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Clinical Judgment Among Nurses Initiating Interpreter Services in Patients with Limited English Proficiency: “Striving for Understanding Amid Constraints”
No full textAbstract
Background: Language barriers compromise patient safety, communication, and trust. Nurses are often the first to initiate interpreter services, yet usage remains inconsistent.
Purpose: Using Tanner’s Clinical Judgment Model, this study describes how nurses recognize and respond to language barriers in acute care. Findings reveal that interpreter initiation reflects clinical judgment shaped by empathy, urgency, and system constraints, expanding understanding of equitable communication in nursing practice.
Methods: Guided by Tanner’s Clinical Judgment Model, semi-structured interviews were conducted with 15 registered nurses across diverse acute care units in the United States. Trustworthiness was supported through verbatim transcription, audit trails, and member checking. Data reflexivity were analyzed using content analysis.
Results: Five themes were identified in nurses’ judgments: balancing patient cues, urgent needs, and policy requirements; navigating family as interpreters; cultural competence and interpreter services; limited access to equipment and resources; and a strong desire to communicate effectively. An overarching theme, “Striving for Understanding Amid Constraints,” reflected how nurses sought to bridge language gaps. Nurses initiated interpreters not only based on patient cues but also on the urgency of the situation, with affective responses such as empathy influencing their commitment to effective communication.
Conclusions: Nurses’ judgment in initiating interpreter services is influenced by their responsiveness to patient needs, cultural sensitivity, and organizational factors. Interpreter services enhance safe, equitable care but are hindered by resource limitations.
Implications: Integrating interpreters into nursing workflows, supported by reliable technology, is crucial to delivering culturally responsive, patient-centered care.2 years2027-12-0
The Chitranjan S. Ranawat Award: Factors That Predict Outcome Five Years Following Total Knee Arthroplasty
No full textBackground: Previous reports have identified several potential predictors of pain and function after total knee arthroplasty (TKA). However, the results of these studies are conflicting, and most have a short follow-up after TKA. The purpose of this study was to identify factors predictive of pain and function five years after TKA.
Methods: A multicenter cohort of 3,688 primary unilateral TKA patients from a comparative effectiveness consortium was enrolled. Demographic data, medical and musculoskeletal comorbidities, and patient-reported outcome measures were collected preoperatively and postoperatively at five years, including the Short-Form Health Survey 36-item (SF-36) and the Knee Disability and Osteoarthritis Outcome Score (KOOS) pain and activities of daily living (ADL) function scores. Multivariate regression models with a 95% confidence interval were used to identify independent predictors of KOOS pain and function scores at five years.
Results: The analysis identified the factors that were independently predictive for KOOS pain score at five years: age, insurance, race, Charlson comorbidity index (CCI), back pain, number of other painful hip and knee joints, contralateral knee pain, preoperative SF-36 mental component summary (MCS), and baseline KOOS pain scores. For KOOS ADL, the following predictive factors were identified: age, body mass index, insurance, race, CCI, back pain, number of other painful joints, contralateral knee pain, ipsilateral hip pain, preoperative SF-36 MCS, and physical component summary (PCS) scores, and baseline KOOS ADL scores.
Conclusion: We have identified the factors that each independently predict less improvement in pain and function five years after TKA. These potentially modifiable factors, such as musculoskeletal comorbidities, can be targeted with preoperative patient optimization programs to improve patient outcomes and patient satisfaction after primary TKA. Knowledge of these factors that predict less improvement in pain and function can assist the surgeon and patient during shared decision-making and in setting appropriate patient expectations preoperatively.No embarg
Challenges oncologists face when caring for hispanics living in puerto rico with colorectal cancer and multiple chronic conditions
Full text linkBackground: Colorectal cancer (CRC) is the leading cause of cancer-related death in Puerto Rico, posing significant challenges for patients with multiple chronic conditions (MCC). This qualitative study aimed to explore oncologists' perspectives regarding the care of patients with CRC and MCC in Puerto Rico.
Methods: We conducted semi-structured interviews in Spanish with nine oncologists providing care for patients with CRC in Puerto Rico. We reached data saturation. We performed thematic analysis to identify key patterns and themes within the interview data. The coding scheme evolved through team discussions, with discrepancies addressed for consistency. Quotes were translated from Spanish to English.
Results: Five key themes were: (1) social determinants of health, (2) diagnosis pathways, (3) factors influencing treatment decisions, (4) survivorship and end-of-life care, and (5) care coordination and communication. Oncologists treating patients with CRC and MCC identified the lack of a social support network as a notable care coordination challenge. The health insurance system's pre-authorization requirements for procedures and treatments further complicated care delivery, particularly for older adults, who faced challenges navigating these administrative processes without sufficient support. A lack of transportation and local specialized care services was a noted barrier to comprehensive patient care. Communication between patients, physician and caregivers proved challenging when multiple physicians and procedures were involved with patient's care, often requiring patients to schedule appointments with different specialists themselves. Inter-provider communication primarily relied on phone calls or notes sent with the patient.
Conclusions: Oncologists caring for Hispanic older adults with CRC and MCC encounter complex challenges influenced by unmet social needs and the presence of comorbidities. Tailored approaches, culturally sensitive care, and improved coordination among physicians are vital to enhance the quality of care for this patient population.No embarg
Modulation of Somatic Repeat Expansion with Small Interfering RNAs as a Therapeutic Approach to Huntington's Disease
No full textHuntington’s disease (HD) is a fatal neurodegenerative disorder with no treatment available. Symptoms present in adulthood (age 30-50) when patients inherit >39 trinucleotide CAG repeats in the huntingtin (HTT) gene, with longer repeat lengths leading to earlier onset. Recent studies have highlighted the significance of somatic CAG expansion, particularly in striatal neurons, in driving HD progression. Genome-wide association studies and mouse genetic knockout work implicate the mismatch repair (MMR) pathway in HD progression. However, it is unclear whether therapeutic MMR pathway lowering can block expansion in vivo and if blocking expansion is necessary to halt HD progression. CNS RNA interference is now possible with chemically stabilized divalent siRNA. Here, we demonstrate that divalent siRNA targeting the MMR component, MSH3, blocks somatic CAG expansion in two HD mouse models. We then systematically mapped the MMR pathway with siRNA in vivo, validating that therapeutic silencing of MMR components, MSH3, MSH2, MLH1, MLH3, PMS1, and POLD3 suppresses CAG expansion while lowering FAN1 and PMS2 accelerates it. Using the MSH3 siRNA, we further show that blocking expansion in HD mice prevented HTT protein aggregation and markedly reversed neurodegenerative transcriptomic signatures. The level of neurodegenerative reversal was enhanced by HTT co-silencing, while HTT silencing alone had no measurable effect. Lastly, we validate a unimolecular dual-targeting siRNA scaffold to silence MSH3 and HTT in the CNS. Together, this work supports that blocking the somatic expansion of HTT is a disease-modifying strategy for HD and validates new therapeutic candidates to slow or prevent HD progression.MD/PhD2 years2027-03-2
Global, regional, and national sepsis incidence and mortality, 1990-2021: a systematic analysis
No full textBackground: The global burden of sepsis, a life-threatening dysregulated host response to infection leading to organ dysfunction, remains challenging to quantify. We aimed to comprehensively estimate the global, regional, and national burden of sepsis, including the impact of the COVID-19 pandemic and underlying causes of sepsis-related deaths with co-occurring infectious syndromes.
Methods: We used multiple cause-of-death, hospital, minimally invasive tissue sampling, and linked death certificate and hospital record data representing 149 million deaths, covering 4290 location-years with mortality estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 to capture explicit and implicit sepsis cases and deaths. We estimated age-location-sex-specific fractions of sepsis-related deaths from 195 underlying causes of death and 22 infectious syndromes from 1990 to 2021 using binomial logistic regression models, and estimated sepsis-related deaths using GBD cause-specific mortality estimates. Using 250 million hospital admissions and 7·82 million deaths from hospital data, representing 1310 location-years, we modelled case fatality rates by use of binomial logistic regression, applied to sepsis death estimates to estimate sepsis incidence by age, location, and year.
Findings: In 2021, we estimated 166 million (95% uncertainty interval 135-201) sepsis cases and 21·4 million (20·3-22·5) all-cause sepsis-related deaths globally, representing 31·5% of total global deaths. Sepsis-related deaths decreased between 1990 and 2019, followed by a surge in 2020 and 2021. As of 2021, individuals aged 15 years and older experienced increases across incidence (230%) and mortality (26·3%) since 1990. Those aged 70 years and older had the highest sepsis-related mortality in 2021 (9·28 million [8·74-9·86] deaths). Sepsis-related deaths from infectious underlying causes decreased from 11·8 million (11·1-12·5) in 1990 to 8·34 million (7·72-9·01) in 2019, then increased by 86·4% to 15·5 million (14·7-16·4) in 2021. Sepsis-related mortality due to non-infectious underlying causes of death increased from 4·69 million (4·35-5·05) in 1990 to 5·81 million (5·40-6·25) in 2021; the leading non-infectious underlying causes of death with sepsis were stroke, chronic obstructive pulmonary disease, and cirrhosis. In 2021, bloodstream infections inclusive of HIV and malaria (3·08 million [2·83-3·35]) and lower respiratory infections inclusive of COVID-19 (11·33 million [1·20-1·47]) were the most prominent infectious syndromes complicating sepsis-related deaths from non-infectious underlying causes, representing a consistent trend since 1990.
Interpretation: The global burden of sepsis increased in 2020 and 2021, reversing progress from 1990. Sepsis incidence and mortality increased in people aged 15 years and older, especially those aged 70 years and older, and as a complication of non-infectious underlying causes of death such as stroke, primarily through bloodstream infections and lower respiratory infections. The global burden of sepsis is substantial, and sepsis is increasingly a complication of non-infectious causes of death.
Funding: Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.No embarg
Knowledge, attitudes, and practices surrounding safe medication disposal in a hospice setting
No full textContext: Proper medication disposal is vital to prevent environmental harm and medication misuse, particularly in a hospice setting. Medication disposal kits are becoming more popular as an effective and environmentally friendly choice. Education and training on this topic are paramount for providers after implementation of a 2018 federal law allowing hospice staff to dispose of patient medications in the home.
Objectives: The goal of this study was to assess knowledge, attitudes, and practices of hospice clinical staff about medication disposal before and after an online medication disposal training.
Methods: Frontline clinical staff at a not-for-profit hospice completed an anonymous survey assessing their knowledge, attitudes, and practices of medication disposal before and after a one-hour synchronous online training about medication disposal. Patient medical record review was conducted to determine frequency of medication disposal methods in this setting.
Results: The one-hour online training was completed by 339 clinical staff in Fall 2020. Pre- and post-training surveys were completed by 278 and 110 clinical staff, respectively. Awareness of the 2018 federal law increased from 59% to 93% following the training. Additionally, a higher proportion of clinical staff reported always educating patients on medication disposal at time of hospice admission (31% vs 46%, p = 0.002) and routinely disposing of medication(s) with patients and families (73% vs 83%, p = 0.048).
Conclusion: This study showed increased patient education about medication disposal by clinical staff and increased medication disposal following a one-hour clinician training. This training has the potential to contribute to improved medication disposal in the hospice setting.No embarg
A national growth mixture modeling analysis of county-level COVID-19 incidence rate trajectories and health inequities during three successive pandemic waves in 2020
Full text linkWe applied Growth Mixture Modeling (GMM) to characterize county-level COVID-19 incidence rate (IR) trajectories across three distinct waves in the United States from March 15 to November 2, 2020. GMM enabled the identification of latent subpopulations with shared temporal patterns of disease spread, offering a flexible analytic framework for uncovering both known and evolving disparities. Across the three periods, up to five trajectory groups were identified, revealing substantial geographic and temporal heterogeneity. To support interpretation and reduce multiple comparisons, we developed and validated a 17-item Social Determinants of Health (SDOH) index representing county-level economic and resource access factors. Higher-incidence rate trajectories consistently aligned with lower SDOH scores and greater proportions of Black or African American residents and younger populations. These disparities shifted over time, with patterns of high-incidence rates emerging in resource-limited counties across the South and Midwest in later waves. By further assessing well-documented inequities and expanding understanding of their dynamic expression across space and time, this study demonstrates the utility of GMM for public health surveillance, planning, and equitable response strategies in future outbreaks.No embarg
A Novel Linguistics-Inspired Framework to Discover RNA-Binding Protein (RBP) Motifs, Contexts, Binding Preferences, and Interactions
No full textRNA-binding proteins (RBPs) are essential modulators in the regulation of mRNA processing. The binding patterns, interactions, and functions of most RBPs are not well-characterized. Previous studies have demonstrated that sequence context and interactions are two important contributors to RBP binding specificity, but their precise roles remain unclear. Existing computational methods are often challenging to interpret and largely lack a categorical focus on these features, highlighting a need for interpretable predictive models to disambiguate the determinants of specific RBP binding in vivo. In this dissertation, I present a novel, comprehensive framework that leverages state-of-the-art computational techniques to investigate RBP binding patterns. In Phase I, I introduce a linguistics-inspired method to deconstruct sequences into entities comprising a central target k-mer and its flanking regions, then use this representation to formulate the RBP binding prediction task as a weakly supervised Multiple Instance Learning problem. In Phase II, I introduce a consensus-based motif discovery algorithm that relies on k-mer properties and is designed to accommodate our data structure, with which we thoroughly characterize the binding motifs, contexts, and preferences for an array of RBPs. Finally, in Phase III, I use feature integration, transitive inference, and a new cross-prediction approach to propose novel cooperative and competitive RBP-RBP interactions, a subset for which we hypothesize potential regulatory functions and mechanisms. Overall, my thesis work has enabled insights into the contextual and interactive determinants of RBP binding patterns through the application of advanced machine learning principles, serving as an important contribution to research in computational RNA biology.Bioinformatics and Computational BiologyOther2 years2027-04-0
Occult Ventricular Fibrillation Visualized by Echocardiogram During Cardiac Arrest: A Retrospective Observational Study From the Real-Time Evaluation and Assessment for Sonography-Outcomes Network (REASON)
No full textObjectives: Cardiac arrest patients with a shockable rhythm are more likely to survive an out-of-hospital cardiac arrest (OHCA) compared with a nonshockable rhythm. An electrocardiogram (ECG) is the most common way to identify a shockable rhythm, but it can miss patients with clinically significant ventricular fibrillation (vfib). We sought to determine the percentage of nonshockable OHCA patients that demonstrated vfib on echo.
Methods: Secondary analysis of echo images recorded from a prior study from our group, Real-Time Evaluation and Assessment for Sonography-Outcomes Network (REASON), a multicenter, observational study of OHCA patients presenting to the emergency department with nonshockable rhythms. Using ECG and echocardiogram images recorded during the initial cardiopulmonary resuscitation (CPR) pause, 2 independent emergency physicians determined the presence of vfib. Two experienced emergency physicians (R.G. and T.G.) reviewed echo images with adjudication by a third if necessary. ECG interpretation was unblinded to patient information. The primary outcome was the proportion of patients in occult vfib.
Results: During the first CPR pause, reviewers noted occult vfib in 22/685 (3.2%; 95% CI, 2.1%-4.8%) subjects. Patients with ECG vfib (n = 55) were defibrillated immediately during the first pause in CPR, but no patients with occult vfib during the first pause in CPR were defibrillated. Subsequently, 50% (11 of 22) of occult vfib patients were defibrillated when ECG vfib was recognized during an ensuing pause in CPR.
Conclusion: One in 33 OHCAs with a nonshockable ECG rhythm exhibits VF on echocardiogram. Patients presenting to the emergency department in a presumed nonshockable rhythm following OHCA may benefit from prompt defibrillation if personnel recognize occult vfib on echo.No embarg
Prevalence and Factors Associated With Receiving a Prescription for Antithrombotic Therapy on Hospice Admission
No full textBackground: Little is known regarding antithrombotic prescribing in U.S. hospice patients. We quantified the prevalence and predictors of receiving an antithrombotic prescription on hospice admission.
Methods: This was a cross-sectional study using electronic health record data from adult (age ≥ 18 years) decedents of a large, for-profit hospice chain who died between January 1, 2017, and December 31, 2019. Our primary outcome was having a prescription for antithrombotic (anticoagulant or antiplatelet) therapy on hospice admission. We used multivariable logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).
Results: Among 54,643 hospice decedents, the mean age was 79.7 (standard deviation (SD) 13.2) years, 44.6% were male, and 57.0% were White. The median hospice length of stay was 9 (interquartile range 3-40) days, and 18,531 patients (33.9%) had a Palliative Performance Scale (PPS) score of 30%. Overall, 11,360 patients (20.8%) had at least one antithrombotic prescription on hospice admission. The most frequently prescribed antithrombotic classes were antiplatelets (15.7%) and direct oral anticoagulants (3.7%). Patients with PPS scores of 20%-30% (adjusted OR (aOR) 9.38, 95% CI 8.03-10.95), 40%-50% (aOR 15.69, 95% CI 13.38-18.40), and 60%-100% (aOR 15.67, 95% CI 12.41-19.79) were significantly more likely to receive an antithrombotic prescription compared to patients with a PPS score < 20%. Additionally, patients receiving care in an assisted living facility (aOR 4.34, 95% CI 3.86-4.87), nursing home (aOR 4.02, 95% CI 3.62-4.47), or at home (aOR 4.08, 95% CI 3.74-4.45) were more likely to receive an antithrombotic prescription compared to patients receiving care in an inpatient hospice setting.
Conclusions: Antithrombotic therapy was prevalent on hospice admission and most associated with better patient prognosis and non-inpatient hospice care locations. More research is needed to optimize antithrombotic prescribing in hospice care.No embarg