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Planning Ahead: protocol for a randomised trial of advance care planning for community dwelling older adults at increased mortality risk
No full textIntroduction: An important goal of advance care planning (ACP) is ensuring that patients receive care concordant with their preferences. High-quality evidence is needed about the effect of ACP on this and other outcomes.
Methods and analysis: Planning Ahead is a randomised controlled trial to test the effectiveness of facilitated ACP in community-dwelling older adults including those with normal cognition and those with Alzheimer's Disease and Related Dementias (ADRD) who are at high risk of death. The primary aim is to determine the effect of the intervention on discordance between preferences for medical treatments and the treatments received in the year after the intervention. Secondary outcomes include decision-making quality, care at the end of life and cost. Eligible patients have a primary care provider at one of two Midwest health systems, have an approximate 33% mortality risk and do not have a POLST form at baseline. Patients with capacity can invite the person they would choose to be their healthcare decision maker to participate as a study partner. A surrogate decision maker enrols and receives the intervention for patients who lack capacity due to ADRD. The intervention uses the Respecting Choices Advanced Steps (RCAS) model of ACP delivered by a registered nurse and includes identification of the patient's values and goals, education about ACP and the POLST form and the opportunity to complete a POLST form.
Ethics and dissemination: The study is approved by the Indiana University Institutional Review Board. Primary and secondary analyses will be published in peer-reviewed journals. We also plan dissemination through the media. We will construct a deidentified data set that could be available to other researchers. Survey data will be preserved and shared via the NIH-supported National Archive of Computerised Data on Ageing's (NACDA) Open Ageing Repository (OAR)
The Utility of Gastric Ultrasound in Anaesthesia Education: Participant Survey Data from a Statewide Gastric POCUS Workshop
Get PDFIntroduction
POCUS education has grown significantly in the past two decades, impacting various medical specialties. Prior studies implementing POCUS into medical education through standardized workshops have been shown to improve knowledge and POCUS confidence. In one study, implementation of a 6-hour-workshop with faculty showed increased confidence in teaching POCUS to medical students, a 36% increase in POCUS knowledge, and an increase in correct identification of anatomic structures1. Likewise, hands-on training and asynchronous online modules increased PGY-1 residents’ confidence in obtaining POCUS images, recognizing anatomical structures, and incorporating POCUS into clinical practice2. Our study aims to reinforce these findings in the population of practicing anaesthesiologists, with an emphasis on the use of gastric ultrasound. Gastric ultrasound can be a vital tool for anaesthesiologists in determining an appropriate anaesthesia induction and maintenance technique when a patient’s fasting status is uncertain3.
Methods
Attendees of the 2024 Indiana Society of Anesthesiologists annual meeting participated in a hands-on gastric point-of-care ultrasound workshop. The workshop included 10 stations, each with a standardized patient model and anaesthesiologists competent in gastric ultrasound to offer immediate feedback and assistance in obtaining images. Using deliberate practice, participants rotated through all 10 standardized patients and faculty. They completed pre- and post-workshop surveys to assess their knowledge and confidence with gastric ultrasound using a 5-point Likert scale. The post-workshop survey also tested participants’ ability to correctly identify structures on classic gastric ultrasound images. This study is a prospective analysis of pre- and post-workshop survey data. Data was analysed using two-tailed Fisher's exact tests, with statistical significance set at p < 0.05.
Results
37 participants completed the pre-workshop survey, and 25 completed the post-workshop survey. Statistically significant differences were found in physicians' confidence in obtaining gastric images (p<0.0001), interpreting gastric ultrasound (p<0.0001), and confidence in incorporating gastric POCUS into practice (p=0.0003) [Fig. 1]. No significant difference was found in general POCUS confidence (p=0.5336).
Conclusions
With the recent conflicting guidelines between the ASA and AGA surrounding duration of fasting status before elective surgeries in patients on GLP-1 agonists, the use of gastric ultrasound is of increasing relevance4. Anaesthesia faculty who attended the workshop reported increased confidence with gastric POCUS, demonstrated improved skills in identifying structures, and reported greater confidence in integrating it into clinical practice, suggesting the addition of deliberate practice was very positive.
References
1. Russell et al, PMID: 33415026.
2. Ferre et al, PMID: 39107748.
3. Gagey et al, PMID: 29265174.
4. Phan et al, PMID: 39016372
Novel Technique for Suture Suspension Arthroplasty of the Thumb Carpometacarpal Joint Using the Locking “Nice” Knot
Get PDFOsteoarthritis (OA) of the first carpometacarpal (CMC) joint is common and often presents as pain, weakness, or sense of instability in the joint. A common surgical technique for treatment is the suture suspension arthroplasty, which was first described in 2009 by DelSignore et al. with successful long term follow up reported in 2023. This technique involves piercing the flexor carpi radialis (FCR) tendon, which poses a risk of tendon rupture. Many adjustments to the original technique have been proposed, including modified suture patterns, suture buttons, and awake surgeries to avoid overtightening. The purpose of this paper is to discuss a novel modification to the original technique that eliminates the need to pierce the FCR tendon by utilizing the “Nice” knot. We believe this technique decreases rates of FCR rupture and also decreases surgical cost and time, which is important in today's value-based healthcare
landscape. Follow-up is needed to determine if these claims are true. Next, we plan to conduct a retrospective chart review to determine if this new technique truly leads to lower rates of FCR tendon rupture, decreased operative time, and decreased patient costs
The responsible conduct of police participatory research: A qualitative study of officers’ ethical beliefs
No full textThe responsible conduct of research must be sensitive to the unique ethical concerns of the police setting, but we have yet to develop an empirical understanding of the ethics of research involving police officers as participants. To develop such an understanding, this study collected qualitative data from 30 officers serving in eight agencies throughout the United States. The interviews situated their ethical sensibilities about research in relation to the Belmont principles that serve as the dominant source of norms in U.S. research ethics, then evoked reactions about consent, compensation, confidentiality, and researchers' motives. The interviews focused on a) how police officers characterize the responsible conduct of research; b) the extent to which their reasoning tracks established ethical principles, and c) which elements of these principles they emphasize. The study also probed which actors and factors were likely to best protect the ethical interests of police as research participants, and how they could be operationalized in a police research setting. Officers stressed the role of the police sergeant as their ethical fiduciary in the planning and execution of research, the distinction between being neutral versus impartial in research, the acceptability of withholding research questions and hypotheses to ensure candid and forthcoming responses, and, generally, the importance of a form of procedural justice in the conduct of research in police settings. The findings provide recommendations for police participatory research that would empower investigators to interpret and navigate the attendant ethical concerns in the context of their own research tradition, encouraging more frequent and higher quality participation in research among police agencies and their officers
Barriers Inhibiting Women's Path to the Pulpit and the Gender Gap in Compensation
No full textThis study examines the gender gap in Protestant churches’ leadership and its connection to head clergy compensation, using the National Study of Congregations’ Economic Practices (NSCEP) data. The analysis reveals that women's leadership as head clergy is most common within smaller and theologically liberal churches and during a time of declining membership. These findings imply that clergywomen face both the barrier of a glass ceiling and the disadvantages of a glass cliff, which limits their access to the pulpits that lead to greater compensation and prestige. The analysis also indicates that head clergy compensation is primarily determined by congregational characteristics, most importantly by church size, and the underrepresentation of women in larger churches’ leadership is what drives the gender pay gap for Protestant clergy. Still, the findings hint that the bottom-up pressure created by the expectations for gender equality from highly educated congregants may help dismantle the barriers for clergywomen
Regional Disparities in the Social Determinants of Stroke Severity
Get PDFIntroduction: Social determinants of health (SDOH) are known factors of stroke risk and outcomes. We aim to gain a comprehensive understanding of the impact of stroke risk-specific SDOH on stroke severity by investigating the patient population served by a regional healthcare system.
Methods: This retrospective cohort study analyzed patient data from the American Heart Association's Get With The Guidelines-Stroke (AHA GWTG-S) Case Record Forms, collected from three stroke centers between January 2022 and May 2024. We compared the patient ordinal modified Rankin Scale (mRS) and the National Institutes of Health Stroke Scale (NIHSS) scores to the predictor variables of age, sex, race, Hispanic ethnicity, ZIP code, payment sources, and mode of arrival.
Results: When age-adjusted, Black or African American patients had higher mean NIHSS scores and higher rates of Minor Stroke Symptoms than White patients (p < 0.01, p < 0.01). ZIP Codes with higher mean NIHSS stroke scale scores correlated significantly with ZIP Codes defined by lower median household income (r=-0.61, p < 0.01), lower education attainment (r=-0.71, p < 0.001), and higher percentages of minority group populations (r = 0.50, p < 0.02). Patients with higher mean scores across all measures were those associated with using Medicare versus private insurance (p < 0.0001) and those arriving at the hospital via EMS versus private transport (p < 0.01).
Conclusions: This research addresses the significance of surveying region-specific social determinants of health for insight into targeted interventions. Initiatives such as expanding stroke awareness education and increasing preventative screenings in the community may reduce disparities in stroke severity and improve outcomes in underserved areas
LSD1 and CoREST2 Potentiate STAT3 Activity to Promote Enteroendocrine Cell Differentiation in Mucinous Colorectal Cancer
No full textNeuroendocrine cells have been implicated in therapeutic resistance and worse overall survival in many cancer types. Mucinous colorectal cancer (mCRC) is uniquely enriched for enteroendocrine cells (EEC), the neuroendocrine cells of the normal colon epithelium, as compared with non-mCRC. Therefore, targeting EEC differentiation may have clinical value in mCRC. In this study, single-cell multiomics uncovered epigenetic alterations that accompany EEC differentiation, identified STAT3 as a regulator of EEC specification, and discovered a rare cancer-specific cell type with enteric neuron-like characteristics. Furthermore, lysine-specific demethylase 1 (LSD1) and CoREST2 mediated STAT3 demethylation and enhanced STAT3 chromatin binding. Knockdown of CoREST2 in an orthotopic xenograft mouse model resulted in decreased primary tumor growth and lung metastases. Collectively, these results provide a rationale for developing LSD1 inhibitors that target the interaction between LSD1 and STAT3 or CoREST2, which may improve clinical outcomes for patients with mCRC. Significance: STAT3 activity mediated by LSD1 and CoREST2 induces enteroendocrine cell specification in mucinous colorectal cancer, suggesting disrupting interaction among LSD1, CoREST2, and STAT3 as a therapeutic strategy to target neuroendocrine differentiation
Innovating Nursing Education Through Partnership With Individuals With Intellectual and Developmental Disabilities
Get PDFBackground Health disparities of individuals with intellectual and developmental disabilities (IDD) have been a longstanding public health concern. Unlike the engagement of service sectors and governmental entities in advocating for human rights and health equity, the nursing profession remains absent from these discussions. Transformational changes are needed to promote systemic changes that will improve health outcomes of individuals with IDD.
Method Strategic planning is needed to effect transformational changes in nursing education. Innovation in nursing education involves an informed understanding of health care barriers that individuals with IDD experience and the necessary processes to effectively engage in partnerships with this population.
Results An approach for change in nursing education is proposed based on IDD concepts in federal legislation and initiatives, social policies, and the self-advocacy movement, and its application in nursing education is described.
Conclusion Integrating IDD concepts into nursing curricula can improve health care equity and health outcomes of individuals with IDD
