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Pentosan polysulfate sodium (PPS), a semisynthetic sulfated polysaccharide, is the only FDA-approved oral therapy for interstitial cystitis. Recent studies have described a progressive, vision-threatening macular condition associated with long-term PPS use. We reviewed all publications concerning PPS maculopathy to consolidate known clinical features and to evaluate the strength of this association. Current literature supports a strong dose-dependent association between PPS exposure and a progressive maculopathy impacting the retinal pigment epithelium (RPE) and RPE-photoreceptor interface that may worsen even after drug cessation. Initial symptoms may include prolonged dark adaptation and difficulty reading with relative visual acuity preservation. Fundus examination often shows macular pigment clumps corresponding to lesions of focal RPE thickening. Fundus autofluorescence most clearly depicts the condition, with a distinctive pattern of hypo- and hyperautofluorescent spots in the posterior pole that sometimes extends to the retinal periphery. Many cases also show a characteristic peripapillary hypoautofluorescent halo. Near infrared reflectance may aid in early detection. RPE atrophy, cystoid macular edema, and macular neovascularization may also occur, potentially resulting in loss of central acuity. This newly described association implies significant public health risk. Ophthalmologists should screen PPS users with multimodal retinal imaging, and prescribers should minimize dose and duration of PPS use.

Purpose Determine the efficacy of combination intravitreal and systemic antiviral therapy for the treatment of acute retinal necrosis (ARN) and risk factors impacting visual acuity (VA) and retinal detachment (RD) outcomes. Design Single-center retrospective case series. Participants Patients with an ARN diagnosis based on clinical features and polymerase chain reaction confirmation who were treated at a tertiary referral, university-based academic practice. Methods Patient records were reviewed for demographic information including age and gender. Snellen VA, disease findings including RD outcomes, optic nerve involvement, and treatments were recorded. Incidence rates of major VA and RD outcomes were calculated based on the number of events and exposure times. Cox proportional hazards regression modeling and survival analyses were used to identify factors related to VA and RD outcomes over time. Main Outcome Measures Logarithm of the minimal angle of resolution VA, 2-line or more VA gain, severe vision loss (SVL) of 20/200 or worse, RD development, and fellow eye involvement. Results Twenty-three eyes of 21 patients (11 male, 10 female) were reviewed. Thirteen patients (62%) had herpes simplex virus and 8 patients (38%) had varicella zoster virus. The event rate for 2-line or more VA gain was 0.49 events/eye-year (95% confidence interval [CI], 0.26–0.86 events/eye-year), whereas the rate of SVL was 0.61 events/eye-year (95% CI, 0.34–1.02 events/eye-year). Retinal detachment development was observed at a rate of 0.59 events/eye-year (95% CI, 0.33–1.00 events/eye-year). Thirteen of 23 eyes (57%) demonstrated RD with a mean time of 120 days after ARN diagnosis. With each additional quadrant of retina involved, a greater risk of RD development over time was observed (hazard ratio, 2.21; 95% CI, 1.12–4.35). Nine percent of eyes progressed with additional quadrantic involvement, despite combination systemic and intravitreal antiviral therapy; however, none of the 19 patients demonstrating unilateral ARN showed fellow-eye involvement after initiation of therapy. Conclusions Combination intravitreal and systemic antiviral therapy for ARN can be effective in improving VA and limiting retinitis progression. Each additional quadrant of retina involved was associated with a 2.2-fold greater risk of RD, which may impact monitoring, timing of intervention, and patient counseling.

Retinal detachment (RD) is associated with poor visual outcomes in patients with acute retinal necrosis (ARN). This research was undertaken to assess the risk factors for RD in ARN.Retrospective cohort study.Patients diagnosed with ARN at a tertiary referral center from 2010 to 2020.A chart review was performed for all clinical and surgical encounters. Univariate and multivariate logistic analyses of demographic and clinical variables associated with RD were performed. Survival analyses with Kaplan-Meier estimates were performed to compare the time to RD in herpes simplex virus (HSV)- and varicella zoster virus (VZV)-associated ARN.Demographic information, clinical information (including visual acuity [VA]), intraocular pressure (IOP), intraocular inflammation level, the extent of retinitis, incidence and timing of retinal detachment, date of diagnosis, and treatments performed (including intravitreal injections of antiviral medications).Fifty-four eyes of 47 patients who were diagnosed with ARN were included, with equal proportions of eyes (n = 27; 50%) with VZV-ARN and HSV-ARN. Patients with VZV-ARN were, on average, older, more likely to be men, and more likely to be immunosuppressed compared with patients with HSV-ARN. The clinical characteristics, including the initial VA, initial IOP, anterior segment inflammation, clock hours, and posterior extent of retinitis, were similar between eyes with VZV- and HSV-ARN. In the univariate analysis of clinical and demographic variables associated with the development of RD, initial VA (P = 0.0083) and greater clock hours of retinitis (P = 0.009) were significantly associated with RD. These 2 variables remained significant in the multivariate logistic regression; worse VA at presentation had an odds ratio of 2.34 (95% confidence interval [CI], 1.01-5.44; P = 0.042), and greater clock hours of retinitis had an odds ratio of 1.23 (95% CI, 1.02-1.47; P = 0.025). A Kaplan-Meier survival analysis demonstrated no statistical difference in RD-free survival between HSV- and VZV-ARN.Patients with VZV-ARN were more likely to be older, male, and immunosuppressed compared with those with HSV-ARN, although no clear difference was observed in RD by viral etiology. Poor initial VA and clock hours of retinitis were significantly associated with RD development and may be relevant for patient counseling and prognosis.

Dysregulation of the ubiquitin–proteasomal system (UPS) enables pathogenic accumulation of disease-driving proteins in neurons across a host of neurological disorders. However, whether and how the UPS contributes to oligodendrocyte dysfunction and repair after white matter injury (WMI) remains undefined. Here we show that the E3 ligase VHL interacts with Daam2 and their mutual antagonism regulates oligodendrocyte differentiation during development. Using proteomic analysis of the Daam2–VHL complex coupled with conditional genetic knockout mouse models, we further discovered that the E3 ubiquitin ligase Nedd4 is required for developmental myelination through stabilization of VHL via K63-linked ubiquitination. Furthermore, studies in mouse demyelination models and white matter lesions from patients with multiple sclerosis corroborate the function of this pathway during remyelination after WMI. Overall, these studies provide evidence that a signaling axis involving key UPS components contributes to oligodendrocyte development and repair and reveal a new role for Nedd4 in glial biology.

During the last decade, results from ELISA test kits have often been criticized as being flawed. Therefore, it may appear counterintuitive that ELISAs are used for most food allergen and gluten analytical needs. One reason, in addition to the nonavailability of comparable alternative methods, is the fact that the methods used underwent a long validation and learning period in the market. This publication presents several case studies on interference, cross-reactivity issues, calibrators, fragmented allergens and gluten, matrix influences, and misunderstood intended-use statements. Afterward, the relevant validation parameter LOD, LOQ, selectivity, and precision are discussed. Finally, a comprehensive list of practical recommendations for ELISA test kit users is presented.

Importance Patient perceptions regarding the risks of obtaining in-person ophthalmic care during the coronavirus disease 2019 (COVID-19) pandemic may affect adherence to recommended treatment plans and influence visual outcomes. A deeper understanding of patient perspectives will inform strategies to optimize adherence with vision-preserving therapies. Objective To evaluate perceptions of COVID-19 exposure risk and their association with appointment attendance among patients at high risk of both reversible and irreversible vision loss from lapses in care. Design, Setting, and Participants This survey study included a nonvalidated telephone survey designed in April and May of 2020 and a retrospective medical record review conducted in parallel with survey administration from May 22 to August 18, 2020. Participants were recruited from 2 tertiary eye care centers (Emory Eye Center in Atlanta, Georgia, and W.K. Kellogg Eye Center in Ann Arbor, Michigan). The study included a random sample of patients with diagnoses of exudative age-related macular degeneration (AMD) or diabetic retinopathy (DR) who received an intravitreal injection between January 6 and March 13, 2020, and were scheduled for a second injection between March 13 and May 6, 2020. Main Outcomes and Measures Association between perceptions regarding COVID-19 risks and loss to follow-up. Results Of 1004 eligible patients, 423 (42%) were successfully contacted, and 348 (82%) agreed to participate (participants’ mean [SD] age, 75 [12] years; 195 women [56%]; 287 White [82%] patients). Respondents had a mean (SD) of 2.7 (1.1) comorbidities associated with severe COVID-19, and 77 (22%) knew someone with COVID-19. Of all respondents, 163 (47%) were very concerned or moderately concerned about vision loss from missed treatments during the pandemic. Although 208 (60%) believed the COVID-19 virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), exposure at the eye clinic was extremely unlikely or unlikely, 49 (14%) believed it was extremely likely or likely. Seventy-eight participants (22%) were lost to follow-up. Concern regarding COVID-19 exposure during clinic visits (odds ratio [OR], 3.9; 95% CI, 1.8-8.4) and diagnosis of DR (vs AMD) (OR, 8.130; 95% CI, 3.367-20.408) were associated with an increase in likelihood of loss to follow-up. Conclusions and Relevance Among patients at high risk for vision loss from lapses in care, many expressed concerns regarding the effect of the pandemic on their ability to receive timely care. Survey results suggest that fear of SARS-CoV-2 exposure was associated with a roughly 4-fold increase in the odds of patient loss to follow-up. These results support the potential importance of clearly conveying infection-control measures.

Introduction This quality improvement pilot study focused on developing and facilitating readiness for transition in youth with spina bifida. The results contribute to a broader institution-wide initiative at a subspecialty pediatric organization. Methods The clinical roles of six nurse care coordinators were restructured to add responsibility for transition care coordination. Together, parents, youth, and nurse transition care coordinators created and implemented individualized family-centered care plans focused on improving self-management and readiness for transition to adulthood. The Transition Readiness Assessment Questionnaire was administered before and after intervention initiation. Results Fourteen youth–parent pairs participated in this study. Postintervention Transition Readiness Assessment Questionnaire results indicated that both parents and youth perceived improvement in transition readiness. Youth perceived more improvement than did parents. Discussion This pilot study showed that budget-neutral processes can be systematically implemented to facilitate transition preparation from pediatric to adult health care services for youth with spina bifida and their families.

A fundamental component of the medical home model is care coordination. In Minnesota, this model informed design and implementation of the state's health care home (HCH) model, a key element of statewide healthcare reform legislation. Children with medical complexity (CMC) often require care from multiple specialists and community resources. Coordinating this multi-faceted care within the HCH is challenging. This article describes the need for specialized models of care coordination for CMC. Two models of care coordination for CMC were developed to address this challenge. The TeleFamilies Model of Pediatric Care Coordination uses an advanced practice registered nurse care (APRN) coordinator embedded within an established HCH. The PRoSPer Model of Pediatric Care Coordination uses a registered nurse/social worker care coordinator team embedded within a specialty care system. We describe key findings from implementation of these models, and conclude with lessons learned. Replication of the models is encouraged to increase the evidence base for care coordination for the growing population of children with medical complexities.

Introduction The past decade has been marked by a gradual expansion of the traditional primary care role of the pediatric nurse practitioner (PNP) into practice arenas that call for more acute and critical care of children. The purpose of the study was to explore the educational programming needs of dual (combined) track PNP programs that prepare graduates to provide care to children and adolescents across the continuum of health and illness. Method A two-phase, exploratory, mixed method design was utilized. An electronic survey was completed by 65% of PNP program directors in the country. Semi-structured telephone interviews were conducted with hospital-based PNPs who were practicing in roles that met a range of health care needs across the primary and acute care continuum. Results Primary care and acute care programs have more common than unique elements, and the vast majority of clinical competencies are common to both types of program. Only three competencies appear to be unique to acute care programs. Discussion The Association of Faculties of Pediatric Nurse Practitioner Programs should utilize existing evidence and develop guidelines for dual PNP programs that focus on the provision of care to children across a wide continuum of health and illness.

www.jpedhc.org The Patient Protection and Affordable Care Act (PPACA) of 2010 is the legislation that created the foundation for reformof theU.S. health care system.The legislation established and funds diverse policies and projects to realign the financial incentives in the current health care insurance market. It encourages efficiency and quality and directs funds toward prevention and population health. Many regulations and rules from the legislation are currently being formulated to translate the law’s provisions into actual changes in health care practices and processes (Table 1). The law includes much for advanced practice nurses (APNs) to celebrate, such as funding for nursemanaged centers and increased nurse education loans and grants. Care innovations, a provision in the health care reform legislation, have significant potential for enhancing APN practice even though physician-exclusive language in the legislation resulted in nurse practitioners (NPs) not being fully included in key provisions of the care innovations reforms. This article focuses on one of the care innovations strongly supported in the PPACA, the health care/medical home. It provides background on the health care/medical home model, the importance of family-focused caremodels, and suggestions for possible partnership for APNs to forge with family advocacy groups to improve access and quality and to strengthen the position of NPs in the newmodels of health care delivery.

Background This study describes rural health care professionals’ perceptions about professional isolation and the availability, accessibility, and relevance of continuing education.Methods:Registered nurses (n = 165) and physicians (n = 59) providing health care services in 26 rural hospitals in two Midwestern states participated in the study.Results:Rural health care providers experience barriers to accessing relevant continuing education. Although physicians reported higher levels of professional isolation than their nurse counterparts, professional isolation was identified as a concern by both provider groups.Conclusions:To ensure an adequate supply of knowledgeable and skillful rural health care professionals, continuing education specific to the delivery of care in rural settings is necessary. Once developed, the continuing education must be delivered in a manner that is acceptable and accessible to isolated rural providers.

Although there is general agreement that noise in the neonatal intensive care unit should be reduced, there is controversy about the use of music as a developmental care strategy with preterm infants. Much literature supports using music with preterm infants, indicating that it enhances physiologic and neurobehavioral functioning, but some experts worry that music is overstimulating. This article presents evidence supporting the use of music with preterm infants as well as criticism of same. Recommendations for music interventions with preterm infants are discussed, although further research is needed before specific guidelines can be established.

Cognitive performance in 7- to 9-year-old preterm neonatal intensive-care survivors was compared with that in age-matched control children. Non-verbal memory span, spatial working-memory abilities, planning, set-shifting, and recognition memory for both spatial and patterned stimuli were assessed using the Cambridge Neuropsychological Testing Automated Battery. Relative to children in the control group, neonatal intensive-care unit (NICU) survivors demonstrated 25% more memory errors on the spatial working-memory task. Their use of strategy on this task was similar to a control group of 5-year-olds. Planning times on 'Tower of London' problems were long relative to those of term controls. NICU survivors demonstrated poorer pattern recognition as well as a shorter spatial memory span. The groups did not differ in visual-discrimination learning or in spatial-recognition memory. No specific neonatal risk factor accounted for the observed differences, although scores on the Neurobiological Risk Score (NBRS), a composite measure of neonatal risk, did predict several aspects of later task performance. Whether these data reflect a developmental delay in brain maturation in NICU survivors or the presence of a permanent information-processing deficit due to adverse neonatal events must be assessed through continued follow-up.

A high prevalence of epilepsy diagnoses and seizure events among students was identified at a large Midwestern school district. In partnership with the Epilepsy Foundation of Minnesota (EFMN), a quality improvement project was conducted to provide education and resources to staff caring for school children with seizures. School nurses ( N = 26) were trained as seizure management educators and instructed staff in 21 schools on seizure awareness and response. School nurses utilized new seizure management resources, a procedural guideline, and care plan updates. The majority of school nurses rated the resources and training interventions as “very helpful.” School nurse confidence in managing students with seizures increased, seizure action plan use increased, and 88% of children’s records with new seizure diagnoses had completed documentation. School nurses played vital roles in increasing seizure awareness as educators and care managers. EFMN is using this project as an exemplar for expanding its Seizure Smart Schools program.

This article is a call for pediatric nurse researchers to lead, participate in, and disseminate care coordination researchand implementation science. This challenge is issued because of aging population demographics, resource scarcity, and the need for evidence-based childhealthpolicyadvocacy.Itisnotnewsthattheburgeoning needs of the elderly population can easily cause children to be pushed off the priority list for research funding. What may be news is the urgent need for nurse scholars to continue to pursue pediatric quality measurement and outcomes research and to engage in visible, high-impact child-focused implementation science studies to shape evolving health sys

This descriptive study of practice barriers compared the perceptions of 67 psychiatric/mental health clinical nurse specialists (PMH-CNSs) with those of 767 nurse practitioners (NPs) in a single state. In addition, it contrasted the barriers identified by the rural and urban PMH-CNS study participants (n=14 and 53, respectively). Though all participants found the practice climate moderately restrictive on a 5-point Likert scale (1=very restrictive to 5=not restrictive), the PMH-CNSs found the practice environment significantly more restrictive than the NPs (3.13 versus 3.61, p

Context: Rural residents experience the same incidence of acute illness as urban populations and have higher levels of chronic illness. Overall, access to adequate rural health care is limited. Nurse practitioners (NPs) have been identified as safe, cost-effective providers in meeting these challenges in rural settings. Purpose: This replication study was conducted to examine NP perceptions of barriers to rural practice in Minnesota. Findings were compared to earlier studies to examine issues that have persisted over time. Methods: A Barriers to Practice checklist was mailed to NPs from the database of the Board of Nursing of a midwestern state. Rural NPs (n = 191) identified and described barriers to practice and rated the overall restrictiveness of their practice. Findings: Barriers to practice were perceived to be prevalent. Persisting barriers continued to stand in the way of full utilization of NP roles. Lack of understanding of NP roles on the part of the public and other health professionals has been particularly problematic over time. Key issues in 2001 were low salaries, lack of adequate office space, and a limited peer network. Perceived restrictiveness of the practice climate, gauged as somewhat restrictive, remained unchanged between 1996 and 2001. Conclusions: NPs have an excellent history of meeting rural primary health care needs. Enhancing the NP work environment could prove instrumental to retaining these professionals in the work force and thereby contribute to improved access and quality of care in underserved rural communities.

Spontaneous regression of primary melanoma lesions is regarded as the result of the recognition of melanoma-associated antigen (MAA)-derived peptides by cytotoxic T-lymphocytes and destruction of melanoma cells. The transporter associated with antigen processing (TAP1/2) is likely to play a crucial role in this process since it loads antigen peptides onto MHC class I molecules. To determine the impact of TAP defects on the spontaneous regression of melanoma lesions, we have compared the expression of TAP1 and TAP2 in 39 primary melanoma lesions exhibiting clinical and histological signs of tumour regression and in 35 primary melanoma lesions without regression phenomena. TAP1 expression was significantly associated with regression of melanoma lesions, since the staining pattern with anti-TAP1 antibody was positive in 38 of the 39 lesions exhibiting regression phenomena and in only 24 of the 35 lesions without histopathological signs of tumour regression. In the latter group, six lesions were stained with a heterogeneous pattern and five with a negative pattern. Furthermore, in lesions with a heterogeneous staining pattern, a clear association was found between TAP1 expression in melanoma cells and the presence of tumour-infiltrating lymphocytes. These results suggest that TAP1 plays an important role in the MAA-specific cytotoxic T-lymphocyte response, which has been suggested to underlie the spontaneous regression of primary melanoma.

The current study examined memory and executive functioning in a sample of children who were hospital ized in a neonatal intensive care unit (NICU) after birth. Thirty-two children born prematurely and/or with medical complications (NICU children) and 25 control children born at term were assessed with the Cambridge Neuropsychological Testing Automated Battery (CANTAB), a multi-dimensional computer-based measure of memory and executive functioning. Comparisons between the NICU and control groups on the CANTAB subscales indicated that the NICU children had a shorter spatial memory span length and committed more forgetting errors on a spatial working memory task. Correlational analyses demonstrated that the number and extent of medical complications at birth was negatively associated with spatial memory span, planning and spatial recognition memory. Multiple regression models suggested that gestational age was of primary importance in predicting spatial memory span, while neurobiological risk was primary in the prediction of spatial working memory errors. Overall, the current results showed fewer deficits in this group of children than were found in a previous neuropsychological assessment of this cohort. The implications of this finding for discerning the effects of neural plasticity over and above normal brain maturational processes are discussed.

BACKGROUND Ill or premature newborns are at increased risk for ongoing morbidity throughout childhood. Federal legislation now mandates that states provide early intervention, special education, and disability accommodations for children with special needs. Because all children born prematurely do not require all services, targeting services to the children with greatest risk is essential. This study examined whether neonatal characteristics could predict special school-based service use (speech, occupational, physical therapy, special education) in later childhood. METHODS Subjects were 53 children, ages 7 to 11 years, graduates of one Midwest Level 3 neonatal intensive care unit (NICU). Neonatal data were used to calculate Neurobiologic Risk Scores (NBRS), a sum of illness factors related to brain damage. Birth weight, length of NICU stay, and NBRS were compared to the children's school performance on standardized tools and to report cards. RESULTS Most children studied were not receiving special school services. The NBRS and parent report of child competency were related (p = 0.01). Length of NICU stay correlated with teachers' reports of children's academic performance (p = 0.04), and to use of special school services use (p = 0.03). As the NBRS score increased, report card performance decreased. CONCLUSIONS Neonatal characteristics predicted school-age service use. This is important for nurses because predicting which children are most likely to need special services can aid in tracking children at high risk for prompt assessments and referrals. Parents, healthcare providers, educators, advocacy groups, and funding agencies need accurate outcome data to influence health, educational, and social policy decisions.

Understanding a care coordination framework, its functions, and its effects on children and families is critical for patients and families themselves, as well as for pediatricians, pediatric medical subspecialists/surgical specialists, and anyone providing services to children and families. Care coordination is an essential element of a transformed American health care delivery system that emphasizes optimal quality and cost outcomes, addresses family-centered care, and calls for partnership across various settings and communities. High-quality, cost-effective health care requires that the delivery system include elements for the provision of services supporting the coordination of care across settings and professionals. This requirement of supporting coordination of care is generally true for health systems providing care for all children and youth but especially for those with special health care needs. At the foundation of an efficient and effective system of care delivery is the patient-/family-centered medical home. From its inception, the medical home has had care coordination as a core element. In general, optimal outcomes for children and youth, especially those with special health care needs, require interfacing among multiple care systems and individuals, including the following: medical, social, and behavioral professionals; the educational system; payers; medical equipment providers; home care agencies; advocacy groups; needed supportive therapies/services; and families. Coordination of care across settings permits an integration of services that is centered on the comprehensive needs of the patient and family, leading to decreased health care costs, reduction in fragmented care, and improvement in the patient/family experience of care.

Pediatric nurse practitioners (PNPs) can create excellent professional roles caring for children with special health care needs (CSHCN) and their families. Children with chronic conditions represent an estimated 31% of the US population younger than 18 years (approximately 20 million children in 1988). Five percent of all children who have multiple special needs account for approximately 40% of all pediatric health care expenditures. Skill building is needed for PNPs who have traditionally focused on wellness and common acute illnesses in primary care settings. Role theory and research can guide PNPs in creating roles and interventions to improve the health, safety, and developmental outcomes for CSHCN and their families. Two roles are described, with examples of specific nursing interventions. Assisting child care centers to serve children and families with special needs is an ideal role for PNPs who have knowledge of health and regulatory issues. Another important PNP role is working with adolescents with special health care needs as they transition from pediatric to adult care. Many resources (such as those from the Maternal and Child Health Bureau) are available to assist PNPs to create new roles and interventions for CSHCN and their families.

To examine outcomes related to health, growth, and use of community health and education services in children ages 6 to 8 years who received newborn intensive care because of prematurity or perinatal complications.Parents of 81 children who had received neonatal intensive care at a Midwest US tertiary care center completed a mailed questionnaire. Three birth weight groups (very low birth weight [VLBW]1500 g, n = 35; low birth weight [LBW] 1501-2500 g, n = 24, and normal birth weight [NBW]2500 g, n = 22) were compared regarding growth, health, and use of community-based services using descriptive statistics and one-way analysis of variance.VLBW and NBW groups had more ongoing health concerns. Growth patterns were similar in all groups. VLBW and NBW groups demonstrated greater use of community-based services, and service use increased at school age.Comprehensive systems are needed for follow-up of high-risk infants to detect and refer problems early. Neonatal histories must be tracked throughout childhood. Seriously ill term NBW infants are at risk for later morbidity and require follow-up similar to that provided for VLBW children.

Nurses are encountering many opportunities and incentives to engage in interdisciplinary initiatives. The aim of these initiatives, which are sponsored by private foundations, academic institutions, and managed care entities, is to increase the quality and efficiency of health care. Maintaining professional integrity in the midst of interdisciplinary collaboration is complex and warrants close examination. Contextual issues, which include differing values, professionalism, boundary questions, communication, and power, affect the success of interdisciplinary activities.

This qualitative study was carried out to add empirical data to the discussion of the essentials of advanced practice graduate nursing education. Study participants were 15 nurse practitioners (NPs) whose original preparation was as clinical nurse specialists (CNSs). These nurses subsequently completed post-master's preparation as NPs at a midwest US school of nursing. The nurses were interviewed regarding similarities and differences between the NP and CNS roles based on their own experiences. They stated that their 1-year post-master's NP educational program broadened their knowledge base and increased their skills of direct data collection in history taking and physical examination. They described increased NP role autonomy and clinical decision making. Comparison of study results with the six practice domains of the National Association of Nurse Practitioner Faculties (NONPF) Curriculum Guidelines appeared to verify the NONPF domains as being operant in advanced nursing practice. Each role had distinct expression of the NONPF practice domains, particularly in two areas: management of client health-illness states and the professional role. Results suggest that advanced practice graduate nursing curricular content needs to be explicit regarding CNS and NP role domains to retain the respective strengths of each. A "hybrid" CNS/NP curriculum faces the danger of lacking both the depth and specificity of knowledge that has resulted in the roles' past successes.

Objective. We performed an outcome evaluation of the impact of public health preparedness training as a group comparison posttest design to determine the differences in the way individuals who had participated in training performed in a simulated emergency. Methods. The Experimental Group 1 included students who had graduated from or were currently enrolled in the bioterrorism and emergency readiness (BT/ER) curriculum at the University of Minnesota School of Public Health. The comparison groups included individuals who had access to the Internet and were aware of the 2006 online simulation Disaster in Franklin County: A Public Health Simulation. The evaluation process employed surveys and the gaming simulation as sources for primary data. Results. Participants in the BT/ER curriculum ( p=0.0001) and other participants completing at least 45 hours of training in the past year ( p=0.0001) demonstrated higher effectiveness scores (accuracy of chosen responses within the simulation) than participants who did not report significant amounts of training. Conclusions. This evaluation research demonstrated that training is significantly associated with better performance in a simulated emergency using gaming technology.

The climate of health care in the United States continues to be tumultuous, with widespread calls for change. Concerns about health care costs are matched by public demands for quality, safety, efficiency, and appropriate access for all (Institute Of Medicine [IOM], 2001; Sorian, 2006). Nurse practitioners (NPs) are increasingly recognized as providing a level of care comparable to physicians (Brooks, 2009), prompting the design of newmodels of care delivery that integrate NPs. This growing recognitionofeffectivenesshasgiven rise to a myriad of new NP positions in diverse settings ranging from community-based to high-acuity critical care. Nursing educators are challenged to effectively deliver NP educational programs to meet the demand for highly skilled advanced practice registered nurses (APRNs). Recent landmark collaboration between theNational Council of State Board of Nursing (NCSBN) and the APRN Joint Dialogue Group has resulted in the widely supported document, ‘‘Consensus Model for APRN Regulation: Legislation, Accreditation, Certification, and Education’’ (NCSBN, 2008). This publication establishes common language around titles, scopes of practice, and patient populations; it clarifies terminology, regulation, and roles of all types of APRNs, including primary care and acute care NPs. The consensus document lays the groundwork to create a consistent approach to APRN credentialing by logically linking the

62 Volume 24 Number 1 this time of intense political and economic challenges. NAPNAP values its representation on many significant physician-directed agencies and committees (e.g., the American Academy of Pediatrics’ [AAPs’] Bright Futures work groups and its Medical Home Project Advisory Committee, the National Institute for Childhood Health and Human Development, and others) and has developed productive new relationships (e.g., the Institute of Medicine, U.S. Preventive Services Task Force, and Patient Centered Primary Care Collaborative). In stark contrast to these successful alliances is continuing and exacerbating resistance to nurse practitioner (NP) autonomy from physician groups. In fact, ongoing during this unprecedented health care reform era is considerable interdisciplinary disagreement over scope of practice, reimbursement, and regulatory language. NAPNAP regrets that physicians and advanced practice registered nurses (APRNs) have reached a new stage of interdisciplinary discord. Nurses must be aware of two coalitions that are responding in very different ways to current health care trends: the Scope of Practice Partnership (SOPP) and the Coalition for Patient Rights (CPR). The SOPP is a coalition convened by the American Medical Association (AMA) in 2005 with various physician organizations that engage in tracking scope of practice legislative and regulatory efforts throughout the United States. The SOPP funds investigations into the educational preparation and licensure requirements of health care providers with the goal of opposing autonomous practice of all providers except physicians. The SOPP monitors state legislation and

BACKGROUND Few validated pediatric tools exist to directly gather data about children's perceptions of their own healthcare; parent surveys are typically used as proxies. A psychometrically sound, child-focused survey captures children's unique perceptions for quality improvement. OBJECTIVES This study developed and evaluated reliability of a survey, assessed score differences by children's age, and compared the responses of children and parents. METHOD The Children's Perceptions of Healthcare Survey was developed for inpatient and outpatient quality improvement. Following expert review, the tool was administered to 237 parent-child dyads at the time of discharge from an inpatient pediatric unit (n = 121) and after outpatient clinic visits (n = 116). Responses were analyzed and compared. RESULTS Internal consistency reliability for the tool was high (child/adolescents: alpha = .84; parents: alpha = .86), with no significant differences by child age or child gender. Parent and child scores were significantly correlated (r = 0.29, P < .001). About half of parents' scores were higher than their children's scores. DISCUSSION This tool worked well to collect data from a wide age range of children across healthcare settings. Children's perceptions were unique; involving children in care assessment is worthwhile and captures insights missed when only parents are surveyed. The Children's Perceptions of Healthcare Survey is a valid, psychometrically sound tool to capture children's unique perspectives regarding their healthcare and may be useful for system quality improvement.

The growing prevalence of chronic conditions in childhood underscores the urgent need to educate pediatric nurse leaders to address the complex issues these children and families face. This article describes a model of graduate education for preparing pediatric nurse leaders who are equipped to manage and advocate for these children and families. Fifty-one master's prepared graduates completed a Strategic Plan Needs Assessment Survey in 2007 and were asked to indicate specific clinical and leadership competencies that they perceived were essential for pediatric nurse leaders in their areas of practice. Results revealed the highest priority for continuing education and outreach regarding pediatric health to be clinical updates and management of children with special healthcare needs (CSHCN), followed by health promotion for CSHCN and care coordination/case management. The highest priority for continuing education and outreach regarding leadership in pediatrics was evidence-based practice, followed by team care/interdisciplinary practice. The challenge for current nurse leaders is to be cognizant of the urgent need to prepare and retain future pediatric nurse leaders who are experts in the care of CSHCN and their families.

Context: Neonatal resuscitation is a critical component of perinatal services in all settings. Purpose: To systematically describe preparedness of rural hospitals for neonatal resuscitation, and to determine whether delivery volume and level of perinatal care were associated with overall preparedness or its indicators. Methods: We developed the 15-point Hospital Neonatal Resuscitation Survey to examine institutional preparedness for neonatal resuscitation in 4 areas: policy and procedure, resuscitation team membership, continuing education, and connections with a wider system of perinatal care. All 58 rural hospitals with perinatal services in 2 upper Midwestern states (North Dakota and Minnesota) were asked to provide information describing preparedness for neonatal resuscitation. Nursing administrators responded to the survey. Findings: A total of 26 hospitals took part. Annual delivery volume ranged from 4 to 958. Preparedness scores ranged from 4 to 12. Hospitals with more than 125 deliveries each year reported significantly higher levels of preparedness than lower volume hospitals (9.50 vs 5.83, P < .001). Overall preparedness was not associated with level of perinatal care. Most rural hospitals did not identify a formal collaborative relationship with a regional level III perinatal center. Conclusions: Substantial variation in hospital preparedness for neonatal resuscitation was identified. Preparedness was associated with delivery volume. Lack of collaborative agreements between rural hospitals and level III perinatal centers was pervasive. Additional research into the measurement of hospital preparedness for neonatal resuscitation as a component of quality rural perinatal care is needed to optimize outcomes for rural-born neonates.

The absorption of a pharmacological dose of vitamin D3 from two different lipid vehicles, peanut oil, containing long chain fatty acids, and a medium chain triglyceride was compared. Serial measurements of the serum concentration of vitamin D3 after dosage were made. The serum levels of 25-hydroxyvitamin D3, the major circulating vitamin D3 metabolite, were also determined. The analytical methods used were based on HPLC. In the fasting state, the serum levels of vitamin D3 were significantly higher after administration in peanut oil than after administration in the medium chain triglyceride. When the vitamin D3 dose was ingested together with food no difference between the two formulations was observed. Only small inter-formulation differences in serum 25-hydroxyvitamin D3 levels were detected. The results indicate that the presence of long chain fatty acids facilitates the absorption of vitamin D3.

Currently, 10.2 million children (13.9%) from birth through 17 years of age in the United States have special health care needs (SHCN); these children represent 29% of households (Child and Adolescent Health Measurement Initiative [CAHMI], 2007). The umbrella term “special health care needs” was officially adopted by the U.S. federal government in the Omnibus Balanced Budget Act of 1989 due to the efforts of an advocacy coalition led by the federal Maternal and Child Health Bureau (MCHB). A child has SHCN if he or she “has or is at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also requires health and related services of a type or amount beyond that required by children generally” (McPherson et al., 1998). Noncategorical terminology such as SHCN is useful because it groups children across many diagnoses and categorizes them by needs and functional difficulties. A recent survey using 2005-2006 data found that 85% of children with SHCN had functional difficulties, 57% had difficulty with bodily functions, 49% had difficulty with participation in any activity, and 42% had emotional or behavioral difficulties (CAHMI, 2007). This report found that needs of children with SHCN are complex: 86% needed prescription medications, 52% needed specialist care, 25% needed mental health care, 23% needed specialized therapies, and 11 % used durable medical equipment (CAHMI). The MCHB (2007) has issued a call to action to urge service providers, communities, states, families, and federal partners to develop and improve community-based systems of care for children with SHCN and their families. Linking information systems, coordinating care, and identifying children with SCHN through ongoing screening are key priorities of the MCHB. Tiedje

Introduction Opinions about satisfaction with care are rarely solicited from children. This study's purpose was to compare children's ratings of patient satisfaction with outpatient care to ratings given by parents. Method This descriptive and comparative survey study compared responses of a convenience sample of children and adolescents (n = 116) who received care at two metropolitan pediatric subspecialty clinics with their parents' responses (n = 115). Ratings were obtained using the "Satisfaction with Child Healthcare Survey," an instrument adapted with permission from the "Kids Count Survey" developed at McMaster Health Center in Ontario, Canada. Additionally, three open-ended questions were solicited and analyzed for major themes. Results There was moderate significant correlation between child-teen and parent scores. Parents rated care significantly higher than did the children. Children's responses to open-ended questions varied somewhat from their parents' opinions on various aspects of clinic visits. Discussion Findings suggested that having parents evaluate children's care may not accurately represent the views of children and teens. Findings supported children and teens' ability to provide valuable perceptions about care that can inform clinic improvement processes.

Social capital is a health-related construct that is a way for pediatric nurse practitioners (PNPs) to conceptualize the interconnectedness between health and social relations. Applying the concept of "social capital" to child and family health has the capacity to help PNPs reframe persistent questions and explore health issues in new and creative ways. A health-enabling environment must be built using a bottom-up approach, with participatory health promotion programs and internally driven community health projects. PNPs must create opportunities for networking and diffusing knowledge about community-related health issues. PNPs also must build their own social capital and practice "vision therapy" to develop new interventions to enhance child and family health.

Maximizing nurse-physician collaboration holds promise for improving patient care and creating satisfying work roles. The purpose of this article is to describe strategies that will facilitate effective nurse-physician collaboration. First the nature and the benefits of collaborative communication will be reviewed. This review will be followed by a discussion of self-development, team-development, and communication-development strategies that can enhance nurse-physician collaboration.

Characterization of the molecular basis of tumor recognition by T cells has shown that major histocompatibility complex (MHC) class I molecules play a crucial role in presenting antigenic peptide epitopes to cytotoxic T lymphocytes. MHC class Ia downregulation has been repeatedly described on melanoma cells and is thought to be involved in the failure of the immune system to control tumor progression. Proper assembly of MHC class I molecules is dependent on several cofactors, e.g. the chaperones calnexin and calreticulin residing in the endoplasmic reticulum. Alterations in the expression of these chaperones may have important implications for MHC class I assembly, peptide loading, and presentation on the tumor cell surface and thus may contribute to the immune escape phenotype of tumor cells. In the present study, we compared melanoma lesions representing different stages of tumor progression with regard to the expression of calnexin and calreticulin in tumor cells by means of immunohistochemistry. Metastatic melanoma lesions exhibited significant downregulation of calnexin as compared to primary melanoma lesions. In contrast, chaperone calreticulin was expressed in melanoma cells of primary as well as of metastatic lesions. Our data suggest that chaperone-downregulation, particularly calnexin-downregulation, may contribute to the metastatic phenotype of melanoma cells in vivo. Consistently, conserved chaperone expression in metastatic melanoma lesions may be a useful criterion for selection of patients for treatment with T cell-based immunotherapies.

Recently, expression of the immunoproteasome subunits low molecular protein (LMP) 2 or LMP7 was shown to reduce the presentation of certain major histocompatibility complex (MHC) class I-restricted tumour peptide epitopes in renal cell carcinoma and melanoma cells. This may provide the tumour cells with an immune escape mechanism. To test the relevance of this hypothesis, we have taken advantage of the fact that spontaneous regression of human primary melanoma is thought to be the result of a successful peptide-specific cellular immune response in vivo. Immunohistochemical staining with anti-LMP2 and anti-LMP7 xenoantibodies showed a significantly higher expression of these immunoproteasome subunits in primary melanoma lesions exhibiting histological signs of tumour regression than in primary melanoma lesions without regression phenomena. In spontaneously regressing melanoma lesions, LMP2 and LMP7 expression was significantly associated with the presence of tumour-infiltrating lymphocytes. Our results are compatible with the possibility that the expression of the immunoproteasome subunits LMP2 and LMP7 rather than their downregulation in melanoma cells is associated with the presence of a successful anti-melanoma immune response.

Care coordination is a process that involves assessment, planning, implementation, evaluation, education, monitoring, support, and advocacy. Pediatric nurse practitioners (PNPs) are well positioned to coordinate care but may not be well educated about potential conflicts of interest in balancing cost-containment constraints with obtaining maximum quality and quantity of care for children and families with complex needs. The philosophy of family-centered care is embodied in some care coordination models and absent in others. PNPs who aim to support families of children with special health care needs need to understand the complexity of interacting with multiple care coordination models across health and educational settings. PNPs may act as change agents to infuse family-centered care principles into existing and future care coordination models.