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Community Health Assessment Collaboration: Implementing a Joint Assessment Between a Healthcare System and a Local Health Department
Get PDFNon-profit hospitals and local health departments (LHDs) often complete community health assessments (CHAs) to help understand the needs of their community and develop implementation strategies to address the community needs. Hospitals and LHDs in the same community often develop separate CHAs with similar results leading to overlap in work and funds. This project aimed to address this issue in the Dallas-Fort Worth Metroplex by convening one local health department, Denton County Public Health, and one non-profit healthcare system, Texas Health Resources, to leverage resources from each other to build a joint CHA. The Mobilizing for Action through Planning and Partnerships 2.0 Toolkit developed by the National Association for County and City Health Officials was used to guide the CHA collaboration process. Both organizations used the toolkit to form a CHA design team, assess current resources and develop an implementation plan to fully assess the community’s needs. This plan will be completed over the next year and will follow with the two organizations jointly developing and implementing strategies
Patient-Centered Preimplant Education Session and Bi-weekly Text Message Adherence Reminders in Patients with a Newly Implanted CardioMEMs® Device: A Quality Improvement Study
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Heart failure is a deadly disease, affecting over 6.2 million individuals and costing the United States an estimated 30.7 billion dollars (Virani et al., 2020). By 2023, heart failure costs in the United States are estimated to grow to 70 billion dollars with 75-80% of these costs attributed to inpatient hospitalizations (Heidereich et al., 2022). The CardioMEMs® is a small device placed in the patient’s pulmonary artery via a minimally invasive procedure by an interventional cardiologist. The use of remote patient data from the CardioMEMs® device has been shown to reduce hospital re-admissions, facilitate tailored medication management, detect increased pulmonary artery pressures before clinical signs of decompensated heart failure, and improve patient quality of life (Haynes et al., 2020). The focus of this project will be to improve patient compliance with daily remote CardioMEMs® readings using patient reminders beyond the standard of care within the Nebraska Medicine healthcare network.
Purpose Statement
The purpose of this quality improvement project is to evaluate the effects of increased CardioMEMs® education and bi-weekly adherence reminders on CardioMEMs® compliance, heart failure-related symptoms, physical and social functioning, self-efficacy, knowledge, quality of life, patient activation, and health care utilization.
PICOT: In ambulatory heart failure patients with a CardioMEMs® device, how do a preimplant education session and bi-weekly text messages affect adherence over two-months?
Objectives:
1. The purpose of this quality improvement project is to evaluate the effects of increased CardioMEMs® education and bi-weekly adherence reminders on data transmission rates, heart failure-related symptoms, physical and social functioning, self-efficacy, knowledge, quality of life, patient activation, and health care utilization (outpatient clinic visits, emergency room visits, and 30-day hospital re-admissions).
2. Compare retrospective cohort and prospective cohort CardioMEMs® adherence data.
3. Perform comparison statistical analyses for retrospective cohort and prospective cohort CardioMEMs® adherence data comparing adherence rates from retrospective review of January 2022-December 2022 and two months following CardioMEMs® implant for the prospective cohort.
Methods:
Design: This is a quality improvement study with retrospective cohort chart review and prospective cohort intervention analysis.
Setting and participants: Participants will be recruited by the Nebraska Medicine Heart Failure Services line.
Outcome and measurements: The primary outcome measure will be CardioMEMs® compliance with at least six out of seven days of the week, or 85% compliance. Secondary outcome measures include the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Patient Activation Measure (PAM), and health care utilization which will be collected at enrollment and two months post-study intervention. Study participants will also receive enhanced education, which will be an individualized Zoom education session with a member of the Doctoral of Nursing Practice (DNP) student research team approximately one week prior to CardioMEMs® implant.
Analysis: Descriptive statistics (counts and percentages) were used to measure patient adherence. The difference in adherence was assessed with a Wilcoxon signed-rank test. Relationships between demographic and outcomes variables were assessed using Pearson\u27s correlational methods.
Results:
A total of 10 participants were enrolled in the study, n=8 male and n=2 female. A total of 10 participants completed the pre-implant education. Average CardioMEMs® compliance from the retrospective cohort was 75% with the prospective cohort having 81% compliance.
While the compliance in the intervention group (Median = 85.0) was higher than compliance for the previous year (Median = 74.8), a Mann-Whitney U test indicated that it was not significantly different U = 74.0, p = .381. While this was not statistically significant, it was clinically significant. Amongst the study participants, our results did show a statistical significance in the decrease of 30-day hospital re-admission rates/HCU3 (U= 1.5, p = 0.020) between those with higher compliance rates (median = 100%) compared to those with lower compliance (median= 67%). Over half (60%, 6) of participants experienced an increase in their diuretic therapy.
A total of n=9 participants had pre- and post-survey results completed. Using a Wilcoxon singed Rank test, he median differences between baseline PAM and 12-week PAM scores equals 0; p= 0.672 (p
Conclusion:
A preimplant education session and increase in weekly SMS reminders to biweekly did improve daily remote CardioMEMs® reading transmission in our study group to the pre-study established goal of 85% compliance. The remote education session has the potential to be streamlined to independent learning for CardioMEMs® patients or complete remotely for convenience of the patient and the educating nurse as all sessions in this study were done remotely. Further research is needed to study factors that impact patient compliance in this population, while accounting for heart failure-related symptoms, physical and social functioning, self-efficacy, knowledge, quality of life and patient activation in the patient with a CardioMEMs® device
Sensory Dysfunction and the Role of NRF2 in the Production of Pain in Chronic Hindlimb Ischemia
No full textPeripheral arterial disease (PAD) is a progressive and debilitating atherothrombotic disorder that is estimated to impact \u3e200 million people worldwide. Higher physical activity levels are associated with better overall survival rates, slower decline of functional capability, and improved quality of life. However, intermittent claudication, pain produced by physical activity, severely limits functional capacity in PAD patients. Despite known sensory dysfunction and documented neuropathy in diseased patients, the neural mechanisms that produce pain in PAD are yet to be identified. Importantly, few animal models of hindlimb ischemia (HLI) successfully recapitulate chronic human PAD. We developed a chronic animal model of HLI using intra-femoral catheter occlusion (IFCO). We found that IFCO persistently reduced blood flow to the hindlimb and produced PAD-associated myopathy, including fibrosis and a reduction in cross-sectional area. Using IFCO, a previous pilot study found increased pro-inflammatory macrophage infiltration and activation within the lumbar dorsal root ganglia (DRGs) at the chronic stage of HLI, not only indicating neural inflammation but also the potential for temporally dimorphous mechanisms of pain. We next devised a new tissue-clearing method to analyze the time-dependent effects of HLI on the organization of sensory nerves and vasculature. Surprisingly, only the sciatic nerve had patent alternations in sensory nerve organization. As expected, capillary networks were severely damaged during the acute stages of IFCO but rebounded chronically to levels significantly higher than baseline. Finally, because pro-inflammatory macrophages are sources of reactive oxygen species and pro-inflammatory cytokines, we sought to investigate whether nuclear factor erythroid 2-related factor (Nrf2), a transcription factor coordinating cellular antioxidative responses, in sensory neurons could protect against ischemia-induced pain. We found that upregulating Nrf2 in a subset of sensory neurons that express the transient receptor potential vanilloid 1 (TRPV1) receptor increased mechanical thresholds, indicating that Nrf2 prevented mechanical hypersensitivity. Collectively, this work demonstrates that IFCO is a reproducible and efficient method for studying HLI in rodents and that Nrf2 signaling is a component of sensory dysfunction and pain
Incorporating a High Fidelity Transgender Simulation into Undergraduate Nursing Curriculum
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The purpose of this study was to evaluate the knowledge and attitudes of nursing students participating in a high-fidelity transgender patient simulation. The aims were to increase student knowledge and confidence to improve communication and provide more inclusive and equitable care.
Healthcare providers are not adequately prepared to manage the unique health needs of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community. Nurses are ideally positioned to address gaps in LGBTQ healthcare by providing culturally competent care. Yet, LGBTQ health education is lacking in most undergraduate nursing school curriculums.
Methods
62 undergraduate nursing students participated in a post-surgical transgender patient simulation using a high-fidelity mannequin. Students completed pre-clinical course work including a brief video depicting interactions between healthcare providers and gender queer folk and a pre-simulation survey. Following the high-fidelity mannequin simulation, students completed a post-simulation survey aimed at assessing students’ knowledge, attitudes, and beliefs about LGBTQ patients. Pre- and post-survey scores will be compared using a paired t-test. Nursing faculty were also asked to complete a short questionnaire evaluating the perceived effectiveness of the transgender patient simulation.
Results
Results of the pre-simulation survey showed 81 % of nursing students harbored favorable attitudes toward transgender individuals. Preliminary post-simulation survey results indicate students increased their confidence and capability to care for transgender individuals. Nursing faculty responded positively towards the transgender patient simulation and expressed intent to utilize the simulation in future semesters.
Conclusion
Integrating a high-fidelity transgender patient scenario in the undergraduate nursing curriculum via stimulation has been shown to increase gender-affirming cultural competency among nursing students. The LGBTQ population needs knowledgeable and competent providers to improve patient outcomes and quality of care. As such, nursing students need further instruction and education about LGBTQ health
Multimodal Investigations for the Identification of Surgically Relevant Brain Areas
Get PDFEpilepsy is a neurological disease leading to recurrent and unpredictable seizures. Patients can be diagnosed as focal onset, where the seizure focus resides in one hemisphere; generalized onset, where seizure foci reside in both hemispheres; or unknown onset. Anti-seizure medications are the first line of treatment, and those whose seizures cannot be controlled with medication are diagnosed with drug-resistant epilepsy (DRE). For patients diagnosed with focal onset epilepsy to achieve seizure freedom, surgical resection of the epileptogenic zone (EZ), the region of the brain that is both necessary and sufficient for initiating seizures, is required. The EZ is a theoretical region, so clinical teams often use the seizure onset zone (SOZ) as a surrogate. Before surgical resection, clinical teams will identify brain regions that must be spared to preserve normal cognitive function and brain regions that must be resected to provide therapeutic value. As current clinical methods rely on subjective evaluation, objective measures could improve clinical evaluation and post-surgical outcomes. Using magnetoencephalography (MEG) and intracranial electroencephalography (iEEG), this work attempts to fill this critical knowledge gap by objectively identifying brain areas relevant to surgical intervention. In Chapter 1, we post-process a distributed source localization method to identify the location and boundary of the brain region that activates in response to a somatosensory task performed during MEG recordings. This region is compared to an anatomical atlas and current clinical methods. Our method has high concordance with an anatomical atlas and does not differ from current clinical approaches. In Chapter 2, we perform time-varying effective connectivity analysis on ictal iEEG recordings to identify electrode contacts that may reside in the SOZ. The weighted out-degree is calculated from 10 seconds before to five seconds after the determined electrographic onset. Channels with normalized weighted out-degrees greater than 0.5 are identified as candidate SOZ channels. We find our algorithm provides useful information for the localization of SOZ channels. These findings highlight using computational methods to extract additional information during pre-surgical evaluation. Further validation of these methods could lead to improved outcomes for patients undergoing surgical intervention in the treatment of focal epilepsy
The Interactions of Centromeric Nucleosomes Elucidated by Atomic Force Microscopy
Get PDFNucleosomes are the fundamental unit of compaction for DNA in the genome. These positively charged proteins have two main types of nucleosomes: canonical (H3 containing) and centromere (CENP-A containing). The compacting of DNA allows for DNA to fit into the nucleus of cells, but creates a barrier for DNA accessibility for operations such as replication or transcription. Centromeric chromatin is a subset of chromatin structure and governs chromosome segregation. Compared to the bulk chromosome, centromeres are composed of H3 and CENP-A nucleosomes in which H3 histones is replaced by its homolog CENP-A histone. This results in nucleosomes with different structures, decreasing the bp of wrapped DNA from 147 bp for H3 nucleosomes to 121 bp for CENP-A nucleosomes. All these factors can contribute to centromere function.
We first studied H3 and CENP-A nucleosomes on dry AFM samples, using a novel three-way junction (3WJ) as a DNA marker, and determined the affinity of mononucleosomes on the 601 sequence, which yielded the result of H3 nucleosomes having a higher binding affinity to the sequence 99% and 92% for H3 and CENP-A nucleosomes, respectively. A similar trend was seen for the dinucleosomes with a lower percentage binding to the 601 for the CENP-A nucleosomes then than H3 nucleosomes. Next, we applied time-lapse, high-speed AFM (HS-AFM) to characterize the dynamics of nucleosomes. For both nucleosomes, spontaneous asymmetric unwrapping of DNA was observed, and this process occurs via a transient state with ~100 bp DNA wrapped around the core, followed by a rapid dissociation of DNA. Additionally, HS-AFM revealed higher stability of CENP-A nucleosomes compared with H3 ones, in which dissociation of the histone core occurs prior to the nucleosome dissociation. The histone core of CENP-A nucleosomes remains intact even after the dissociation of DNA. All of the nucleosomes dynamics studies, indicated a higher stability in CENP-A nucleosome cores vs H3 nucleosomes, a surprising finding due to the lower DNA wrapping of CENP-A nucleosomes.
Transcription is a crucial biological function, and we studied the interaction of H3 and CENP-A nucleosomes separately with NF-κB, one of the critical transcription factors for regulating the immune response and inflammation. We utilized Atomic Force Microscopy (AFM) to characterize complexes of both types of nucleosomes with NF-κB. We found that this transcription factor unravels H3 nucleosomes removing more than 20 base pairs of DNA, and that NF-κB binds to the nucleosome core. Similar results were obtained for the truncated variant of NF-κB comprised only of the Rel Homology domain and missing the transcription activation domain (TAD). This finding suggests that the RelA TAD is not critical in unraveling H3 nucleosomes by NF-κB. By contrast, NF-κB did not bind to or unravel CENP-A nucleosomes. These findings with different affinities for two types of nucleosomes to NF-κB may have implications for understanding the mechanisms of gene expression which are different for the bulk and centromere chromatin.
Atomic Force Microscopy (AFM) is widely used for topographic imaging of DNA and protein–DNA complexes in ambient conditions with nanometer resolution. In AFM studies of protein–DNA complexes, identifying the protein’s location on the DNA substrate is one of the major goals. Such studies require distinguishing between the DNA ends, which can be accomplished by end-specific labeling of the DNA substrate. We selected as labels the three-way DNA junctions (3WJ) assembled from synthetic DNA oligonucleotides with two arms of 39–40 bp each. The third arm has a three-nucleotide overhang, GCT, which is paired with the sticky end of the DNA substrate generated by the SapI enzyme. Ligation of the 3WJ results in the formation of a Y-type structure at the end of the linear DNA molecule, which is routinely identified in the AFM images. The yield of labeling is 69%. The relative orientation of arms in the Y-end varies, such dynamics were directly visualized with time-lapse AFM studies using high-speed AFM (HS-AFM). This labeling approach was applied to the characterization of the nucleosome arrays assembled on different DNA templates. HS-AFM experiments revealed a high dynamic of nucleosomes resulting in a spontaneous unraveling followed by disassembly of nucleosomes.
Future studies expanding on this body of work would look at the effect of three or more nucleosomes on a single DNA strand and how the addition of more nucleosomes starts the higher-order compaction, including both H3 nucleosomes and CENP-A nucleosomes to better elucidate the effects both in the centromere and throughout the chromosome. Additionally the effect of NF-κB on dinucleosomes or trinucleosomes could better elucidate what happens in vivo when DNA is completely wrapped by nucleosomes and a transcription factor must access a specific DNA sequence
Online & Blended Learning Environments: A Mixed Methods Study Evaluating the Feasibility, Acceptability, & Influence of an Online Professional Development Course for Health Professions Educators
Get PDFOnline and blended teaching and learning (OBTL) are integral to the future and success of higher education, including health professions education. Institutions with a goal of developing high-quality online and blended programs must prioritize time and resources dedicated to professional development and training. This research study utilized an online professional development course as an intervention to gain deeper insights into the scope of faculty development to effectively teach in online and blended learning environments. The study, utilizing a convergent mixed methods approach, gathered data through a pre- and post- intervention survey measuring health professions faculty readiness to teach online, a knowledge-based test, and post-intervention focus group discussions. Statistically significant differences in survey and test scores were observed between pre- and post-intervention and advantages of the intervention were highlighted in the focus group discussions. These key findings suggest the efficacy and influence of the educational intervention. Additionally, barriers and recommendations for enhancement were identified, including a notable gap between perceived importance and perceived capability among faculty members. This information pinpoints areas where professional development and support may be beneficial. Outcomes of the study provide valuable insights into health professions faculty members\u27 knowledge, readiness, and perceptions related to teaching in online or blended educational environments
Elucidating the Luteal Microenvironment: The Role of Fibroblasts in Luteal Regression
Get PDFThe corpus luteum is a transient endocrine gland that produces progesterone, a steroid hormone needed for pregnancy. It is a heterogenous gland containing many different cell types: small and large steroidogenic cells, endothelial cells, immune cells, and fibroblasts. At the end of a non-fecund reproductive cycle, the corpus luteum undergoes cyclic regression, a process which is divided into two processes: 1) functional regression, in which progesterone production rapidly declines and 2) structural regression, in which the tissue undergoes rapid remodeling into a fibrotic scar called a corpus albicans. Although fibroblasts are well-known for their role in tissue remodeling, very little is known about the role of fibroblasts in the bovine corpus luteum. In this study, we have isolated bovine luteal fibroblasts and treated them with factors that are elevated in luteal regression. We observed that luteal fibroblasts contribute to inflammation of the corpus luteum by release of the luteolysin prostaglandin F2α (PGF2α) in response to inflammatory cytokines. We also observed that luteal fibroblasts proliferate and produce more collagen in response to fibroblast growth factor 2 (FGF2). RNA sequencing data of bovine luteal tissue identified FGF2 to be elevated in response to PGF2α-induced regression, thereby contributing to the fibrotic phenotype of the regressed corpus luteum. This research has determined that although they are a small population in the corpus luteum, fibroblasts are responsive to growth factors and cytokines during luteal regression and that they can release factors into the luteal microenvironment that contribute to luteal demise. To study the luteal microenvironment in vitro in a way that better reflects the tissue, we have created a three-dimensional (3D) culture system utilizing primary bovine luteal cells. We have found that this system retains the appropriate cell types, is responsive to luteinizing hormone, and produces more progesterone compared to two-dimensional (2D) cultures. Therefore, we have identified a new role for fibroblasts in the corpus luteum and created a new culture system to better study the corpus luteum, which can aid in the search for therapies to improve women’s health and fertility in not just women, but also farm animals
Compensatory Changes in the Visual System as a Result of Neurodegeneration
Get PDFThe brain has the remarkable ability to compensate for damage and maintain physiological set points. In the visual system where even after significant damage has been done, the brain fills in visual gaps because of this compensation. This thesis attempts to understand several components of visual changes after damage in disorders such as glaucoma. This was accomplished by using several models of vision loss in mice including the DBA/2J (D2) and silicone oil (SO) models of glaucoma, the RD10 model of retinitis pigmentosa, and a retina-specific knockout of brain-derived neurotrophic factor (BDNF)— the Chx10-cre; BDNFfl/fl mouse. Through these models we discovered that the cause of the well-known D2 electroretinogram abnormalities were due to a combination of pupil dilation deficits and likely sectorial photoreceptor damage causing a shift in the photoreceptor response curve and decreased amplitude, respectively, compared to strain-matched controls. Additionally, while there are compensatory effects in the excitability of thalamocortical (TC) neurons in the dorsolateral geniculate nucleus for loss of retinal input as a result of IOP increases, we did not find any changes in the superior colliculus in the silicone oil model for glaucoma. Finally, we found that when the neurotrophin BDNF was selectively deleted from the retina, that there were visual deficits in the optomotor response, decreased TC neuron dendritic complexity, and increased single vesicular release events as measured by mEPSCs and mIPSCs. Together, these findings show the ability of visual system to respond to changes in retinal input
Examining The Impact of Racial and Ethnic Disparities in Colorectal Cancer Screening Compliance in The United States and The Potential of Targeted Interventions.
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Examine Colorectal cancer (CRC) screening compliance among racial and ethnic groups in the United States (US) based on the US Preventive Services Task Force (USPSTF) recommendations.
Identify targeted interventions to promote screening compliance, early diagnosis, and CRC survivorship.
Methods: This cross-sectional study utilized 165,878 selected participant responses from the 2022 Behavioral Risk Factor Surveillance System. We modeled and investigated CRC screening compliance based on the USPSTF recommendations as inclusion criteria between racial/ethnic groups in the US while adjusting for covariates using a weighted stepwise logistic regression.
Results: With covariates adjustment, Hispanics (POR 1.16 95%CI 1.04-1.29), Asian American/Native Hawaiians/Pacific Islander (POR 1.88 95%CI 1.57-2.26), and American Indian/Alaskan Native (POR 1.37 95%CI 1.05-1.78) reported less CRC screening compliance compared to White participants. However, Black participants were (POR 0.87 95%CI 0.802-0.95) 13% more likely to comply with CRC screening recommendations.
Conclusions: This study provided further evidence that racial/ethnic disparities in the US are associated with CRC screening compliance. These findings could guide public health in implementing interventions to increase CRC screening compliance among minorities