Diverse perspectives on unit-level nurse staffing ratios in medical-surgical units: A Delphi policy analysis.

BACKGROUND: Appropriate staffing is essential to acute care delivery. Staffing ratio policy generates controversy. PURPOSE: This study examines perspectives on unit-level nurse-to-patient ratio policy in adult medical-surgical units. METHOD: Delphi methodology uses an invited diverse panel to analyze a policy's effects. Panelists completed iterative surveys about the impact they expect from unit-level ratio policy. FINDINGS: Panelists demonstrated moderate agreement that the proposed policy could increase staffing levels, decrease patient length of stay, and reduce nurse attrition. Other potential outcomes included reducing staffing in units above the minimum and increasing short-term costs. Panelists agreed that the policy could increase patient safety and nurse satisfaction and did not agree about the effect on long-term cost and innovation. Panelists also anticipated a mostly positive effect on patients and nurses. DISCUSSION: Policies that set unit-level nurse-to-patient ratios offer a potential strategy to improve medical-surgical staffing. Policy design should consider the range of expected outcomes.

The Invisibility of Women.

Why the gender data gap matters.

The Cost of Living While Human.

Observations on the craziness in American health care.

Why Black Americans 'Live Sicker and Die Quicker'.

Exposing the hidden toll of persistent racism.

Establishment and characterization of a new mantle cell lymphoma cell line with a NOTCH2 mutation, Arbo.

Cell lines represent an essential tool used in preclinical research. Most hematologic malignancies have a wide array of cell lines representing their respective molecular and pathologic spectra. In mantle cell lymphoma (MCL), cell lines become specifically valuable in view of the heterogeneity of this disease. Unfortunately, the number of MCL cell lines that are available for the research community remains small, with only nine cell lines available for purchase through the American Type Culture Collection (ATCC). We have established a novel blastoid MCL cell line, isolated from the malignant pleural effusion of a 69-year-old male with refractory MCL. Arbo was fully characterized with cytogenetics, immunophenotyping, whole exome sequencing and drug sensitivity assays. One of the most notable mutations identified in Arbo (but not in normal tissue) was the missense mutation NOTCH2 R2400*, which has been proposed as a clinically significant mutation in MCL seen in 5% of cases. NOTCH2 R2400* results in a truncated Notch2 protein, leading to a more stable and active protein. Using pharmacologic inhibition of Notch2, we showed a dependence of Arbo on NOTCH2 signaling, as well as a link between CD23 expression on Arbo and NOTCH2 activity. Arbo represents a NOTCH2 mutated model that is useful in MCL as well as other lymphomas with such mutation. We plan to deposit Arbo at the ATCC to be available for the research community.

The Beauty in Breaking and the Power to Heal.

Michele Harper's striking memoir contextualizes racism in health care.

A Retrospective Study of Psychotropic Drug Use and Prescription Opioid Initiation Among Older Adults.

Individuals with mental health problems may be more vulnerable to using prescription opioids than their counterparts. Therefore, the main objective of this study was to assess the initiation of prescription opioids in older adults who used psychotropic drugs compared with those who did not. The authors used a retrospective cohort design and included a sample of older adults enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program who did not use prescription opioids in 2013. Using pharmacy claims, patients who used anxiolytics/sedatives/hypnotics (n = 13,512) or antidepressants (n = 17,492) between October and December 2013 were identified and compared with those who did not use anxiolytics/sedatives/hypnotics (n = 114,091) or antidepressants (n = 110,111) during that period, to determine the incidence of prescription opioid use in 2014. Chi-square tests and multivariate logistic regressions were performed for analyses. Compared with patients who did not use anxiolytics/sedatives/hypnotics, those who used were more likely to initiate prescription opioids (15.0% versus 22.0%, P < .0001). Similarly, compared with patients who did not use antidepressants, those who used were more likely to initiate prescription opioids (14.7% versus 21.9%, P < .0001). Multivariate logistic regression indicated that the odds of prescription opioid initiation increased with anxiolytic/sedative/hypnotic use by 44% (AOR = 1.44; P < .0001) and antidepressant use by 48% (AOR = 1.48; P < .0001) among older adults after adjusting for potential confounding variables. Results showed that prescription opioid initiation is associated with prior anxiolytic/sedative/hypnotic or antidepressant use among older adults. Patients with mental health problems should also be queried about pain experiences for effective treatment.

Aroused: A Rousing Look at Hormones.

Stories of discovery, wrong turns, and hope.

Systemic vs. intrathecal central nervous system prophylaxis in primary adrenal/renal diffuse large b-cell LYMPHOMA: A multi-institution retrospective analysis and systematic review.

Primary adrenal lymphoma (PAL) and primary renal lymphoma (PRL) are rare extranodal lymphomas, predominantly of diffuse large B-cell lymphoma subtype. Primary adrenal and renal lymphomas (PARL) exhibit a high predilection for the central nervous system (CNS). Therefore, current guidelines support the use of CNS prophylaxis in PARL, particularly in cases of high-risk Central Nervous System International Prognostic Index (CNS-IPI). However, the route of administration (i.e. systemic vs. intrathecal chemotherapy) has not been clearly elucidated. With this in mind, we initiated an international collaboration and literature review to analyze 50 patient cases, 20 of which received CNS prophylaxis. Based on our analysis, we conclude that PARL may indicate a need for CNS chemo-prophylaxis in the form of systemic high-dose methotrexate (HD-MTX) over intrathecal methotrexate (IT-MTX), although IT-MTX may still have utility in certain cases.

COVID-19 and Our National 'Moral Imperative'.

A novel take on epidemic disease management.

Translating Virtual Reality Cue Exposure Therapy for Binge Eating into a Real-World Setting: An Uncontrolled Pilot Study.

Binge-eating disorder (BED) and bulimia nervosa (BN) have adverse psychological and medical consequences. Innovative interventions, like the integration of virtual reality (VR) with cue-exposure therapy (VR-CET), enhance outcomes for refractory patients compared to cognitive behavior therapy (CBT). Little is known about the feasibility and acceptability of translating VR-CET into real-world settings. To investigate this question, adults previously treated for BED or BN with at least one objective or subjective binge episode/week were recruited from an outpatient university eating disorder clinic to receive up to eight weekly one-hour VR-CET sessions. Eleven of 16 (68.8%) eligible patients were enrolled; nine (82%) completed treatment; and 82% (9/11) provided follow-up data 7.1 (SD = 2.12) months post-treatment. Overall, participant and therapist acceptability of VR-CET was high. Intent-to-treat objective binge episodes (OBEs) decreased significantly from 3.3 to 0.9/week (p < 0.001). Post-treatment OBE 7-day abstinence rate for completers was 56%, with 22% abstinent for 28 days at follow-up. Among participants purging at baseline, episodes decreased from a mean of one to zero/week, with 100% abstinence maintained at follow-up. The adoption of VR-CET into real-world clinic settings appears feasible and acceptable, with a preliminary signal of effectiveness. Findings, including some loss of treatment gains during follow-up may inform future treatment development.

Identification and Targeting of Thomsen-Friedenreich and IL1RAP Antigens on Chronic Myeloid Leukemia Stem Cells Using Bi-Specific Antibodies.

INTRODUCTION: Quiescent leukemia stem cells (LSCs) play a major role in therapeutic resistance and disease progression of chronic myeloid leukemia (CML). LSCs belong to the primitive population; CD34+CD38-Lin-, which does not distinguish normal hematopoietic stem cells (HSC) from CML LSCs. Because Thomsen-Friedenreich/CD176 antigen is expressed on CD34+ HSC and IL1RAP is tightly correlated to BCR-ABL expression, we sought to increase the specificity towards LSC by using additional biomarkers. METHODS: We evaluated the co-expression of both antigens on CD34+ peripheral blood mononuclear cells (PBMCs) from both healthy volunteers and CML patients, using flow cytometry. Then, we used site-directed mutagenesis to induce knob-in-hole mutations in the human IgG heavy chain and the human lambda light chain to generate the bi-specific antibody (Bis-Ab) TF/RAP that binds both antigens simultaneously. We measured complement-directed cytotoxicity (CDC) in CML samples with the Bis-Ab by flow cytometry. RESULTS: In contrast to healthy volunteers, CML samples displayed a highly significant co-expression of CD176 and IL1RAP. When either a double-positive cell line or CML samples were treated with increasing doses of Bis-Ab, increased binding and CDC was observed indicating co-operative binding of the Bis-Ab as compared to monoclonal antibodies. DISCUSSION: These results show that the bi-specific antibody is capable of targeting IL1RAP+ and CD176+ cell population among CML PBMCs, but not corresponding normal cells in CDC assay. We hereby offer a novel strategy for the depletion of CML stem cells from the bulk population in clinical hematopoietic stem cell transplantation.

The 'Grueling Process' of Emancipation.

Black Americans' fight for health care remains highly relevant.

The prognostic implications of tetraploidy/near-Tetraploidy in acute myeloid leukemia: a case series and systematic review of the literature.

The prognostic significance and optimal management of tetraploidy/near-tetraploidy acute myeloid leukemia (T/NT AML) remains unclear given its limited data. This is especially true after factoring in additional chromosomal alterations, which carry their own prognostic weight. Here, we analyze 128 cases of T/NT in AML from the literature along with two additional cases, which is the largest review of this subject to date. Based on our retrospective analysis, we found that regardless of the risk status attributed to cytogenetics, the prognosis of tetraploid or near-tetraploid AML is dismal and should be incorporated within the unfavorable risk group. Complete remission is paramount to survival in this population. Specific induction protocols for high-risk AML appear to have higher rates of complete remission in the T/NT AML population. Moreover, longer overall survival can be achieved with chemotherapy followed by allogeneic stem cell transplantation at first complete remission.

Special Report: Frontline Nurses Say 'Never Again'.

Nurses share experiences from the pandemic and strategies to successfully manage future health care crises.

How Marketing Practices Undermine Nurses.

Author Quinn Grundy on the undue influence of vendors.

Association between psychotropic drug use and prescription opioid use among older adults.

This study investigated the association between psychotropic drug use and prescription opioid use/high dosage opioid use among older adults. A sample of 203,750 older adults enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program during 2017 was evaluated for prescription opioid and psychotropic drug usage. High dosage opioid use was defined as using >90 morphine milligram equivalents (MME)/day for ≥90 consecutive days. Overall, 20.7% of enrollees filled opioid prescriptions, of which 1.4% used them at high dosages. Multivariate logistic regression indicated that the odds of prescription opioid use increased with anxiolytic/sedative/hypnotic use and antidepressant use. Moreover, high dosage opioid use was significantly associated with anxiolytic/sedative/hypnotic use, antidepressant use and other factors including being younger, male, white, and married but living separately, and having multiple opioid prescribers. Clinicians should carefully evaluate opioid use among older patients using anxiolytics or antidepressants to minimize risks for adverse consequences of opioids.

Confronting Medical Error.

A new book makes the case for 'a culture shift of epic proportions.'

Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy.

Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.

'Kindly Women and Practically Trained Subordinates'.

How nursing's past holds back our present.