Mitigating Moral Distress in Leaders of Healthcare Organizations: A Scoping Review.

GOAL: Moral distress literature is firmly rooted in the nursing and clinician experience, with a paucity of literature that considers the extent to which moral distress affects clinical and administrative healthcare leaders. Moreover, the little evidence that has been collected on this phenomenon has not been systematically mapped to identify key areas for both theoretical and practical elaboration. We conducted a scoping review to frame our understanding of this largely unexplored dynamic of moral distress and better situate our existing knowledge of moral distress and leadership. METHODS: Using moral distress theory as our conceptual framework, we evaluated recent literature on moral distress and leadership to understand how prior studies have conceptualized the effects of moral distress. Our search yielded 1,640 total abstracts. Further screening with the PRISMA process resulted in 72 included articles. PRINCIPAL FINDINGS: Our scoping review found that leaders-not just their employees- personally experience moral distress. In addition, we identified an important role for leaders and organizations in addressing the theoretical conceptualization and practical effects of moral distress. PRACTICAL APPLICATIONS: Although moral distress is unlikely to ever be eliminated, the literature in this review points to a singular need for organizational responses that are intended to intervene at the level of the organization itself, not just at the individual level. Best practices require creating stronger organizational cultures that are designed to mitigate moral distress. This can be achieved through transparency and alignment of personal, professional, and organizational values.

Facing disruption: Learning from the healthcare supply chain responses in British Columbia during the COVID-19 pandemic.

The healthcare supply chain crisis surrounding Personal Protective Equipment (PPE) during the onset of the COVID-19 pandemic presented unique and complex challenges in achieving the primary aim of supply chain management, that is, delivering the right amount of the right supplies to the right people at the right time. This article describes the key findings from a case study on PPE supply chain responses to the COVID-19 pandemic in British Columbia (BC). It highlights a set of constructive response mechanisms to potential crises along healthcare supply chain. Effective and trusted leadership, a unity of purpose, integrated and robust digital infrastructure and capabilities, consistent learning, resilience building, and environmental sensing for reliable intelligence were found to be essential for preparing, for containing, and mitigating the crisis as it evolved across various phases of crisis management.

Public Health and Health Sector Crisis Leadership During Pandemics: A Review of the Medical and Business Literature.

The global scale and unpredictable nature of the current COVID-19 pandemic have put a significant burden on health care and public health leaders, for whom preparedness plans and evidence-based guidelines have proven insufficient to guide actions. This article presents a review of empirical articles on the topics of "crisis leadership" and "pandemic" across medical and business databases between 2003 (since SARS) and-December 2020 and has identified 35 articles for detailed analyses. We use the articles' evidence on leadership behaviors and skills that have been key to pandemic responses to characterize the types of leadership competencies commonly exhibited in a pandemic context. Task-oriented competencies, including preparing and planning, establishing collaborations, and conducting crisis communication, received the most attention. However, people-oriented and adaptive-oriented competencies were as fundamental in overcoming the structural, political, and cultural contexts unique to pandemics.

Crisis standards of care in a pandemic: navigating the ethical, clinical, psychological and policy-making maelstrom.

The COVID-19 pandemic has caused clinicians at the frontlines to confront difficult decisions regarding resource allocation, treatment options and ultimately the life-saving measures that must be taken at the point of care. This article addresses the importance of enacting crisis standards of care (CSC) as a policy mechanism to facilitate the shift to population-based medicine. In times of emergencies and crises such as this pandemic, the enactment of CSC enables concrete decisions to be made by governments relating to supply chains, resource allocation and provision of care to maximize societal benefit. This shift from an individual to a population-based societal focus has profound consequences on how clinical decisions are made at the point of care. Failing to enact CSC may have psychological impacts for healthcare providers particularly related to moral distress, through an inability to fully enact individual beliefs (individually focused clinical decisions) which form their moral compass.

Calmodulin Binding to Connexin 35: Specializations to Function as an Electrical Synapse.

Calmodulin binding is a nearly universal property of gap junction proteins, imparting a calcium-dependent uncoupling behavior that can serve in an emergency to decouple a stressed cell from its neighbors. However, gap junctions that function as electrical synapses within networks of neurons routinely encounter large fluctuations in local cytoplasmic calcium concentration; frequent uncoupling would be impractical and counterproductive. We have studied the properties and functional consequences of calmodulin binding to the electrical synapse protein Connexin 35 (Cx35 or gjd2b), homologous to mammalian Connexin 36 (Cx36 or gjd2). We find that specializations in Cx35 calmodulin binding sites make it relatively impervious to moderately high levels of cytoplasmic calcium. Calmodulin binding to a site in the C-terminus causes uncoupling when calcium reaches low micromolar concentrations, a behavior prevented by mutations that eliminate calmodulin binding. However, milder stimuli promote calcium/calmodulin-dependent protein kinase II activity that potentiates coupling without interference from calmodulin binding. A second calmodulin binding site in the end of the Cx35 cytoplasmic loop, homologous to a calmodulin binding site present in many connexins, binds calmodulin with very low affinity and stoichiometry. Together, the calmodulin binding sites cause Cx35 to uncouple only at extreme levels of intracellular calcium.

Localized Calcium Signaling and the Control of Coupling at Cx36 Gap Junctions.

A variety of electrical synapses are capable of activity-dependent plasticity, including both activity-dependent potentiation and activity-dependent depression. In several types of neurons, activity-dependent electrical synapse plasticity depends on changes in the local Ca2+ environment. To enable study of local Ca2+ signaling that regulates plasticity, we developed a GCaMP Ca2+ biosensor fused to the electrical synapse protein Connexin 36 (Cx36). Cx36-GCaMP transfected into mammalian cell cultures formed gap junctions at cell-cell boundaries and supported Neurobiotin tracer coupling that was regulated by protein kinase A signaling in the same way as Cx36. Cx36-GCaMP gap junctions robustly reported local Ca2+ increases in response to addition of a Ca2+ ionophore with increases in fluorescence that recovered during washout. Recovery was strongly dependent on Na+-Ca2+ exchange activity. In cells transfected with NMDA receptor subunits, Cx36-GCaMP revealed transient and concentration-dependent increases in local Ca2+ on brief application of glutamate. In HeLa cells, glutamate application increased Cx36-GCaMP tracer coupling through a mechanism that depended in part on Ca2+, calmodulin-dependent protein kinase II (CaMKII) activity. This potentiation of coupling did not require exogenous expression of glutamate receptors, but could be accomplished by endogenously expressed glutamate receptors with pharmacological characteristics reminiscent of NMDA and kainate receptors. Analysis of RNA Sequencing data from HeLa cells confirmed expression of NMDA receptor subunits NR1, NR2C, and NR3B. In summary, Cx36-GCaMP is an effective tool to measure changes in the Ca2+ microenvironment around Cx36 gap junctions. Furthermore, HeLa cells can serve as a model system to study glutamate receptor-driven potentiation of electrical synapses.

Therapy services and specialized devices for conjoined twins: Unique challenges with conjoined twins and the importance of physical and occupational therapy.

Conjoined twins are a rare occurrence that offer unique challenges and circumstances to therapists. The overall goal of physical and occupational therapy treatment is to provide care that promotes developmental progression to two conjoined individuals with distinct personalities and potentially different physical and medical needs. The unique presentation of conjoined twins must be considered in determining therapeutic goals, interventions and plans of care. Providing therapeutic interventions throughout the NICU stay is a dynamic, evolving process, which challenges the therapy team to work together to find solutions. This paper aims to highlight the considerations, challenges, and strategies used to address barriers in the therapeutic care of conjoined twins.

Calcium Imaging with Super-Resolution Radial Fluctuations.

Calcium signals act as a ubiquitous secondary messenger in regulating many body functions. The detection of calcium microdomain signals is greatly facilitated by the existence of biomarker-targeted fluorescent probes. In this study, SRRF (super-resolution radial fluctuations) algorithm were used to compare the loci and the intensity of fluorescent probes before and after SRRF analysis. The implementation of SRRF algorithm was aimed for automatically resolving delicate and small calcium signals (to avoid the overlapped loci) on original images. For assessing the spatial accuracy of image intensity, immunofluorescence staining of retina cryostat slice for connexin 36 (Cx36) was microscopically imaged with or without the successive SRRF reconstruction. For characterizing the temporal association between SRRF and non-SRRF images, the changes of Cx36-GCaMP calcium indicator were recorded from transfected HeLa cells in response to the transient puffing of ionomycin. Image processing and analyses were conducted with Image J and Matlab. Through this study, SRRF reconstruction was found to confer an accurate measure for the identification of subcellular molecules, such as gap junctions. Compared with the conventional imaging, SRRF reconstruction generated better image resolution for the precise registration of individual signals. Temporally, the ratios of change in fluorescence intensity between SRRF and non-SRRF images were significantly correlated in the presence or absence of the subtraction of high background intensity. Quantitatively, the ratios of change in fluorescence intensity between SRRF and non-SRRF images with or without background subtraction were also significantly correlated. The merit of SRRF application on calcium live imaging was validated with the reporter gene system we worked on.

Zebrafish connexin 79.8 (Gja8a): A lens connexin used as an electrical synapse in some neurons.

In the mammalian central nervous system, a remarkably small number of connexins is used in electrical synapses, with the majority formed from Cx36. A larger number has been detected in teleosts, with some seeming to serve restricted roles. Here, we report the discovery of a new connexin expressed in the zebrafish lens and a limited set of neurons. Zebrafish cx79.8 (gja8a), previously annotated incorrectly as cx50.5 based on a partial cDNA sequence, is a homologue of mammalian Cx50 (Gja8). We examined its expression through transgenic promoter-reporter constructs, in situ hybridization, and immunolabeling, and examined regulation of coupling in transfected HeLa cells. cx79.8 was expressed most strongly in the lens, but expression was also found in several groups of neurons in the cerebellum and related areas at the midbrain-hindbrain boundary, in cone photoreceptors, and in neurons in the retinal inner nuclear and ganglion cell layers. Labeling in the retina with antibodies against two C-terminal epitopes revealed numerous small punctate spots in the inner plexiform layer and along the somata of cones. Abundant gap junctions were labeled in the outer 1/3 of the lens, but were absent from the center, suggesting that the epitopes or the entire protein was absent from the center. Cx79.8 tracer coupling was strongly regulated by phosphorylation, and was extremely low in control conditions in HeLa cells due to protein phosphatase 2A activity. These properties allow coupling to be strongly restricted in situ, a frequently observed property for electrical synapses. © 2016 Wiley Periodicals, Inc. Develop Neurobiol 77: 548-561, 2017.

Two-color fluorescent analysis of connexin 36 turnover: relationship to functional plasticity.

Gap junctions formed of connexin 36 (Cx36, also known as Gjd2) show tremendous functional plasticity on several time scales. Changes in connexin phosphorylation modify coupling in minutes through an order of magnitude, but recent studies also imply involvement of connexin turnover in regulating cell-cell communication. We utilized Cx36 with an internal HaloTag to study Cx36 turnover and trafficking in cultured cells. Irreversible, covalent pulse-chase labeling with fluorescent HaloTag ligands allowed clear discrimination of newly formed and pre-existing Cx36. Cx36 in junctional plaques turned over with a half-life of 3.1 h, and the turnover rate was unchanged by manipulations of protein kinase A (PKA) activity. In contrast, changes in PKA activity altered coupling within 20 min. New Cx36 in cargo vesicles was added directly to existing gap junctions and newly made Cx36 was not confined to points of addition, but diffused throughout existing gap junctions. Existing connexins also diffused into photobleached areas with a half-time of less than 2 s. In conclusion, studies of Cx36-HaloTag revealed novel features of connexin trafficking and demonstrated that phosphorylation-based changes in coupling occur on a different time scale than turnover.

The Clinical and Health Economic Value of Clinical Laboratory Diagnostics.

The ultimate goal of diagnostic testing is to guide disease management in order to improve patient outcomes and patient well-being. Patient populations are rarely homogenous and accurate diagnostic tests can dissect the patient population and identify those patients with similar symptoms but very different underlying pathophysiology that will respond differently to different treatments. This stratification of patients can direct patients to appropriate treatment and is likely to result in clinical benefits for patients and economic benefits for the healthcare system. In this article we look at the clinical and economic benefits afforded by clinical laboratory diagnostics in three disease areas that represent substantial clinical and healthcare burdens to society; heart failure, Alzheimer's disease and asthma.

Lower weight gain and hepatic lipid content in hamsters fed high fat diets supplemented with white rice protein, brown rice protein, soy protein, and their hydrolysates.

The physiological effects of the hydrolysates of white rice protein (WRP), brown rice protein (BRP), and soy protein (SP) hydrolyzed by the food grade enzyme, alcalase2.4 L, were compared to the original protein source. Male Syrian Golden hamsters were fed high-fat diets containing either 20% casein (control) or 20% extracted proteins or their hydrolysates as the protein source for 3 weeks. The brown rice protein hydrolysate (BRPH) diet group reduced weight gain 76% compared with the control. Animals fed the BRPH supplemented diet also had lower final body weight, liver weight, very low density lipoprotein cholesterol (VLDL-C), and liver cholesterol, and higher fecal fat and bile acid excretion than the control. Expression levels of hepatic genes for lipid oxidation, PPARα, ACOX1, and CPT1, were highest for hamsters fed the BRPH supplemented diet. Expression of CYP7A1, the gene regulating bile acid synthesis, was higher in all test groups. Expression of CYP51, a gene coding for an enzyme involved in cholesterol synthesis, was highest in the BRPH diet group. The results suggest that BRPH includes unique peptides that reduce weight gain and hepatic cholesterol synthesis.

How and why do patients use home blood pressure monitors?

INTRODUCTION: Little is known about how and why patients use home blood pressure monitoring (HBPM). We investigated from where patients obtain their monitor, their reasons for using HBPM, and their frequency of performing blood pressure (BP) measurements. We also examined whether those using HBPM provide written reports of measurements to their doctor and whether they have ever had their monitor checked. METHODS: We conducted a cross-sectional mail survey of adult patients with hypertension enrolled in a practice-based research network of 24 primary care practices throughout the state of North Carolina. We analyzed results using descriptive statistics. RESULTS: We received 530 returned questionnaires (76% response rate). Of the 43% (n=226) who reported performing HBPM, 68% purchased their monitor from a pharmacy or department store; the remaining purchased their monitor elsewhere or received it as a gift. Approximately 19% [95% confidence interval (CI): 13.6-23.9] check their BP every day or almost every day; 26% (95% CI: 20.5-32.2) check their BP a few times per week; and 29% (95% CI: 3.0-35.0) check their BP a few times per month. For nearly one-third, their primary reason for using HBPM was because their doctor recommended it. Over one-half said they used HBPM because they were 'just interested in knowing' their BP. The majority (70%; 95% CI: 64.4-76.4) indicated that they did not provide a written report of BP readings to their doctor. Less than one-third (29%, 95% CI: 22.9-34.9) has had their monitor checked by a doctor or nurse. CONCLUSION: Most patients with hypertension using HBPM do so because of a doctor's recommendation or a simple desire to know their BP. The majority of those performing home measurements do so at least a few times per month. Most do not provide their doctor with a written report of measurements, and most have not had their monitor checked.

Using an advanced practice nursing model for a rapid response team.

Outcomes, including reductions in codes per 1,000 discharges, failure-to-rescue rates, and medical-surgical mortalities and improvement in staff satisfaction, were all indicative of the efficacy of the APN-model RRT. Future studies might compare these outcomes with those of other team models.

Regulation of gap junction coupling through the neuronal connexin Cx35 by nitric oxide and cGMP.

Gap-junctional coupling among neurons is subject to regulation by a number of neurotransmitters including nitric oxide. We studied the mechanisms by which NO regulates coupling in cells expressing Cx35, a connexin expressed in neurons throughout the central nervous system. NO donors caused potent uncoupling of HeLa cells stably transfected with Cx35. This effect was mimicked by Bay 21-4272, an activator of guanylyl cyclase. A pharmacological analysis indicated that NO-induced uncoupling involved both PKG-dependent and PKG-independent pathways. PKA was involved in both pathways, suggesting that PKG-dependent uncoupling may be indirect. In vitro, PKG phosphorylated Cx35 at three sites: Ser110, Ser276, and Ser289. A mutational analysis indicated that phosphorylation on Ser110 and Ser276, sites previously shown also to be phosphorylated by PKA, had a significant influence on regulation. Ser289 phosphorylation had very limited effects. We conclude that NO can regulate coupling through Cx35 and that regulation is indirect in HeLa cells.

Calcium-dependent binding of calmodulin to neuronal gap junction proteins.

We examined the interactions of calmodulin with neuronal gap junction proteins connexin35 (Cx35) from perch, its mouse homologue Cx36, and the related perch Cx34.7 using surface plasmon resonance. Calmodulin bound to the C-terminal domains of all three connexins with rapid kinetics in a concentration- and Ca2+-dependent manner. Dissociation was also very rapid. K(d)'s for calmodulin binding at a high-affinity site ranged from 11 to 72 nM, and K(1/2)'s for Ca2+ were between 3 and 5 microM. No binding to the intracellular loops was observed. Binding competition experiments with synthetic peptides mapped the calmodulin binding site to a 10-30 amino acid segment at the beginning of the C-terminal domain of Cx36. The micromolar K(1/2)'s and rapid on and off rates suggest that this interaction may change dynamically in neurons, and may occur transiently when Ca2+ is elevated to a level that would occur in the near vicinity of an activated synapse.

Protein kinase A mediates regulation of gap junctions containing connexin35 through a complex pathway.

Connexin 35 (Cx35) is a major component of electrical synapses in the central nervous system. Many gap junctions containing Cx35 are regulated by dopamine receptor pathways that involve protein kinase A (PKA). To study the mechanism of PKA regulation, we analyzed direct phosphorylation of Cx35 by PKA in vitro and studied the regulation of neurobiotin tracer coupling in HeLa cells expressing Cx35 or Cx35 mutants that lack phosphorylation sites. In Cx35-transfected cells, application of the PKA activator Sp-8-cpt-cAMPS caused a significant decline in coupling, while a PKA inhibitor, Rp-8-cpt-cAMPS, significantly increased tracer coupling. In vitro phosphorylation and mutagenic analysis showed that PKA phosphorylates Cx35 directly at two major sites, Ser110 in the intracellular loop and Ser276 in the carboxyl terminus. In addition, a minor phosphorylation site in the C-terminus was identified by truncation of the last 7 amino acids at Ser298. The mutations Ser110Ala or Ser276Ala significantly reduced regulation of coupling by the PKA activator while a combination of the two eliminated regulation. Truncation at Ser298 reversed the regulation such that the PKA activator significantly increased and the PKA inhibitor significantly decreased coupling. The activation was eliminated in the S110A, S276A, S298ter triple mutant. We conclude that PKA regulates Cx35 coupling in a complex manner that requires both major phosphorylation sites. Furthermore, the tip of the C-terminus acts as a "switch" that determines whether phosphorylation will inhibit or enhance coupling. Reliance on the combined states of three sites provides fine control over the degree of coupling through Cx35 gap junctions.

Activation of protein kinase C reduces GLAST in the plasma membrane of rat Müller cells in primary culture.

In this study, a Müller cell culture preparation from young rats was used to investigate the regulation of GLAST transport activity in native cells. Immunohistochemical analysis confirmed GLAST to be the predominant glutamate transporter expressed by the cells through five passages. [3H]-glutamate uptake assays showed the typical Na+-dependent glutamate transport which was blocked by L-(-)-threo-3-hydroxyaspartate (L-THA), a competitive inhibitor. Glutamate transport was decreased significantly in Müller cells exposed to phorbol-12-myristate-13-acetate (PMA), a protein kinase C (PKC) activator. A similar effect on [3H]-D-aspartate (nonmetabolizable glutamate analog) uptake ruled out the possibility that the decrease was a consequence of altered metabolism. However, PMA did not affect Na+-dependent [3H]-glycine transport, indicating the absence of a nonspecific change in the electrochemical gradients. The PMA effect on glutamate uptake was evidenced by partial blocking with a specific PKC inhibitor, bisindolymaleimide II (Bis II). Activation of PKC did not change the Km, but the Vmax was significantly reduced. Image analysis of Müller cells with biotinylated cell membranes immunolabeled with GLAST shows a reduction of GLAST in the plasma membrane. In conclusion, these data show that rat Müller cells in primary cultures express GLAST and that PKC activation affects GLAST transport activity by decreasing cell surface expression.