High-Dose Immunoglobulin Therapy for Multiple Thromboembolism in Persisting Heparin-Induced Thrombocytopenia.

This report presents a case of an 81-year-old male with acute respiratory distress syndrome secondary to aspiration pneumonia who developed heparin-induced thrombocytopenia (HIT). His platelet count remained persistently low despite discontinuing unfractionated heparin and initiating intravenous argatroban. Multiple thromboembolisms, including a new aortic mural thrombus in the descending aorta, were observed on contrast-enhanced computed tomography (CT), resulting in a diagnosis of autoimmune HIT (aHIT). Subsequent high-dose intravenous immunoglobulin (IVIG) therapy substantially improved the platelet count and resolved thromboembolisms. This case is notable owing to the improvement of aHIT complicated by multiple thromboembolisms, including an aortic mural thrombus, following high-dose IVIG therapy. In recent years, a growing number of reports have documented the effectiveness of high-dose IVIG therapy for aHIT. However, reports on whether high-dose IVIG therapy could improve an aortic mural thrombus complicating aHIT are lacking. The successful use of high-dose IVIG therapy in the current case highlights its potential efficacy in treating aHIT complicated by multiple thromboembolisms. Further studies are required to clarify the role of IVIG in the management of aHIT with thromboembolism.

Factors associated with the acceptance of employing nursing assistants aged 65 and older among those younger than 65 years old.

Objectives: Japan has implemented a policy to facilitate the employment of people aged 65 and older. It should be common practice for hospitals to employ older nursing assistants. We investigated factors associated with the acceptance of employing older nursing assistants among those younger than 65. Materials and Methods: The subjects were female nursing assistants younger than 65 working in 30 hospitals. A questionnaire-based survey was conducted. We performed factor analyses of both respondents' opinions on the employment of "Nursing assistants aged 65-69" and "Nursing assistants aged 70-74". To examine the associations between the "Acceptance of employing nursing assistants aged 65-69" and the "Opinions on the employment of nursing assistants aged 65-69", we conducted multiple regression analysis (Statistical Model 1). To examine the associations between the "Acceptance of employing nursing assistants aged 70-74" and the "Opinions on the employment of nursing assistants aged 70-74", we also conducted multiple regression analysis (Statistical Model 2). Results: By factor analyses of the opinions on the employment of both "Nursing assistants aged 65-69" and "Nursing assistants aged 70-74", the same factors were extracted. These factors were: "Health and job performance", "Utilization of the knowledge and experience of older nursing assistants", "Reducing the workload of nursing assistants", and "Manners of older nursing assistants". By multiple regression analyses in both "Statistical Models 1 and 2", "Health and job performance", "Utilization of the knowledge and experience of older nursing assistants", and "Reducing the workload of nursing assistants" were significant variables. Moreover, only in "Statistical Model 1", full-time nursing assistants were more accepting of employing nursing assistants aged 65-69 compared to part-time nursing assistants. Conclusion: To facilitate the acceptance of employing older nursing assistants, hospital managers should pay careful attention to these findings.

Facilitating the acceptance of employment of older registered nurses among Japanese female registered nurses younger than 65 years old.

Objective: In Japan, policies to ensure employment for persons aged 65 and older are being implemented. To facilitate the employment of older registered nurses working in hospitals, the understanding of registered nurses younger than 65 is necessary. We investigated the factors associated with the acceptance of employment of older registered nurses among registered nurses younger than 65. Materials and Methods: The subjects were female registered nurses younger than 65 working in 34 hospitals in Mie Prefecture. We distributed anonymous self-administered questionnaires. We conducted factor analyses of both respondents' opinions on the employment of "Registered nurses aged 65-69" and "Registered nurses aged 70-74". Multiple regression analysis was conducted to examine the associations between the "Acceptance of employing registered nurses aged 65-69" and "Opinions on the employment of registered nurses aged 65-69" (Statistical model 1). Moreover, multiple regression analysis was also conducted to examine the associations between the "Acceptance of employing registered nurses aged 70-74" and the "Opinions on the employment of registered nurses aged 70-74" (Statistical model 2). Results: Using factor analyses, the same factors were extracted for both, "Registered nurses aged 65-69" and "Registered nurses aged 70-74". These factors were: "Health and job performance", "Utilization of the knowledge and experience of older registered nurses", "Reducing the workload burden of registered nurses", and "Manners of older registered nurses". Using multiple regression analyses, "Health and job performance", "Utilization of the knowledge and experience of older registered nurses", and "Reducing the workload burden of registered nurses" were significantly associated with "Acceptance of employing registered nurses aged 65-69" (Statistical model 1). The same 3 factors were also significantly associated with "Acceptance of employing registered nurses aged 70-74" (Statistical model 2). Conclusion: Hospital managers must pay careful attention to these 3 factors.

Efficacy of Preoperative Bilateral Thoracic Paravertebral Block in Cardiac Surgery Requiring Full Heparinization: A Propensity-Matched Study.

OBJECTIVES: To assess the efficacy of preoperative bilateral paravertebral block (PVB) with general anesthesia (GA) in contributing to early extubation and decreasing opioid consumption in cardiac surgery. DESIGN: A propensity score-matched retrospective study. SETTING: A single tertiary medical center between January 2018 and December 2020. PARTICIPANTS: Adult patients undergoing isolated first-time aortic valve replacement and coronary artery bypass grafting with full sternotomy. INTERVENTIONS: A cohort of 44 patients who received PVB with GA (PVB group) was matched with 44 patients who underwent similar surgery with GA only (GA only group). MEASUREMENTS AND MAIN RESULTS: The completion rate of extubation in the operating room was significantly greater in the PVB group (65.9%) than in the GA only group (43.2%; p = 0.032). The completion rate of extubation within eight hours after surgery also was significantly greater in the PVB group (86.4%) than in the GA only group (68.2%; p = 0.042). The median amount of intraoperative fentanyl administered was significantly less in the PVB group (4.8 µg/kg; interquartile range [IQR], 3.3-7.2) than in the GA only group (8.4 µg/kg; IQR, 5.4-12.7; p < 0.001). The median amount of postoperative fentanyl administered was significantly less in the PVB group (6.8 µg/kg; IQR, 3.9-10.6) than in the GA only group (8.1 µg/kg; IQR, 6.2-15.9; p = 0.012). CONCLUSIONS: This study demonstrated that preoperative bilateral PVB combined with GA contributed to early extubation in isolated first-time aortic valve replacement and coronary artery bypass grafting and in the reduction of intraoperative and postoperative fentanyl consumption.

Effect of malnutrition and frailty status on surgical aortic valve replacement.

OBJECTIVES: To date, assessment of nutritional and frailty status in patients undergoing surgical aortic valve replacement remains unclear. This study aimed to assess the effect of geriatric nutritional risk index (GNRI) and Rockwood clinical frailty scale (CFS) on short-term and mid-term survival in patients who underwent surgical aortic valve replacement for aortic stenosis. METHODS: In total, 219 patients who underwent aortic valve replacement for aortic stenosis between Jan 1 2011 and Dec 31 2018 were retrospectively monitored in a single center. Mid-term survival was assessed using Kaplan-Meier analysis. Logistic and Cox regression analyses were performed to detect independent predictors for early and mid-term mortality. Follow-up was 97.7% complete, and a GNRI score ≤ 98 denoted malnutrition. RESULTS: In the univariable analysis, GNRI [odds ratio (OR) 0.91, 95% confidence interval (CI), 0.86-0.96, p < 0.001] and CFS (OR 2.00 95% CI 1.38-2.94, p < 0.001) were identified as significant risk factors for in-hospital mortality. Mid-term survival was significantly decreased in patients with malnutrition (3 and 5 year survival rates 83.9 and 76.9%, respectively, p < 0.001). Mid-term freedom from major cardiac and cerebrovascular events was significantly decreased in patients with malnutrition (p = 0.039). The CFS (hazard ratio 1.78) and GNRI (hazard ratio 0.95) were independent risk factors for mid-term survival in the univariable and multivariable analyses, respectively. CONCLUSIONS: A lower GNRI is associated with poor mid-term mortality and major cardiac and cerebrovascular events after surgical aortic valve replacement. A lower CFS score is associated with unfavorable mid-term outcomes.

Successful ligation of posterior tibial vein aneurysm performed according to intraoperative venography results.

A 23-year-old woman was diagnosed with a posterior tibial vein aneurysm that had resulted in deep vein thrombosis and a pulmonary embolism. The patient responded well to anticoagulation therapy, and surgical resection was planned to prevent recurrence. She was scheduled to undergo tangential aneurysmectomy and lateral venorrhaphy. However, the aneurysm could not be completely exposed because of adhesions. Therefore, venography was performed to identify the inflow and outflow vessels, which were ligated because an accessory venous communication was identified. Intraoperative venography can aid in the selection of simple ligation or reconstruction of a venous communication for the treatment of posterior tibial vein aneurysms.

Predictors associated with the mental health of Japanese male registered nurses: focusing on environments with many female registered nurses and female patients' refusal to accept nursing services from male registered nurses.

Objective: To study the improvement of the mental health of Japanese male registered nurses, we investigated the predictors associated with the Japanese version of the 12-item General Health Questionnaire (GHQ-12). For those predictors, we focused on environments with many female registered nurses and female patients' refusal to accept nursing services from male registered nurses. Materials and Methods: This study was conducted in 93 hospitals in the Aichi, Gifu, and Mie prefectures of Japan. The analyzed subjects were 1,216 full-time male registered nurses. The average age (standard deviation) was 34.5 (9.2) years. Multiple logistic regression analysis was conducted. A GHQ-12 score of ≤3 indicated good mental health, and a score of ≥4 indicated poor mental health. "Mental health" was a dependent variable. The independent variables were: "Age", "Male registered nurses as important partners on the job", "Female registered nurses' good manners toward male registered nurses", "Fairness regarding male registered nurses' promotions", and "Female patients' refusal to accept nursing services from male registered nurses". Results: There were 728 (59.9%) full-time male registered nurses with good mental health and 488 (40.1%) with poor mental health. The mental health of the male registered nurses who had negative feelings regarding, "Male registered nurses as important partners on the job" was significantly worse, and that of those who had negative feelings regarding, "Female registered nurses' good manners toward male registered nurses" was also significantly worse. Conclusion: Female registered nurses must recognize that their attitudes toward male registered nurses influence the mental health of male registered nurses. Hospital managers should provide male registered nurses who cannot establish appropriate relations with female registered nurses with consultation opportunities. Such organizational action by managers is necessary.

Reducing the risk of developing walled-off necrosis in patients with acute necrotic collection using recombinant human soluble thrombomodulin.

BACKGROUND/PURPOSE: The purpose of the present study was to investigate the possibility of reducing clinical impacts of acute necrotic collection (ANC) on patients with acute pancreatitis (AP) using recombinant human soluble thrombomodulin (rTM). METHODS: In this retrospective multicenter study, 233 consecutive AP patients with ANC and acute peripancreatic fluid collection (APFC) from 2012 to 2016 were enrolled. To assess clinical impacts of ANC, severity on admission (JPN score, JPN CT grade, and Modified CT severity index), development of walled-off necrosis (WON), imaging costs for follow-up, and mortality were recorded. Finally, we investigated whether rTM could reduce the clinical impacts, adjusting the severity using propensity analysis with Inverse probability of treatment weighting. RESULTS: Patients with ANC developed WON with higher ratio than APFC (58/98 [59.2%] vs 20/135 [14.8%], OR = 8.3, P < .01]. Severity on admission and imaging costs for follow-up in ANC patients were significantly higher than those in APFC (P < .01). However, regarding mortality, there was no significant difference between patients with ANC and APFC (P = .41). Adjusting severity, it was revealed that rTM administration significantly reduced the risk of ANC developed WON (OR = 0.23, P = .01). CONCLUSIONS: While ANC had a higher clinical impact than that of APFC, we found that early administration of rTM may reduce the impact.

Endoscopic placement of covered versus uncovered self-expandable metal stents for palliation of malignant gastric outlet obstruction.

OBJECTIVE: Stenting is an established endoscopic therapy for malignant gastric outlet obstruction (mGOO). The choice of stent (covered vs uncovered) has been examined in prior randomised studies without clear results. DESIGN: In a multicentre randomised prospective study, we compared covered (CSEMS) with uncovered self-expandable metal stents (UCSEMS) in patients with mGOO; main outcomes were stent dysfunction and patient survival, with subgroup analyses of patients with extrinsic and intrinsic tumours. RESULTS: Overall survival was poor with no difference between groups (probability at 3 months 49.7% for covered vs 48.4% for uncovered stents; log-rank for overall survival p=0.26). Within that setting of short survival, the proportion of stent dysfunction was significantly higher for uncovered stents (35.2% vs 23.4%, p=0.01) with significantly shorter time to stent dysfunction. This was mainly relevant for patients with extrinsic tumours (stent dysfunction rates for uncovered stents 35.6% vs 17.5%, p<0.01). Subgrouping was also relevant with respect to tumour ingrowth (lower with covered stents for intrinsic tumours; 1.6% vs 27.7%, p<0.01) and stent migration (higher with covered stents for extrinsic tumours: 15.3% vs 2.5%, p<0.01). CONCLUSIONS: Due to poor patient survival, minor differences between covered and uncovered stents may be less relevant even if statistically significant; however, subgroup analysis would suggest to use covered stents for intrinsic and uncovered stents for extrinsic malignancies.

Mechanism of aspirin-induced inhibition on the secondary hyperalgesia in osteoarthritis model rats.

AIMS: The daily activity of osteoarthritis (OA) patients is limited by chronic pain and central sensitization. Although non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are the first-line drugs for the treatment of OA-related pain, their efficacy on central sensitization remains unclear. In the present study, we evaluated the effect of acetylsalicylic acid (ASA, Aspirin) using an OA model induced by monosodium iodoacetate (MIA), which has a similar disease progression to human OA. MAIN METHODS: Secondary hyperalgesia was assessed at the plantar surface of the hind paw by Von Frey test. We evaluated the expression of acid-sensing ion channel 3 (ASIC3) in dorsal root ganglia and that of tumor necrosis factor-α (TNF-α) and interleukin-1ß (IL-1ß) in the spinal cord, which may cause secondary hyperalgesia in OA, by immunohistochemical analysis and real-time qPCR. KEY FINDINGS: The administration of ASA attenuated secondary hyperalgesia at 1-3 weeks after MIA, while celecoxib, a selective cyclooxygenase (COX)-2 inhibitor, failed to attenuate secondary hyperalgesia at week 2 after MIA injection, suggesting that ASA exerts its analgesic effect through a COX-2-independent pathway. Immunohistochemical analysis of the dorsal root ganglia indicated that ASA reduced the expression of ASIC3 during OA progression. Expression of TNF-α mRNA, but not IL-1ß mRNA, in the spinal cord following MIA injection was suppressed by ASA administration. SIGNIFICANCE: These findings suggest that ASA may have the ability to attenuate secondary hyperalgesia through suppression of ASIC3 and/or TNF-α expression. ASA is therefore a clinically useful analgesic drug for treatment of secondary hyperalgesia in OA.

Job satisfaction and intention to remain on the job among Japanese nursing assistants.

Objective: To establish work environments that prevent Japanese nursing assistants from leaving their jobs, we investigated the associations between their job satisfaction levels and intentions to remain on their jobs. Materials and Methods: We distributed anonymous self-administered questionnaires to Japanese female nursing assistants in 30 different hospitals. Regarding job satisfaction, we investigated various items relevant to both intrinsic facets (e.g., gaining various experiences) and extrinsic facets (e.g., salary), and conducted factor analyses of those items. Standardized partial regression coefficients were then calculated using multiple regression analyses. Intention to remain on the job was the dependent variable for this study. The factor scores calculated by the factor analyses of job satisfaction and respondents' characteristics were the independent variables. Since multicollinearity occurred, we utilized two types of statistical models. After questionnaires with one or more missing values were excluded, 618 questionnaires were analyzed. Results: Using factor analyses, we discovered six factors related to job satisfaction among nursing assistants: "Intrinsic motivation", "Salary", "Relationships among nursing assistants", "Registered nurses' attitudes", "Fatigue reduction", and "Opportunities for vocational skills". In statistical model 1, "Intrinsic motivation", "Salary", "Fatigue reduction", "Age", "Employment status", and "Certified care worker status" were significantly associated with "Intention to remain on the job". In statistical model 2, "Salary", "Registered nurses' attitudes", "Fatigue reduction", "Opportunities for vocational skills", "Age", and "Employment status" were significantly associated with "Intention to remain on the job". Conclusion: "Intrinsic motivation" and "Opportunities for vocational skills" are included in intrinsic facets. To prevent nursing assistants from leaving their jobs, raising only their extrinsic job satisfaction levels is insufficient. Because nursing assistants have not received formal nursing education, they cannot take pride in having the same skills and expertise as registered nurses. However, hospital managers must respect their feelings and establish an appropriate working environment.

Usefulness of immunohistochemical staining for MUC5AC in differentiating primary pancreatic cancer from pancreatic metastasis of breast cancer.

Diagnosis of pancreatic ductal adenocarcinoma (PDAC) and its differentiation from metastases to the pancreas from other organs remains challenging. We report a case in which immunohistochemical staining for MUC5AC was useful in distinguishing primary pancreatic cancer from breast cancer metastasis. A 51-year-old Japanese woman who underwent curative resection of her breast cancer was referred to our hospital with a pancreatic head tumor. Although we surmised her pancreatic tumor to be metastatic breast cancer based on her past history and imaging studies, she was subsequently diagnosed with PDAC on the basis of immunohistochemical staining for MUC5AC using specimens obtained by endoscopic ultrasound-fine-needle aspiration. Thus, MUC5AC may be a useful diagnostic marker for discriminating PDAC from a secondary malignancy.

Predictors of female registered nurses' interest in enrolling in master's programs of nursing graduate schools in Japan.

Objective: Enrollment in graduate schools presents a useful opportunity for registered nurses to enhance their expertise in their nursing field and gain better opportunities to achieve their desired career advancements. This study investigates the predictors associated with registered nurses' interest in enrolling in master's programs of nursing graduate schools. Materials and Methods: For the predictors associated with interest in enrolling in master's programs of nursing science, we evaluated items related to registered nurses' perceptions of their work environments and their impressions regarding master's programs in nursing. The analyzed subjects were 3,611 female registered nurses working in 30 hospitals in Mie prefecture, Japan. Multiple linear regression analyses were conducted to investigate registered nurses' predictors of interest in enrolling in master's programs of nursing graduate schools. We included the variables with Variance Inflation Factor (VIF) less than (<) 2 in the statistical model. Results: Full-time nurses were more interested in enrolling in master's programs than part-time nurses. Registered nurses who felt that they could keep up with courses in graduate schools, that they would be able to acquire skills to contribute to society, and that their colleagues were competent, showed stronger interest in master's programs. Registered nurses who were under the impression that graduate school teachers were dedicated to their students showed lower interest in master's programs. Registered nurses who felt that their superiors were competent and that they were expected to perform well by physicians also showed lower interest in master's programs. Conclusion: Predictors significantly associated with registered nurses' interest in enrolling in master's programs of nursing graduate schools were determined. Further studies are required to gain a more detailed understanding of the nurses' attitudes investigated.

Comparison between a rotatable sphincterotome and a conventional sphincterotome for selective bile duct cannulation.

BACKGROUND: Selective biliary cannulation (SBC) is the first challenge of endoscopic retrograde cholangiopancreatography (ERCP), especially for trainees, and a rotatable sphincterotome may be useful to guide the directional axis of the scope and SBC. METHODS: We performed a prospective randomized single-center trial, enrolling 200 patients with a native papilla who required therapeutic biliary ERCP. Patients were randomly assigned to the rotatable sphincterotome group (n = 100) or the conventional sphincterotome group (n = 100). The primary endpoint was successful SBC by the trainees within 10 minutes. RESULTS: The early and late cannulation success rates did not differ significantly between the groups (P = 0.46 and P > 0.99, respectively). For the patients in whom trainees failed to achieve SBC, the rotatable sphincterotome was used as a rescue cannulation technique in four patients from the conventional group; in no patients in the rotatable group was the conventional sphincterotome used for SBC. Post-ERCP pancreatitis (PEP) occurred in 11 patients (5.5 %; 6 mild, 5 moderate); the incidence did not differ significantly between the two groups (rotatable group 3 %, conventional group 8 %; P = 0.21). The two groups were thus combined for evaluation of the factors relating to cannulation difficulty for trainees, which revealed that orientation of the papilla was a significant factor (P < 0.001). CONCLUSIONS: The type of sphincterotome used did not affect the success of SBC by trainees. However, orientation of the papilla was revealed to be a significant factor relating to cannulation difficulty for trainees overall.

Management of Pancreatolithiasis: A Nationwide Survey in Japan.

OBJECTIVES: The aim of this study was to assess prevailing treatment of pancreatolithiasis in Japan. METHODS: We surveyed clinical data from 1834 patients (1479 men and 355 women) at 125 hospitals. RESULTS: Extracorporeal shock-wave lithotripsy (ESWL) was performed alone in 103 patients (5.6%), ESWL plus an endoscopic procedure in 446 (24.3%), endoscopic treatment alone in 261 (14.2%), and surgery in 167 (9.1%). Other treatments were given to 358 (19.5%), whereas 499 (27.2%) received no treatment. Symptoms were relieved in 85.7% after ESWL, 80.8% after endoscopic treatment alone, and 92.8% after surgery. Early complication rates within 3 months after ESWL, endoscopic treatment alone, and surgery were 8%, 4.5%, and 27.1%, respectively. Late complications after ESWL, endoscopic procedures alone, and surgery were 1.7%, 2.5%, and 8.2%, respectively. Symptom relief but also early and late complications were greater after surgery than after ESWL and endoscopic treatment. Among 417 patients undergoing ESWL, 61 (14.6%) required surgery, as did 32 (16%) of 200 patients treated endoscopically. Surgery was required less frequently following initial operative treatment (11/164 patients [6.7%]). Nonsurgical initial treatments were chosen more frequently. CONCLUSIONS: First-line treatment of pancreatolithiasis should be ESWL with or without endoscopy because of minimal invasiveness and fewer complications.

Feelings about Nursing Assistants that Enhance the Work Motivation of Japanese Registered Nurses and Licensed Practical Nurses.

Registered nurses and licensed practical nurses have received professional education, but to enhance their work motivation it is necessary to create work environments in which they can concentrate on their jobs as specialists. One of the methods to develop such work environments is to use nursing assistants effectively. We investigated professional nurses' feelings toward nursing assistants and then examined the associations between those feelings and their work motivation. The analyzed subjects were 2,170 female nurses working in 25 hospitals with from 55 to 458 beds. The average age of the respondents was 38.0 (standard deviation, 10.6 years). Factor analyses extracted four factors of professional nurses' feelings toward nursing assistants: 1. knowledge related to healthcare, 2. nursing assistants' attitudes toward work, 3. human relations, and 4. distinguishing between professional nurses' work and nursing assistants' work. Using multiple linear regression analysis, our results revealed that scores of maintaining a high motivation to work thanks to nursing assistants became lower as the ages of the respondents increased. Scores of maintaining a high motivation to work thanks to nursing assistants became higher as professional nurses gained satisfaction from: knowledge related to healthcare, nursing assistants' attitudes toward work, and human relations. Hospital managers should consider these findings to improve working environments in which professional nurses can feel motivated to work.

Predictors of a Desire to be Helpful to Professional Nurses Among Japanese Nursing Assistants in Small- to Medium-Sized Hospitals.

Registered nurses and licensed practical nurses have been educated as professional nurses. Professional nurses can concentrate on their jobs requiring a high degree of expertise with help they get from nursing assistants.If professional nurses have improper attitudes toward nursing assistants, it is most likely that the nursing assistants will not help them to the best of their ability. We investigated nursing assistants' impressions regarding professional nurses' attitudes, and what effects nursing assistants' impressions have on their "desire to be helpful to professional nurses." The study design was a cross sectional study. Twenty-five small- to medium-sized hospitals with 55 to 458 beds were included in this study. The analyzed subjects were 642 nursing assistants (96 males, 546 females). Factor analyses were conducted to extract the factors of nursing assistants' impressions regarding professional nurses' attitudes. Multiple linear regression analysis was conducted to investigate the predictors of "desire to be helpful to professional nurses." We discovered 5 factors: 1. professional nurses' model behavior, 2. manner dealing with nursing assistants, 3. respect for nursing assistants' passion for their work, 4. respect for nursing assistants' work, and 5. enhancing the ability of nursing assistants to do their work. The "desire to be helpful to professional nurses" was significantly associated with "professional nurses' model behavior," "manner dealing with nursing assistants" and "respect for nursing assistants' passion for their work." Factors 1 to 3 are fundamental principles when people establish appropriate relationships. Professional nurses must consider these fundamentals in their daily work in order to get complete cooperation from nursing assistants.