prepOSCE: A Virtual, Scalable Solution to Prepare Residents for Their OSCE Examination.

The Royal College Comprehensive Objective Examination in Neurology provides certification for Canadian neurologists and consists of a written examination and the Observed Structured Clinical Encounter (OSCE). The OSCE portion of the certification involves residents visiting several patient stations where they address case scenarios with an examiner. Unfortunately, residents lack exam preparation time due to demanding work hours. In response to resident needs, we created a novel, virtual preparation OSCE program - "prepOSCE" - and evaluated its efficacy. The prepOSCE program employed a proprietary virtual solution from CTC Communications Corp. Ten virtual sessions accommodated 70 residents totally. Seven Canadian physicians and two co-chairs created case scenarios for the stations. On session day, seven residents arrived in a virtual plenary room for briefing followed by assignment to a station by CTC. Residents then moved virtually through prepOSCE stations a different examiner and case scenario in each. Following their session, residents and evaluators were surveyed to capture experiences. The average program rating was 4.22 out of 5 (n = 36 residents of 70 residents who participated in the program) and 4.35 (n = 17 evaluators). Ninety-two percent of residents agreed or strongly agreed that they would recommend this program to their peers; they would like prepOSCE to continue next year; and the program was relevant and added value to their studies. The positive feedback received from prepOSCE participants indicates there is a need for a program like prepOSCE. This model has potential for expansion and it is hoped that specialties outside of neurology could benefit from a similar program.

Avoidance-Endurance Model in Older Black Men with Low Back Pain: Exploring Relationships.

OBJECTIVE: The objective of the study was to investigate functional performance and pain intensity outcomes for associations with negative cognitive orientations, avoidance behaviors, and fear of pain in older Black men with low back pain (LBP). METHODS: Sixty Black men aged 60 and older (70 years[Formula: see text]) with LBP completed the Short Physical Performance Battery (SPPB), the 400-m walk test, and subjective measures of avoidance behaviors, back performance, pain intensity, and pain catastrophizing (i.e., rumination, magnification, and helplessness). Multiple regression models were used to examine associations. RESULTS: Higher helplessness scores were associated with worse back performance (ß = 0.55, p = 0.02), slower walking speed (ß = 0.30, p = 0.02), and higher average pain intensity (ß = 0.22, [Formula: see text] p = 0.03). Higher rumination scores were associated with better back performance (ß = - 0.36, p = 0.04). Avoidance behaviors, fear of pain, and magnification were not significantly associated with any of the variables included in the tested models. CONCLUSION: Negative cognitive internalization is associated with limitations in functional performance in older Black men with LBP. Additional research is needed to further examine the cognitive orientations for understanding experienced pain and function in this population. Such research may inform the development of interventions for improving functional performance outcomes of older Black men with LBP.

The i-ACT™ in Obesity educational intervention: a pilot study on improving Canadian family physician care in obesity medicine.

BACKGROUND: Obesity is a chronic problem in Canada and although the Canadian Medical Association recognizes obesity as a disease, health care professionals (HCPs) are not necessarily proactively managing it as one. This study aimed to assess current obesity management knowledge and practices of Canadian family physicians (FPs) and evaluate the feasibility of an online self-directed learning platform, i-ACT™ in Obesity, in delivering learning and changing practice intentions to advance obesity management. METHODS: i-ACT™ in Obesity is an online self-directed learning program designed by Canadian obesity medicine experts to provide individualized learning curricula to participants. One hundred FPs, with an interest in weight management and managing patients with obesity, were recruited across Canada to participate in a pilot study. FP education was delivered in a stepwise manner. Each participant completed a practice profile assessment to determine knowledge gaps and educational needs. Learners then watched didactic videos across disciplines on topics assigned to their curriculum by the program algorithm based on the relative difference between indicated and desired current knowledge. FPs also completed 10 retrospective patient assessments to assess clinical management practices and planned behaviour change. Feasibility, acceptability, and satisfaction of the learning program were assessed to formulate the rationale for a more widespread deployment in the future. Survey responses and related data were analyzed using comparative measures and descriptive statistics. RESULTS: The program was piloted by ninety-one Canadian FPs, where 900 patients were assessed. FPs showed distinct differences between their current and desired levels of comfort in a variety of obesity-related topics. Participation was associated with an intention to use more obesity treatment interventions moving forward. The program received an overall satisfaction rating of 8.6 out of 10 and 100% of the evaluators indicated that they would recommend it to their colleagues. CONCLUSION: The program was overall well received and successfully changed obesity management intentions among participating FPs, thus setting the stage for a larger more comprehensive study to examine the efficacy of i-ACT™ in Obesity in addressing knowledge gaps and advancing evidence-based, guidelines-aligned approach to obesity treatment.

A Randomized Controlled Trial of a Positive Family Holistic Health Intervention for Probationers in Hong Kong: A Mixed-Method Study.

Introduction: Probationers, offenders with less serious and non-violent offences, and under statutory supervision, have low levels of self-esteem and physical health, and high level of family conflict, and poorer quality of family relationships. This study examined the effectiveness of the existing probation service and the additional use of a positive family holistic health intervention to enhance physical, psychological, and family well-being in probationers and relationships with probation officers. Methods: Probationers under the care of the Hong Kong Social Welfare Department were randomized into a care-as-usual control group (CAU), a brief intervention group (BI) receiving two 1-h individual sessions [of a brief theory-based positive family holistic health intervention integrating Zero-time Exercise (simple and easy-to-do lifestyle-integrated physical activity) and positive psychology themes of "Praise and Gratitude" in the existing probation service], or a combined intervention group (CI) receiving BI and a 1-day group activity with family members. The outcomes were physical activity, fitness performance, self-esteem, happiness, anxiety and depression symptoms, life satisfaction, quality of life, family communication and well-being, and relationships with probation officers. Self-administered questionnaires and simple fitness tests were used at baseline, 1-month and 3-month follow-up. Linear mixed model analysis was used to compare difference in the changes of outcome variables among groups, adjusted of sex, age, and baseline values. Focus group interviews were conducted. Thematic content analysis was used. Results: 318 probationers (51% male) were randomized into CAU (n = 105), BI (n = 108), or CI (n = 105) group. CAU showed enhanced physical activity, fitness performance and psychological health, and family communication with small effect sizes (Cohen's d: 0.19-0.41). BI and CI showed further improved physical activity, family communication and family well-being (Cohen's d: 0.37-0.70). Additionally, CI reported greater improvements in the relationships with probation officers than CAU with a small effect size (Cohen's d: 0.43). CI also reported greater increases in physical activity and family communication than BI with small to moderate effect sizes (Cohen's d: 0.38-0.58). Qualitative feedbacks corroborated the quantitative findings. Conclusion: Our trial provided the first evidence of the effectiveness of probation service and the additional use of an innovative, relatively low-cost, theory-based brief positive family holistic health intervention. This intervention may offer a new model for enhancing probation service. Trial Registration: The research protocol was registered at the National Institutes of Health (identifier: NCT02770898).

The Role of Nitroreductases in Resistance to Nitroimidazoles.

Antimicrobial resistance is a major challenge facing modern medicine, with an estimated 700,000 people dying annually and a global cost in excess of $100 trillion. This has led to an increased need to develop new, effective treatments. This review focuses on nitroimidazoles, which have seen a resurgence in interest due to their broad spectrum of activity against anaerobic Gram-negative and Gram-positive bacteria. The role of nitroreductases is to activate the antimicrobial by reducing the nitro group. A decrease in the activity of nitroreductases is associated with resistance. This review will discuss the resistance mechanisms of different disease organisms, including Mycobacterium tuberculosis, Helicobacter pylori and Staphylococcus aureus, and how these impact the effectiveness of specific nitroimidazoles. Perspectives in the field of nitroimidazole drug development are also summarised.

Development of Electrochemical DNA Biosensor for Equine Hindgut Acidosis Detection.

The pH drop in the hindgut of the horse is caused by lactic acid-producing bacteria which are abundant when a horse's feeding regime is excessively carbohydrate rich. This drop in pH below six causes hindgut acidosis and may lead to laminitis. Lactic acid-producing bacteria Streptococcus equinus and Mitsuokella jalaludinii have been found to produce high amounts of L-lactate and D-lactate, respectively. Early detection of increased levels of these bacteria could allow the horse owner to tailor the horse's diet to avoid hindgut acidosis and subsequent laminitis. Therefore, 16s ribosomal ribonucleic acid (rRNA) sequences were identified and modified to obtain target single stranded deoxyribonucleic acid (DNA) from these bacteria. Complementary single stranded DNAs were designed from the modified target sequences to form capture probes. Binding between capture probe and target single stranded deoxyribonucleic acid (ssDNA) in solution has been studied by gel electrophoresis. Among pairs of different capture probes and target single stranded DNA, hybridization of Streptococcus equinus capture probe 1 (SECP1) and Streptococcus equinus target 1 (SET1) was portrayed as gel electrophoresis. Adsorptive stripping voltammetry was utilized to study the binding of thiol modified SECP1 over gold on glass substrates and these studies showed a consistent binding signal of thiol modified SECP1 and their hybridization with SET1 over the gold working electrode. Cyclic voltammetry and electrochemical impedance spectroscopy were employed to examine the binding of thiol modified SECP1 on the gold working electrode and hybridization of thiol modified SECP1 with the target single stranded DNA. Both demonstrated the gold working electrode surface was modified with a capture probe layer and hybridization of the thiol bound ssDNA probe with target DNA was indicated. Therefore, the proposed electrochemical biosensor has the potential to be used for the detection of the non-synthetic bacterial DNA target responsible for equine hindgut acidosis.

Baseline Susceptibility Status of Florida Populations of Aedes aegypti (Diptera: Culicidae) and Aedes albopictus.

Resistance to insecticides used to control mosquito vectors threatens the ability of mosquito-control organizations to protect public health. Aedes aegypti (Linnaeus) and Aedes albopictus (Skuse) are invasive species widely distributed throughout Florida and have been implicated in recent epidemics of Zika, dengue, and chikungunya viruses. Knowledge of the susceptibility status of these mosquito species to pyrethroid and organophosphate active ingredients (AIs) is needed to inform product selection and treatment decisions. The susceptibility of 37 Ae. aegypti and 42 Ae. albopictus populations from Florida was assessed in response to six pyrethroid and three organophosphate AIs using the CDC bottle bioassay method. Of all bioassays completed with a pyrethroid AI, 95% for Ae. aegypti and 30% for Ae. albopictus resulted in a resistant outcome. For organophosphate AIs, ~31% of assays conducted for both species were classified as resistant. The highest frequency of susceptibility for both species was observed in response to the organophosphate AI, naled. Lambda-cyhalothrin was the only pyrethroid to result in a susceptible status for Ae. aegypti and also had the highest frequency of susceptibility for Ae. albopictus. Resistance was detected to every AI tested for both Ae. aegypti and Ae. albopictus, but there was a pronounced trend of pyrethroid resistance in Florida populations of Ae. aegypti. The results of this work provide evidence for the need to decrease reliance on pyrethroids and to implement different methods of control of Ae. aegypti in Florida.

Rights to social determinants of flourishing? A paradigm for disability and public health research and policy.

BACKGROUND: The term evidence based medicine was introduced in the early 1990s in clinical medicine to educate clinicians about how to assess the 'credibility' of research to ensure best treatments for their patients. The evidence based medicine paradigm has become more diffuse in times of austerity and randomised controlled designs are being used to address complex issues in public health and disability research. This research is not addressing inequalities in terms of disability nor how people can live well with disabilities. MAIN TEXT: We argue that there are four ways that public health research needs to change if it wants to address inequalities linked to disability: 1) rethinking theoretical connections between public health and disability; 2) building ethics and equity into interventions through a human rights approach; 3) ensuring ethical inclusion through intersectionality; and 4) evaluating policy and other social impacts to ensure they capture diversity. We argue that these are key issues to building a social determinants of flourishing. CONCLUSIONS: We need to understand how disability might have an accumulative impact across the life course, as well as how to ensure equity for people living with disabilities. This means conceptualising a social determinants of flourishing where we evaluate how exactly randomised controlled trials and public health interventions, not only lead to greater equality but also ensure rights to health and wellbeing.

Rapid Detection of Botulinum Neurotoxins-A Review.

A toxin is a poisonous substance produced within living cells or organisms. One of the most potent groups of toxins currently known are the Botulinum Neurotoxins (BoNTs). These are so deadly that as little as 62 ng could kill an average human; to put this into context that is approximately 200,000 × less than the weight of a grain of sand. The extreme toxicity of BoNTs leads to the need for methods of determining their concentration at very low levels of sensitivity. Currently the mouse bioassay is the most widely used detection method monitoring the activity of the toxin; however, this assay is not only lengthy, it also has both cost and ethical issues due to the use of live animals. This review focuses on detection methods both existing and emerging that remove the need for the use of animals and will look at three areas; speed of detection, sensitivity of detection and finally cost. The assays will have wide reaching interest, ranging from the pharmaceutical/clinical industry for production quality management or as a point of care sensor in suspected cases of botulism, the food industry as a quality control measure, to the military, detecting BoNT that has been potentially used as a bio warfare agent.

Enhancing the decision-making process when considering artificial nutrition in advanced dementia care.

BACKGROUND: Nutritional problems often manifest during late-stage dementia, and some families may request to instigate artificial nutrition and hydration (ANH) therapies. In the US, an estimated one-third of nursing home patients with a severe cognitive impairment have artificial feeding tubes inserted. Fear that a relative could experience extreme hunger or thirst if they are not mechanically fed tends to be the main driver behind family's requests to implement artificial or enteral feeding methods. In contrast, artificial hydration is rarely given to older people with dementia in the UK and this practice of non-intervention tends to apply across all healthcare and hospice type environments. AIM: This literature review aims to evaluate the evidence to support the use and non-use of ANH. METHOD: A literature review was undertaken to examine the evidence around ANH for patients with dementia to offer support to families or carers contemplating feeding choices. CONCLUSION: This paper challenges the implementation of invasive ANH worldwide. It highlights how resorting to ANH does not necessarily lead to improvements in comfort, survival or wound healing. The risk of aspiration does not appear to significantly alter either.

Development and feasibility of a brief Zero-time Exercise intervention to reduce sedentary behaviour and enhance physical activity: A pilot trial.

A brief intervention using Zero-time Exercise (ZTEx), a foot-in-the-door approach, was developed to reduce sedentary behaviour and increase physical activity. ZTEx refers to the integration of simple strength- and stamina-enhancing physical activity into daily life, which can be done anytime, anywhere and by anyone. This paper presents the development, feasibility, and preliminary evidence for the effectiveness of this intervention under the Hong Kong Jockey Club FAMILY Project. Needs assessments were conducted with social workers from the Christian Family Services Center(CFSC) and the Social Welfare Department (SWD). This single group prospective ZTEx intervention trial, guided by the Health Action Process Approach, included a 3-hr core session at baseline and a 1-hr booster session at 1-month follow-up. Fifty-six participants (social and service-related workers) from CFSC (n = 28) and SWD (n = 28) received the intervention and completed the self-administered questionnaires at baseline. Forty-nine and 43 participants completed the 1-month and 3-month self-administered questionnaires, respectively. Fifteen participants attended the focus group interviews to share their feedback on ZTEx intervention after implementing their community-based ZTEx activities. Intention-to-treat analysis was conducted with missing data replaced by baseline values. Participants reported significant decreases in sitting time by 27 (2, 52) minutes (mean [95% confidence interval]) and 36 (0.2, 71) minutes on a weekday, increases in physical activity while seated by 0.7 (0.2, 1.4) days and 1.1 (0.6, 1.7) days in a week, and improvements in perceived knowledge, outcome expectancies and plan on doing ZTEx at the 1-month and 3-month follow-up, respectively. Balance and muscle strength significantly improved at the 1-month follow-up. The effect ranged from small to large (Cohen's d: 0.27-1.05, all p < 0.05). The qualitative feedbacks support the quantitative findings. Our findings show early evidence that ZTEx effectively reduced sedentary behaviour and enhanced physical activity and fitness. Further trials on this simple and low-cost intervention as the first step to promote higher intensity exercise are warranted.

Family carers' experiences of coping with the deaths of adults in home settings: A narrative analysis of carers' relevant background worries.

BACKGROUND: Internationally, evidence on the support needs of family carers who look after a terminally ill adult in home settings is incomplete. AIM: To illustrate the relevance of 'relevant background worries' in family carers' accounts of caring at home for a dying adult. DESIGN: A qualitative cross-sectional observational study was conducted in England, United Kingdom, in 2011-2013 on the experiences of adult family carers ( n = 59) of older dying adults (aged 50+ years) with malignant and/or non-malignant conditions. Interviews occurred post-bereavement. This article reports on a subset of participants' interview transcripts ( n = 30) where narrative analysis was undertaken. SETTING/PARTICIPANTS: Carers were interviewed in their home setting, having been purposively recruited via general practitioner practices in two study sites in England. The subset of participants ( n = 30) was purposively selected from the parent sample with reference to carers' age, relationship to the patient, family circumstances and study sites. RESULTS: Evidence is provided on the importance of what we conceptualise as carers' 'relevant background worries'; these varied in nature, significance and impact. Four case studies are presented where these worries constituted psychosocial factors that impacted on caregivers' actions and emotional well-being. Two themes are discussed: (1) whether relevant background worries are important enough to be identified and responded to and (2) how such worries could be picked up and managed by professionals. CONCLUSION: It is argued that the quality of clinical practice could be improved if specialist palliative care teams in community contexts both identified and responded to significant support needs associated with family carers' relevant background worries.

Caring for a dying spouse at the end of life: 'It's one of the things you volunteer for when you get married': a qualitative study of the oldest carers' experiences.

BACKGROUND: older people aged 80 and over are increasingly providing end-of-life care to spouses at home and often do so for long periods of time, while also trying to manage their own illnesses and disabilities. Little of the research on older spousal carers has focussed on the oldest carers; hence, the needs of this particular population are not fully known. OBJECTIVE: to explore the experiences of the 'oldest carers' in caring for a dying spouse at home. METHODS: secondary analysis was undertaken on a subset of data from a larger qualitative interview study; this dataset comprised 17 interviews from participants aged 80 or over. Framework analysis methods were used, with items derived from the thematic analysis of the main study. RESULTS: the oldest carers in this subset demonstrated high levels of resilience and the ability to adapt to their caring role. Caring until death was accepted as an integral part of the commitment made to their partner as part of the 'wedding contract'. Carers felt they benefitted from the support provided by family, friends and care services; however, their own care needs were not always recognised by health and social care services. CONCLUSIONS: these findings underscore the complexity of the oldest carers' experiences and challenges in times of illness and end of life. Healthcare professionals should be alerted to the myriad ways caregiving is enacted in serious illness and seek opportunities for developing supportive interventions specifically for older carers.

Unpacking the impact of older adults' home death on family care-givers' experiences of home.

Public Health England (2013) survey data indicates that while the place of death is geographically uneven across England, given a choice, many older people nearing end of life would prefer to die at home. There is, however, a growing critique that policies designed to support home death fail to understand the needs and preferences of older people and the impact on family carers. Such policies also make assumption about within whose home the home death takes place. Hence, there are major gaps in our understanding of firstly, where and how care work undertaken by family members within domestic settings takes place; and secondly, how it can create tensions between home and care that fundamentally disrupt the physical and socio-emotional meaning of home for family carers, impacting on their sense of home post-death. This can have consequences for their own well-being. In this paper we draw on interview data from our 'Unpacking the Home' study to elicit an in-depth understanding of how facilitating a home death can create an ambiguity of place for family carers, where the issues faced by them in caring for a dying older person at home, and the home death itself, can fundamentally reshape the meaning and sense of home.

Managing end of life medications at home--accounts of bereaved family carers: a qualitative interview study.

OBJECTIVE: To explore how bereaved family members recall managing end of life medications when delivering care to a patient dying at home in England. DESIGN: Qualitative study. SETTING: Domestic homes in two contrasting areas in England. PARTICIPANTS: 59 bereaved family carers who have delivered care to a patient who spent a minimum of 2 weeks at home prior to their death from cancer or other non-malignant condition. Cases were excluded if the place of death was: a hospice, nursing home or National Health Service (NHS) hospital. RESULTS: Participants identified a number of important concerns about managing end of life medication for the dying person at home. Although some support with medications is provided by general practitioners and nurses in the community, family carers take primary responsibility for drug administration and storage. They reported anxiety about giving correct and timely dosages, and concerns about keeping the patient comfortable without overdosing them or risking shortening their lives. In particular, they reported that certain analgesic medications, especially opioids, were considered to have a symbolic significance increasing analgesia requirements, and the use of a syringe driver was associated with deterioration and approaching death. Key barriers to managing end of life medications at home included: complex regimes; unwanted responsibility in deciding when to use 'as needed' medication; disagreements with professional staff, and anxiety about medication errors, especially if perceived to have implications for survival. CONCLUSIONS: Family carers require more information about end of life drugs and their effects, support and training in managing medication for a dying person.

Clinical psychology and disability studies: bridging the disciplinary divide on mental health and disability.

PURPOSE: Clinical psychology and disability studies have traditionally occupied very different academic, philosophical and political spaces. However, this paper aims to illustrate the positive consequences and implications of attempts to understand and bridge this disciplinary divide. METHOD: A narrative review format was used with evidence selected pragmatically as opposed to systematically. The construction of the argument determined the evidence selected. RESULTS: The concept of psycho-emotional disablism, which originated within disability studies, is argued to be a useful concept to bridge the divide between understandings of distress from both disability studies and clinical psychology perspectives. However, this can be usefully augmented by psychological research on the mechanisms through which disablism can affect individuals. CONCLUSION: Perspectives from both disability studies and clinical psychology can be usefully combined to bring important new perspectives; combined, these perspectives should help - on theoretical, service and social levels - to improve the mental health of disabled people. Implications for Rehabilitation Mental health is an important determinant of overall health-related quality of life and psychological therapy should be available for those disabled people who would value it. Psychological therapists working with disabled people should be more aware of the challenging social context in which disabled people live. Understandings of distress should not just include individual factors but also incorporate the psychological impact of stresses caused by societal barriers preventing inclusion. Psychologists should be more willing to work and engage at a societal and political level to influence change.

Dying at home: a qualitative study of family carers' views of support provided by GPs community staff.

BACKGROUND: Dying at home is the preference of many patients with life-limiting illness. This is often not achieved and a key factor is the availability of willing and able family carers. AIM: To elicit family carers' views about the community support that made death at home possible. DESIGN AND SETTING: Qualitative study in East Devon, North Lancashire, and Cumbria. METHOD: Participants were bereaved family carers who had provided care at the end of life for patients dying at home. Semi-structured interviews were conducted 6-24 months after the death. RESULTS: Fifty-nine bereaved family carers were interviewed (54% response rate; 69% female). Two-thirds of the patients died from cancer with median time of home care being 5 months and for non-cancer patients the median time for home care was 30 months. An overarching theme was of continuity of care that divided into personal, organisational, and informational continuity. Large numbers and changes in care staff diluted personal continuity and failure of the GPs to visit was viewed negatively. Family carers had low expectations of informational continuity, finding information often did not transfer between secondary and primary care and other care agencies. Organisational continuity when present provided comfort and reassurance, and a sense of control. CONCLUSION: The requirement for continuity in delivering complex end-of-life care has long been acknowledged. Family carers in this study suggested that minimising the number of carers involved in care, increasing or ensuring personal continuity, and maximising the informational and organisational aspects of care could lead to a more positive experience.

The perspectives of bereaved family carers on dying at home: the study protocol of 'unpacking the home: family carers' reflections on dying at home.

BACKGROUND: Recent end of life care policy prioritises patient choice over place of care and in particular promotes dying at home. This policy is predicated on the assumption that there are family carers able and willing to provide care for the dying person. Through the accounts of bereaved family members, the 'Unpacking the home' study aims to gain an in-depth understanding of 'home' and the issues faced by family members caring for a dying older person at home; it also aims to examine the way the home is transformed in the process of providing end of life care, and offer a critical analysis of policies that aim to increase home deaths. This paper presents the protocol for this study. METHODS/DESIGN: A cross-sectional qualitative study has been designed to achieve the study aims. In-depth interviews will be conducted in the north and south of England with 50 bereaved family carers to elicit their accounts of witnessing the dying in the home of an older person (50+ years). All interviews will be subjected to thematic analysis, and narrative analysis will be undertaken on a subset of 30 interview transcripts. A final phase of integration and policy analysis will be conducted towards the end of the study. User involvement is integral to this study, with service users actively engaged at every stage. DISCUSSION: This study will seek to take a qualitative approach by explicitly recognising that family carers are central to the experience of dying at home for older people, and they have needs that may be amenable to support and anticipatory planning. The strengths of this study, which include its interdisciplinary and participatory approach, and in-depth data collection and analysis methods, will be explored. The limitations and challenges of this research will also be considered. This study seeks to make recommendations that will ensure that family carers receive appropriate and adequate support in caring for their loved ones at the end of life.

Monitoring for and preventing the long-term sequelae of bariatric surgery.

PURPOSE: To present a case study of a patient with multiple comorbid diseases who undergoes bariatric surgery. DATA SOURCES: Recent clinical and research articles, bariatric professional society guidelines, and government sources were culled to provide recommendations for the care of the person who chooses bariatric surgery as the treatment for the comorbid conditions of obesity, type 2 diabetes, obstructive sleep apnea, hypertension, and hyperlipidemia. CONCLUSIONS: As surgical management of obesity becomes more prevalent in an attempt to improve health-related quality of life, reduce mortality, and address the comorbidities that are prevalent in this population, nurse practitioners (NPs) need to understand what long-term management these patients will require. IMPLICATIONS FOR PRACTICE: NPs are primary care providers for patients with chronic diseases. It is likely that they will make referrals for this surgery and follow the patient after the procedure at some point. Knowledge of what the procedures involve, what changes to expect in the comorbid conditions, and what long-term monitoring and treatment should take place in the care of these patients will provide these patients with optimal care.