Does polygenic risk for substance-related traits predict ages of onset and progression of symptoms?

BACKGROUND AND AIMS: Genetic risk can influence disease progression. We measured the impact of genetic risk for substance use disorders (SUDs) on substance use onset and progression of symptoms. DESIGN, SETTING, PARTICIPANTS: Using findings from genome-wide association studies (GWASs) of alcohol use disorder (AUD), opioid use disorder (OUD) and smoking trajectory (SMK) as discovery samples, we calculated polygenic risk scores (PRSs) in a deeply phenotyped independent target sample. Participants in the target sample were recruited from 2000 to 2020 from US inpatient or outpatient settings or through advertisements and comprised 5692 European-ancestry individuals (EUR) (56.2% male) and 4918 African-ancestry individuals (AFR) (54.9% male). MEASUREMENTS: This study measured age of first substance use, regular use, reported problems and dependence diagnosis and progression from regular use to onset of problems and dependence for alcohol, opioids and smoking. We examined the contribution of PRS to each milestone and progression measure. FINDINGS: EUR and males reported an earlier onset and shorter progression times than AFR and females, respectively. Among EUR, higher AUD PRS predicted earlier onset and more rapid progression to alcohol-related milestones (P < 0.001). Although the AUD PRS was a stronger moderator of problem onset among females (P = 0.017), it was more predictive of the progression to problems among males (P = 0.005). OUD and SMK PRS in EUR also predicted earlier onset of the respective milestones (P < 0.001). Among AFR, where power is lower due to the smaller discovery sample, AUD PRS predicted age of regular alcohol use (P = 0.039) and dependence (P = 0.001) and progression from regular use to diagnosis (P = 0.045), while SMK PRS predicted earlier age of initiation (P = 0.036). CONCLUSIONS: Genetic risk for SUDs appears to predict substance use milestones and symptom progression among European-ancestry individuals and, to a lesser extent, African-ancestry individuals.

Critical Care Teamwork in the Future: The Role of TeamSTEPPS® in the COVID-19 Pandemic and Implications for the Future.

At our institution, we observed inconsistency in the application of structural facilitators for interprofessional teamwork such as handoffs and communication of contingency planning, complete formation and engagement of teams on interprofessional rounds, regular situation monitoring, interprofessional huddles, use of "check back" during code situations, and standard debriefings after codes and procedures (TeamSTEPPS®). To enhance team performance, we piloted TeamSTEPPS® training and reinforcement for all healthcare team members in the medical intensive care unit (MICU), inclusive of trainees, advanced practice providers (APPs), nurses, and respiratory therapists rotating through the unit. Seven months after the training launch, the initial COVID-19 surge interrupted the reinforcement stage of the pilot providing an opportunity to study the retention of TeamSTEPPS® principles and its potential role in response to a crisis. We conducted interprofessional focus groups after a year of crisis management during the pandemic. Themes revealed how TeamSTEPPS® training impacted teamwork and communication, as well as factors that influenced the use of TeamSTEPPS®. This work points to the value of team training in unexpected scenarios. Additional studies at multiple sites are needed to determine scalability for all MICU teams or for onboarding new team members.

A qualitative exploration of self-identity during the role transition to a nurse educator.

BACKGROUND: There is a critical shortage of nursing faculty in the U.S. and globally that is limiting the number of eligible nursing students admitted into nursing programs. To assist in recruitment and retention of faculty, it is necessary to understand how the transition from clinical bedside nursing practice to college and university nursing education work impacts the educator's self-identity. OBJECTIVES: This purpose of this study was to explore the effect of transitioning from a nursing role to an educator role on nurses' self-identity. The research question was, "How do nurses perceive the impact on their self-identity when transitioning from a nursing practice role to an educator role?" DESIGN: In this qualitative study, data collection consisted of semi-structured interviews and a demographic survey. Semi-structured interviews were conducted virtually one-on-one with one of the researchers. After the interviews, the data was analyzed, and themes essential to the experience were identified. SETTING: The participants were a sample of eight registered nurses who currently work in a nurse educator's role and were enrolled as doctoral graduate nursing students. METHODS: Eight nurse educators were interviewed about their transition from clinical nursing to academia and its' impact on their self-identity. Analysis of data included open, axial and selective coding. RESULTS: Four themes emerged from data analysis, including: transition to academia shock, being a novice, grief and loss, and grounded in purpose. CONCLUSION: To recruit and retain faculty, it may benefit nursing programs to develop processes that mitigate the shock, grief and loss that occurs with transition to academia while leveraging strategies that emphasize educators' impact on the profession and society.

Parenteral treatment of episodic tension-type headache: a systematic review.

BACKGROUND: Tension-type headache is highly prevalent in the general population and is a consistent if not frequent cause of visits to acute care settings. Analgesics such as nonsteroidal anti-inflammatory drugs, acetaminophen, and salicylates are considered first-line therapy for treatment of tension-type headache. For patients who present to an acute care setting with persistent tension-type headache despite analgesic therapy, it is not clear which parenteral agent should be administered. We performed a systematic review of the medical literature to determine whether parenteral therapies other than salicylates or nonsteroidals are efficacious for acute tension-type headache. METHODS: We performed a systematic review of Medline, EMBASE, CINAHL, Google scholar, and the Cochrane Central Registry of Controlled Trials from inception through August, 2012 using the search terms "tension-type headache" and "parenteral or subcutaneous or intramuscular or intravenous." Our goal was to identify randomized trials in which one parenteral treatment was compared to another active comparator or to placebo for the acute relief of tension-type headache. Parenteral was defined as intravenous, intramuscular, or subcutaneous administration. We only included studies that distinguished tension-type headache from other primary headache disorders, such as migraine. The primary outcome for this review was measures of efficacy one hour after medication administration. Data abstraction was performed by two authors. Disagreements were resolved by a third author. We assessed the internal validity of trials using the Cochrane Collaboration risk of bias tool. Because of the small number of trials identified, and the substantial heterogeneity among study design and medications, we decided that combining data and reporting summary statistics would serve no useful function. The results of individual studies are presented using Number Needed to Treat (NNT) with 95%CI when dichotomous outcomes were available and continuous outcomes otherwise. RESULTS: Our search returned 640 results. One hundred eighty-seven abstracts were reviewed, and 8 studies involving 486 patients were included in our analysis. The most common reasons for exclusion of abstracts were no assessment of acute pain relief, use of nonparenteral medications only, and no differentiation of headache type. Risk of bias ranged from low to high. The following medications were more effective than placebo for acute pain (NNT, 95%CI): metamizole (4, 2-26), chlorpromazine (4, 2-26), and metoclopramide (2, 1-3). The combination of metoclopramide + diphenhydramine was superior to ketorolac (4, 2-8) The following medications were not more effective than placebo: mepivacaine, meperidine + promethazine, and sumatriptan. CONCLUSIONS: Various parenteral medications other than salicylates or nonsteroidals provide acute relief of tension-type headache. Comparative efficacy studies are needed.

Isolated thoracolumbar transverse process fractures: call physical therapy, not spine.

BACKGROUND: Historically, thoracolumbar spine transverse process fractures (TVPFx) found on "plain films" of the spine were occasionally associated with occult, mechanically significant vertebral fractures. Thus, "log-roll precautions" have been used pending formal spine evaluation and further imaging. As integrated helical computed tomography (CT) scans of the torso have become routine screening tools in high-energy trauma, TVPFx have been diagnosed with far greater frequency. Yet, where no associated spine injuries are found initially, such isolated TVPFx appear to be benign. METHODS: We retrospectively reviewed the diagnosis and management of TVPFx in a large Level I trauma center in the period between 2002 and 2005. Of 314 patients with TVPFx who survived more than 48 hours, 17% had fractures of the weight-bearing columns of the thoracolumbar spine noted on the same CT scan and were excluded from study. The management and outcome of the remaining "isolated" TVPFx were assessed by review of trauma registry and charted data. RESULTS: The 248 patients included sustained 2.3 +/- 1.5 (SD) TVPFx. They spent 29 hours +/- 32 hours on log-roll precautions while being evaluated by spine consultants and "cleared" before initiating physical therapy. Despite this prolonged immobilization and substantial further investigation, none of the patients with TVPFx judged to be isolated on the basis of screening truncal CT scan proved to have a missed injury of a major vertebral element on further study. CONCLUSIONS: Isolated thoracolumbar TVPFx are found frequently when helical CT scan is used to screen the torso after high-energy injury. TVPFx are usually multiple. They can be markers for visceral injuries, and in this study, 17% were associated with "significant" fractures. TVPFx require careful pain management and benefit by early mobilization. Yet, where no other vertebral fracture is seen on an adequate screening CT scan, investigation may reasonably end. Further imaging and consultations with spine services waste scarce resources, and lead to prolonged log-roll precautions, which delay mobilization and are potentially deleterious to overall patient care.