolfa et al., 2013)., Results: When distinct time points in training and licensure or registration were considered (i.e., entry-level supervised practice in practicum settings, advanced-level supervised practice during internship, entry level independent practice, and advanced practice), there was limited agreement by survey respondents with the competency framework's proposal about when specific competencies should be attained. In contrast, greater agreement was evident by respondents with the competency framework when the reference point was focused on entry to independent practice (i.e., the competencies necessary for licensure or registration)., Conclusion: We discuss the implications of these findings for the development of competency models, as well as for the implementation of competency requirements in both licensure or registration and training contexts., (© 2016 Wiley Periodicals, Inc.)

Background: Antibiotic treatment decisions for medically complex patients are complicated, as the risk of undertreatment may be severe, whereas overtreatment may be associated with adverse effects and the emergence of antibiotic resistant pathogens., Objective: To determine the influence of patient complexities on providers' decisions to prescribe antibiotics in 3 common hospital-based clinical vignettes., Design: A physician survey., Setting: Three urban medical centers in Los Angeles County, California., Participants: Hospital-based physicians., Measurements: Physicians were presented 3 clinical vignettes, with variations by patient age, comorbidity burden, functional status, and follow-up, and asked to choose the best antibiotic regimen. We described the association of additional patient complexity on the proportion of guideline-adherent antibiotic choices., Results: In the survey, 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with either older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P < 0.01)., Conclusions: In 3 vignettes depicting common clinical scenarios among hospitalized adults, inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities. Treatment guidelines should consider addressing medically complex patients in the context of infection management., (© 2015 Society of Hospital Medicine.)

Objectives: The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies., Methods: Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression., Results: Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014)., Conclusions: Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes., (© 2015 by the Society for Academic Emergency Medicine.)

Introduction: In 2004, the Midwives Alliance of North America's (MANA's) Division of Research developed a Web-based data collection system to gather information on the practices and outcomes associated with midwife-led births in the United States. This system, called the MANA Statistics Project (MANA Stats), grew out of a widely acknowledged need for more reliable data on outcomes by intended place of birth. This article describes the history and development of the MANA Stats birth registry and provides an analysis of the 2.0 dataset's content, strengths, and limitations., Methods: Data collection and review procedures for the MANA Stats 2.0 dataset are described, along with methods for the assessment of data accuracy. We calculated descriptive statistics for client demographics and contributing midwife credentials, and assessed the quality of data by calculating point estimates, 95% confidence intervals, and kappa statistics for key outcomes on pre- and postreview samples of records., Results: The MANA Stats 2.0 dataset (2004-2009) contains 24,848 courses of care, 20,893 of which are for women who planned a home or birth center birth at the onset of labor. The majority of these records were planned home births (81%). Births were attended primarily by certified professional midwives (73%), and clients were largely white (92%), married (87%), and college-educated (49%). Data quality analyses of 9932 records revealed no differences between pre- and postreviewed samples for 7 key benchmarking variables (kappa, 0.98-1.00)., Discussion: The MANA Stats 2.0 data were accurately entered by participants; any errors in this dataset are likely random and not systematic. The primary limitation of the 2.0 dataset is that the sample was captured through voluntary participation; thus, it may not accurately reflect population-based outcomes. The dataset's primary strength is that it will allow for the examination of research questions on normal physiologic birth and midwife-led birth outcomes by intended place of birth., (© 2014 by the American College of Nurse-Midwives.)