Palliative Care Research and Clinical Practice Priorities in the United States as Identified by an Interdisciplinary Modified Delphi Approach.

Background: Palliative care demands in the United States are growing amid a comparatively small workforce of palliative care clinicians and researchers. Therefore, determining research and clinical practice priorities is essential for streamlining initiatives to advance palliative care science and practice. Objectives: To identify and rank palliative care research and clinical practice priority areas through expert consensus. Design: Using a modified Delphi method, U.S. palliative care experts identified and ranked priority areas in palliative care research and clinical practice. Priorities were thematically grouped and analyzed for topic content and frequency; univariate analysis used the median of each priority item ranking, with a cutoff median of ≤8 indicating >76% agreement for an item's ranking. Results: In total, 27 interdisciplinary pediatric and adult palliative care experts representing 19 different academic institutions and medical centers participated in the preliminary survey and the first Delphi round, and 22 participated in the second Delphi round. The preliminary survey generated 78 initial topics, which were developed into 22 priority areas during the consensus meeting. The top five priorities were (1) access to palliative care, (2) equity in palliative care, (3) adequate financing of palliative care, (4) provision of palliative care in primary care settings, and (5) palliative care workforce challenges. Conclusions: These expert-identified priority areas provide guidance for researchers and practitioners to develop innovative models, policies, and interventions, thereby enriching the quality of life for those requiring palliative care services.

Patient decision-making in left ventricular assist devices for destination therapy.

BACKGROUND: Heart failure is a common life-limiting disease. A destination therapy for people who will not have a heart transplant is a left ventricular assist device. AIMS: To discover how patients who have a left ventricular assist device for destination therapy make decisions about their healthcare after implantation of the device. METHODS: A descriptive qualitative design with semi-structured, in-depth interviews with 11 participants who are living with a left ventricular assist device for destination therapy. FINDINGS: People with a left ventricular assist device felt they had 'no choice' when making decisions about their healthcare. CONCLUSION: Engaging with patients to contemplate present and future healthcare decisions is a complex process that includes cognitive processes within the patient. Clinicians need to be aware that a gap may occur between what is said and what is heard in communication.

High-fidelity simulation and nurse clinical competence-An integrative review.

AIM: The aim of this review was to synthesise current knowledge of high-fidelity simulation practices and its impact on nurse clinical competence in the acute care setting. BACKGROUND: There is no consensus or standardisation surrounding best practices for the delivery of high-fidelity simulation in the acute care setting. This is an understudied area. DESIGN: An integrative review using Johns Hopkins Nursing Evidence-Based Practice Model. METHODS: Medical subject heading terms 'Clinical Competence', AND 'High Fidelity Simulation Training', AND 'Clinical Deterioration' were systematically searched in PubMed, CINAHL and Embase databases for peer-reviewed literature published through September 2020. The current study was evaluated using PRISMA checklist. RESULTS: Seven studies met the inclusion criteria. Three main concepts were identified: modes of delivery, approach to learner participation and outcome measurement. CONCLUSIONS: This review substantiated the use of high-fidelity simulation to improve acute care nurses' early identification and management of clinical deterioration. Global variations in course design and implementation highlight the need for future approaches to be standardised at the regional level (i.e., country-centric approach) where differing scopes of practice and sociocultural complexities are best contextualised. RELEVANCE TO CLINICAL PRACTICE: These findings add to the growing body of evidence of simulation science. Important considerations in course planning and design for nursing clinical educators were uncovered. This is especially relevant given the current COVID-19 pandemic and urgent need to train redeployed nurses safely and effectively from other units and specialties to acute care.

Stigma and Relationship Quality: The Relevance of Racial-Ethnic Worldview in Interracial Relationships in the United States.

The current study explored the associations between relationship stigma, Racial-ethnic Worldview (REW; a construct developed as a comprehensive assessment of individual's perceptions of race and ethnicity), and relationship quality among those in interracial relationships (i. e., participants indicated their race was different than the race of their partner). One type of REW (Color-blind Achieved) was especially susceptible to the negative consequences of stigma from family members. Other significant differences in relationship quality and relationship stigma were found based on REW. Most notable is that individuals who acknowledge institutional racism, have positive intergroup attitudes, and a positive ethnic identity reported better relationship quality than those who denied institutional racism and/or had less positive attitudes toward their own ethnic group. These results demonstrate the utility of REW in contextualizing the experiences of individuals in interracial relationships as it relates to perceived stigma and relationship quality. The study offers a critical account of how individuals understanding of the racial and ethnic social context shapes relationship outcomes for those in interracial relationships in the United States.

Chaotic heteroclinic networks as models of switching behavior in biological systems.

Key features of biological activity can often be captured by transitions between a finite number of semi-stable states that correspond to behaviors or decisions. We present here a broad class of dynamical systems that are ideal for modeling such activity. The models we propose are chaotic heteroclinic networks with nontrivial intersections of stable and unstable manifolds. Due to the sensitive dependence on initial conditions, transitions between states are seemingly random. Dwell times, exit distributions, and other transition statistics can be built into the model through geometric design and can be controlled by tunable parameters. To test our model's ability to simulate realistic biological phenomena, we turned to one of the most studied organisms, C. elegans, well known for its limited behavioral states. We reconstructed experimental data from two laboratories, demonstrating the model's ability to quantitatively reproduce dwell times and transition statistics under a variety of conditions. Stochastic switching between dominant states in complex dynamical systems has been extensively studied and is often modeled as Markov chains. As an alternative, we propose here a new paradigm, namely, chaotic heteroclinic networks generated by deterministic rules (without the necessity for noise). Chaotic heteroclinic networks can be used to model systems with arbitrary architecture and size without a commensurate increase in phase dimension. They are highly flexible and able to capture a wide range of transition characteristics that can be adjusted through control parameters.

Education Following Pediatric Gastrostomy Tube Placement: An Integrative Review.

BACKGROUND: There is a gap in knowledge regarding the necessary components for pediatric gastrostomy tube education. This integrative review addresses the question "What are the educational components following pediatric gastrostomy placement?" METHODS: A literature search was conducted using PubMed, CINAHL, and Cochrane Library electronic databases, along with a hand search. Articles for review included those in the pediatric population, English language, and publication dates between 2010 and 2020. RESULTS: Ultimately, 7 articles met the inclusion criteria for review. Articles were all pediatric focused (0-18 years), and were a mix of quantitative and qualitative designs, along with one non-research paper. Three major themes were identified from the literature including that gastrostomy tube education should be a multidisciplinary effort, that education should take a standardized approach, and that it should include psychosocial elements that enhance caregiver knowledge and empowerment. DISCUSSION: This review demonstrates that while there is no consensus on a superior mode or means of education, pediatric gastrostomy discharge education must be standardized and high quality to promote the best patient and caregiver outcomes. Further research should aim to address which forms of education, if any, lead to the best outcomes, and how education can best be delivered to promote caregiver knowledge and ease.

Nonlinear control of networked dynamical systems.

We develop a principled mathematical framework for controlling nonlinear, networked dynamical systems. Our method integrates dimensionality reduction, bifurcation theory, and emerging model discovery tools to find low-dimensional subspaces where feed-forward control can be used to manipulate a system to a desired outcome. The method leverages the fact that many high-dimensional networked systems have many fixed points, allowing for the computation of control signals that will move the system between any pair of fixed points. The sparse identification of nonlinear dynamics (SINDy) algorithm is used to fit a nonlinear dynamical system to the evolution on the dominant, low-rank subspace. This then allows us to use bifurcation theory to find collections of constant control signals that will produce the desired objective path for a prescribed outcome. Specifically, we can destabilize a given fixed point while making the target fixed point an attractor. The discovered control signals can be easily projected back to the original high-dimensional state and control space. We illustrate our nonlinear control procedure on established bistable, low-dimensional biological systems, showing how control signals are found that generate switches between the fixed points. We then demonstrate our control procedure for high-dimensional systems on random high-dimensional networks and Hopfield memory networks.

Abuse and Misuse of Pregabalin and Gabapentin: A Systematic Review Update.

BACKGROUND: A 2017 systematic review (SR) identified 59 studies examining gabapentinoid (pregabalin and gabapentin) misuse/abuse. Evidence of gabapentinoid misuse/abuse has since grown substantially. OBJECTIVE: Update previous SR and describe new insights regarding gabapentinoid abuse. METHODS: A SR of PubMed was conducted to identify studies published from 7/29/2016-8/31/2020. Four searches were performed using the following terms: "gabapentin [MeSH] OR pregabalin [MeSH] OR gabapentinoid" AND one of the following substance misuse/abuse-related terms: "substance-related disorders [MeSH]", "overdose", "abuse", or "misuse". Clinicaltrials.gov and the Cochrane Library database were searched to identify ongoing studies or similar SRs. Reference lists of included studies were reviewed to identify additional literature. All studies with novel data related to pregabalin and/or gabapentin abuse, misuse, or overdose conducted during the study period were included. Articles not written in English, review articles, and animal studies were excluded. RESULTS: Fifty-five studies were included (29 [52.7%] from North America, 17 [30.9%] Europe, 6 [10.9%] Asia, and 3 [5.5%] Australia). Forty-six observational studies and 10 case reports/series were included (one manuscript included both). Twenty (36.4%) studied gabapentin only, 18 (32.7%) pregabalin only, and 17 (30.9%) both pregabalin/gabapentin. These studies corroborate findings from the previous SR that gabapentinoids are increasingly abused or misused to self-medicate, that gabapentinoids can produce desirable effects alone but are often used concomitantly with other drugs, and that opioid use disorder is the greatest risk factor for gabapentinoid abuse. While the original SR identified the largest studies having been published in Europe, this review identified several more generalisable US studies that have subsequently been conducted. The most concerning finding was increased evidence of associated patient harm, including increased hospital utilisation and opioid-related overdose mortality risk. CONCLUSION: Evidence suggests that gabapentinoid misuse/abuse represents a growing trend that is causing significant patient harm. Prescribers should exercise appropriate caution with use in high-risk populations and monitor for signs of misuse or abuse.

Community detectability and structural balance dynamics in signed networks.

We investigate signed networks with community structure with respect to their spectra and their evolution under a dynamical model of structural balance, a prominent theory of signed social networks. The spectrum of the adjacency matrix generated by a stochastic block model with two equal-size communities shows detectability transitions in which the community structure becomes manifest when its signal eigenvalue appears outside the main spectral band. The spectrum also exhibits "sociality" transitions involving the homogeneous structure representing the average tie value. We derive expressions for the eigenvalues associated with the community and homogeneous structure as well as the transition boundaries, all in good agreement with numerical results. Using the stochastically generated networks as initial conditions for a simple model of structural balance dynamics yields three outcome regimes: two hostile factions that correspond with the initial communities, two hostile factions uncorrelated with those communities, and a single harmonious faction of all nodes. The detectability transition predicts the boundary between the assortative and mixed two-faction states and the sociality transition predicts that between the mixed and harmonious states. Our results may yield insight into the dynamics of cooperation and conflict among actors with distinct social identities.

Nonlinear Control in the Nematode C. elegans.

Recent whole-brain calcium imaging recordings of the nematode C. elegans have demonstrated that the neural activity associated with behavior is dominated by dynamics on a low-dimensional manifold that can be clustered according to behavioral states. Previous models of C. elegans dynamics have either been linear models, which cannot support the existence of multiple fixed points in the system, or Markov-switching models, which do not describe how control signals in C. elegans neural dynamics can produce switches between stable states. It remains unclear how a network of neurons can produce fast and slow timescale dynamics that control transitions between stable states in a single model. We propose a global, nonlinear control model which is minimally parameterized and captures the state transitions described by Markov-switching models with a single dynamical system. The model is fit by reproducing the timeseries of the dominant PCA mode in the calcium imaging data. Long and short time-scale changes in transition statistics can be characterized via changes in a single parameter in the control model. Some of these macro-scale transitions have experimental correlates to single neuro-modulators that seem to act as biological controls, allowing this model to generate testable hypotheses about the effect of these neuro-modulators on the global dynamics. The theory provides an elegant characterization of control in the neuron population dynamics in C. elegans. Moreover, the mathematical structure of the nonlinear control framework provides a paradigm that can be generalized to more complex systems with an arbitrary number of behavioral states.

A Principled Approach to the Construction of Risk Assessment Categories: The Council of State Governments Justice Center Five-Level System.

Consistent risk category placement of criminal justice clients across instruments will improve the communication of risk. Efforts coordinated by the Council of State Governments (CSG) Justice Center led to the development of a principled (i.e., a system based on a given set of procedures) method of developing risk assessment levels. An established risk assessment instrument (Level of Service Inventory-Revised [LSI-R]) was used to assess the risk-level concordance of the CSG Justice Center Five-Level system. Specifically, concordance was assessed by matching the defining characteristics of the data set with its distribution qualities and by the level/category similarity between the observed reoffending base rate and the statistical probability of reoffending. Support for the CSG Justice Center Five-Level system was found through a probation data set (N = 24,936) having a greater proportion of offenders in the lower risk levels than a parole/community data set (N = 36,303). The statistical probabilities of reoffending in each CSG Justice Center system risk level had greater concordance to the observed Five-Level base rates than the base rates from the LSI-R original categories. The concordance evidence for the CSG Justice Center Five-Level system demonstrates the ability of this system to place clients in appropriate risk levels.

Impact of Population Differences: Post-Kidney Transplant Readmissions.

Early hospital readmissions after kidney transplantation are common and considered an indicator of healthcare quality. The purpose of this study was to identify and describe the risk factors for and causes of 30-day readmission post-kidney transplant for adults in a predominantly Hispanic Southern Texas population in comparison to the United States kidney transplant population and published research. A single-center, descriptive, retrospective study of adult kidney transplant recipients readmitted to a hospital in southern Texas was conducted. Results indicated that this population had lower education levels, a greater percentage of Spanish-speaking patients, and a high number of patients with either or both diabetes mellitus and hypertension, necessitating the development of additional methods of increasing understanding and adherence to restrictions, requirements, and medication regimes.

Meta-lay theories of scientific potential drive underrepresented students' sense of belonging to science, technology, engineering, and mathematics (STEM).

The current research investigates people's perceptions of others' lay theories (or mindsets), an understudied construct that we call meta-lay theories. Six studies examine whether underrepresented students' meta-lay theories influence their sense of belonging to science, technology, engineering, and math (STEM). The studies tested whether underrepresented students who perceive their faculty as believing most students have high scientific aptitude (a universal metatheory) would report a stronger sense of belonging to STEM than those who think their faculty believe that not everyone has high scientific aptitude (a nonuniversal metatheory). Women PhD candidates in STEM fields who held universal rather than nonuniversal metatheories felt greater sense of belonging to their field, both when metatheories were measured (Study 1) and manipulated (Study 2). Undergraduates who held more universal metatheories reported a higher sense of belonging to STEM (Studies 3 and 4) and earned higher final course grades (Study 3). Experimental manipulations depicting a professor communicating the universal lay theory eliminated the difference between African American and European American students' attraction to a STEM course (Study 5) and between women and men's sense of belonging to STEM (Study 6). Mini meta-analyses indicated that the universal metatheory increases underrepresented students' sense of belonging to STEM, reduces the extent of social identity threat they experience, and reduces their perception of faculty as endorsing stereotypes. Across different underrepresented groups, types of institutions, areas of STEM, and points in the STEM pipeline, students' metaperceptions of faculty's lay theories about scientific aptitude influence their sense of belonging to STEM. (PsycINFO Database Record

Abuse and Misuse of Pregabalin and Gabapentin.

BACKGROUND: Gabapentinoid (pregabalin and gabapentin) abuse is increasingly being reported. OBJECTIVE: To assess the extent of gabapentinoid abuse, characteristics of typical abusers, patterns of abuse, and potential harms in order to bring this trend to providers' attention. METHODS: A systematic review of MEDLINE, Cochrane Library, ClinicalTrials.gov, and US FDA data, indexed through 28 July 2016, utilizing the following searches: pregabalin OR gabapentin OR gabapentinoid AND one of the following: abuse, misuse, overdose, or substance-related disorders[MESH], was conducted. Additional studies were identified through review of references. English-language epidemiological studies, clinical studies, and case reports/series of gabapentinoid abuse/misuse/overdose were included. The authors reached consensus regarding study inclusion after full-text review. The body of literature was assessed for bias qualitatively. RESULTS: Fifty-nine studies were included in this systematic review (24 epidemiological, three clinical abuse liability, 16 abuse/misuse/dependence case reports/series, 17 acute overdose case reports/series-one included both an epidemiological study and case series and was included in both counts). Analysis of these studies indicates increasing numbers of patients are self-administering higher than recommended doses to achieve euphoric highs. In the general population, a 1.6% prevalence of gabapentinoid abuse was observed, whereas prevalence ranged from 3% to 68% among opioid abusers. An international adverse event database identified 11,940 reports of gabapentinoid abuse from 2004-2015, with >75% reported since 2012. Risk factors include a history of substance abuse, particularly opioids, and psychiatric co-morbidities. While effects of excessively high doses are generally non-lethal, gabapentinoids are increasingly being identified in post-mortem toxicology analyses. CONCLUSION: Evidence suggests gabapentinoids possess potential for abuse, particularly in individuals with a history of opioid abuse, and reports of such abuse are increasingly being documented. Prescribers should be aware of high-risk populations and monitor for signs of abuse.

Quantity and Quality of Economic Evaluations in U.S. Nursing Research, 1997-2015: A Systematic Review.

BACKGROUND: The United States has a complex healthcare system that is undergoing substantial reformations. There is a need for high-quality, economic evaluations of nursing practice. An updated review of completed economic evaluations relevant to the field of nursing within the U.S. healthcare system is timely and needed. OBJECTIVES: The purpose of this study was to evaluate and describe the quantity and quality of economic evaluations in nursing-relevant research performed in the United States between 1997 and 2015. METHODS: Four databases were searched. Titles, abstracts, and full-text content were reviewed to identify studies that analyzed both costs and outcomes, relevant to nursing, performed in the United States, and used the quality-adjusted life year to measure effectiveness. For included studies, data were extracted from full-text articles using criteria from U.S. Public Health Service's Panel on Cost-Effectiveness in Health and Medicine. RESULTS: Twenty-eight studies met the inclusion criteria. Most (n = 25, 89%) were published in the last decade of the analysis, from 2006 to 2015. Assessment of quality, based on selected items from the panel guidelines, found that the evaluations did not consistently use the recommended societal perspective, use multiple resource utilization categories, use constant dollars, discount future costs and outcomes, use a lifetime horizon, or include an indication of uncertainty in results. The only resource utilization category consistently included across studies was healthcare resources. DISCUSSION: Only 28 nursing-related studies meeting the inclusion criteria were identified as meeting robust health economic evaluation methodological criteria, and most did not include all important guideline items. Despite increases in absolute numbers of published studies over the past decade, economic evaluation has been underutilized in U.S. nursing-relevant research in the past two decades.

City mouse, country mouse: a mixed-methods evaluation of perceived communication barriers between rural family physicians and urban consultants in Newfoundland and Labrador, Canada.

OBJECTIVES: To examine perceived communication barriers between urban consultants and rural family physicians practising routine and emergency care in remote subarctic Newfoundland and Labrador (NL). DESIGN: This study used a mixed-methods design. Quantitative and qualitative data were collected through exploratory surveys, comprised of closed and open-ended questions. The quantitative data was analysed using comparative statistical analyses, and a thematic analysis was applied to the qualitative data. PARTICIPANTS: 52 self-identified rural family physicians and 23 urban consultants were recruited via email. Rural participants were also recruited at the Family Medicine Rural Preceptor meetings in St John's, NL. SETTING: Rural family physicians and urban consultants in NL completed a survey assessing perceived barriers to effective communication. RESULTS: Data confirmed that both groups perceived communication difficulties with one another; with 23.1% rural and 27.8% urban, rating the difficulties as frequent (p=0.935); 71.2% rural and 72.2% urban as sometimes (p=0.825); 5.8% rural and 0% urban acknowledged never perceiving difficulties (p=0.714). Overall, 87.1% of participants indicated that perceived communication difficulties impacted patient care. Primary trends that emerged as perceived barriers for rural physicians were time constraints and misunderstanding of site limitations. Urban consultants' perceived barriers were inadequate patient information and lack of native language skills. CONCLUSIONS: Barriers to effective communication are perceived between rural family physicians and urban consultants in NL.

Comparison of patient and partner quality of life and health outcomes in the first year after an implantable cardioverter defibrillator (ICD).

Recovery following an implantable cardioverter defibrillator (ICD) impacts both the patient and partner, often in divergent ways. Patients may have had a cardiac arrest or cardiac arrhythmias, whereas partners may have to perform CPR and manage the ongoing challenges of heart disease therapy. Currently, support for post-ICD care focuses primarily on restoring patient functioning with few interventions available to partners who serve as primary support. This descriptive study examined and compared patterns of change for both patients and partners during the first year post-ICD implantation. For this longitudinal study, the sample included 42 of 55 (76.4 %) patient-partner dyads who participated in the 'usual care' group of a larger intervention RCT with patients following ICD implant for secondary prevention of cardiac arrest. Measures taken at across five time points (at hospital discharge and at 1, 3, 6 and 12 months follow up) tracked physical function (SF-12 PCS, symptoms); psychological adjustment (SF-12 MCS; State-Trait Anxiety Inventory; CES-D); relationship impact (Family Functioning, DOII; Mutuality and Interpersonal Sensitivity, MIS); and healthcare utilization (ED visits, outpatient visits, hospitalizations). Repeated measures analysis of variance was used to characterize and compare outcome trends for patients and partners across the first 12 months of recovery. Patients were 66.5 ± 11.3 (mean + SD) years old, predominately Caucasian male (91 %), with Charlson co-morbidities of 4.4 ± 2.4. Partners were 62.5 ± 11.1 years old, predominantly female (91 %) with Charlson co-morbidities of 2.9 ± 3.0. Patient versus partner differences were observed in the pattern of physical health (F = 10.8, p < 0.0001); patient physical health improved while partner health showed few changes. For partners compared to patients, anxiety, depression, and illness demands on family functioning tended to be higher. Patient mutuality was stable, while partner mutuality increased steadily (F = 2.5, p = 0.05). Patient sensitivity was highest at discharge and declined; partner sensitivity increased (F = 10.2, p < 0.0001) across the 12-month recovery. Outpatient visits for patients versus partners differed (F = 5.0, p = 0.008) due most likely to the number of required patient ICD visits. Total hospitalizations and ED visits were higher for patients versus partners, but not significantly. The findings highlight the potential reciprocal influences of patient and partner responses to the ICD experience on health outcomes. Warranted are new, sound and feasible strategies to counterbalance partner needs while simultaneously optimizing patient recovery outcomes.