ß-glucans from Agaricus bisporus mushroom products drive Trained Immunity.

Introduction: Macrofungi, such as edible mushrooms, have been used as a valuable medical resource for millennia as a result of their antibacterial and immuno-modulatory components. Mushrooms contain dietary fibers known as ß-glucans, a class of polysaccharides previously linked to the induction of Trained Immunity. However, little is known about the ability of mushroom-derived ß-glucans to induce Trained Immunity. Methods & results: Using various powdered forms of the white button mushroom (Agaricus bisporus), we found that mouse macrophages pre-treated with whole mushroom powder (WMP) displayed enhanced responses to restimulation with TLR ligands, being particularly sensitive to Toll-like receptor (TLR)-2 stimulation using synthetic lipopeptides. This trained response was modest compared to training observed with yeast-derived ß-glucans and correlated with the amount of available ß-glucans in the WMP. Enriching for ß-glucans content using either a simulated in-vitro digestion or chemical fractionation retained and boosted the trained response with WMP, respectively. Importantly, both WMP and digested-WMP preparations retained ß-glucans as identified by nuclear magnetic resonance analysis and both displayed the capacity to train human monocytes and enhanced responses to restimulation. To determine if dietary incorporation of mushroom products can lead to Trained Immunity in myeloid cells in vivo, mice were given a regimen of WMP by oral gavage prior to sacrifice. Flow cytometric analysis of bone-marrow progenitors indicated alterations in hematopoietic stem and progenitor cells population dynamics, with shift toward myeloid-committed multi-potent progenitor cells. Mature bone marrow-derived macrophages derived from these mice displayed enhanced responses to restimulation, again particularly sensitive to TLR2. Discussion: Taken together, these data demonstrate that ß-glucans from common macrofungi can train innate immune cells and could point to novel ways of delivering bio-available ß-glucans for education of the innate immune system.

Durable Learning Strategies in Nursing Education: State-of-the-Evidence Review.

BACKGROUND: Health professions (HP) students must achieve durable learning (DL) to transfer and apply knowledge from the classroom to the clinical setting. This review examines the state of the science of classroom-based DL in HP. METHOD: The Joanna Briggs Systematic Review Methodology was used. MEDLINE, CINAHL, PsycINFO, and ERIC databases were searched for articles published from 2006 to 2022. A total of 2,000 titles were identified for review, with 51 studies being selected for inclusion. RESULTS: Multiple classroom-based learning strategies generally reported as being effective were identified, including flipped classroom, educational technology, spaced learning, team-based learning, concept mapping and schema, testing, and case study and problem-based learning. CONCLUSION: Although DL has been proven to be effective in the classroom setting for HP, no one type has been shown to be more effective than others. Additional research is needed within the context of transferring knowledge to clinical settings and in nursing education. [J Nurs Educ. 2024;63(1):24-31.].

Nurturing a Spirit of Inquiry: Fundamentals of Evidence-Based Practice in Nursing.

Implementing evidence-based practice in nursing is essential for connecting theoretical knowledge with practical patient care. The spirit of inquiry serves as the foundational step in the evidence-based practice process. Nephrology nurses are positioned to improve patient and system outcomes through an evidence-based practice process, highlighting its transformative impact on nursing practice and patient care. This article provides an overview of evidence-based practice and explores the essential elements for the development of a spirit of inquiry.

The feasibility of Technology, Application, Self-Management for Kidney (TASK) intervention in post-kidney transplant recipients using a pre/posttest design.

BACKGROUND: Weight gain after a kidney transplant remains a major problem that can lead to adverse effects on morbidity and mortality. The posttransplant phase provides a window of opportunity to improve the engagement of self-management of care for lifestyle modifications for diet and physical activity. The purpose of our study was to (1) test the feasibility of recruitment, retention, and adherence for using the Technology, Application, Self-Management for Kidney (TASK) intervention in post-kidney transplant recipients (≥ 18 years of age) at baseline, 4, 8, and 12 weeks; and (2) estimate the preliminary effects of the TASK intervention in producing change over time for blood pressure (BP), weight, fruits/vegetable intake, fiber intake, sodium intake, self-efficacy to exercise, and perceived stress. METHODS: This study used a 12-week pre/posttest design using to test the feasibility of the TASK intervention. We applied paired t-tests and McNemar's test to compare the outcomes at weeks 4, 8, and 12. RESULTS: We met our recruitment goal (N = 20) and found a 15% attrition rate (n = 3) at Week 12. Adherence rate among the study completers for recording daily food intake was 83-94% over the 12 weeks and for recording daily physical activity was 17-33% over the 12 weeks. We observed improvements over time for BP, weight, fruits/vegetable intake, fiber intake, and sodium intake; these differences were non-significant, although clinically important. We did find a significant difference from baseline to 12 weeks in weight reduction (p = 0.02), self-efficacy to exercise (p = 0.003), and perceived stress (p = 0.04). CONCLUSIONS: The data suggest the TASK intervention was feasible for kidney recipients to use and resulted in weight control, increased self-efficacy to exercise, and decreased perceived stress. TRIAL REGISTRATION: ClinicalTrials.gov #:NCT05151445.

A comparative analysis of graduate preparedness for a career in General Internal Medicine before and after national subspecialty recognition to inform curricular changes: have we met the mark?

Background: A survey of General Internal Medicine (GIM) graduates published in 2006 revealed large training gaps that informed the development of the first national GIM objectives of training in 2010. The first recognized GIM certification examination was written by candidates in 2014. The landscape is again changing with the introduction in 2019 of competency-by-design (CBD) to GIM training. This study aims to examine pre-existing and emerging training gaps with standardization of GIM curricula and identify new training needs to inform CBD curricula. Methods: GIM graduates from all 16 Canadian programs from 2014 -2019 were emailed a survey modeled after the original study published in 2006. Graduates were asked about their preparedness and importance ratings for various elements of practice. Results: Many of the previously identified gaps (difference between importance and preparedness ratings) have been resolved in specific clinical areas (obstetrical and perioperative medicine) and skills (exercise stress testing) although some still require ongoing work in areas such as substance use disorders. Importantly, gaps still exist in preparedness for some intrinsic roles (e.g. managerial skills). Conclusions: The development of a national GIM curriculum has helped close some educational gaps but some still exist. Our study provides data needed to meet the evolving needs of our graduates.

Contexte: Une enquête auprès des diplômés en médecine interne générale (MIG), publiée en 2006, a révélé d'importantes lacunes dans leur formation, menant à l'élaboration des premiers objectifs nationaux de formation en MIG en 2010. Le premier examen de certification en MIG a été organisé en 2014. La formation est à nouveau en train de changer avec l'introduction en 2019 de la compétence par conception (CPC) dans la formation en MIG. Cette étude vise à examiner les lacunes de formation préexistantes et émergentes avec la normalisation de la formation en MIG et à identifier les nouveaux besoins de formation pour éclairer la définition des programmes de formation selon l'approche fondée sur les compétences. Méthodes: Les diplômés des 16 programmes canadiens en MIG entre 2014 et 2019 ont reçu par courriel un sondage inspiré de l'étude originelle publiée en 2006. Les diplômés ont été interrogés sur leur état de préparation et sur l'importance qu'ils accordaient à divers éléments de la pratique. Résultats: Un grand nombre des lacunes décelées précédemment (différence entre les cotes d'importance et de préparation) ont été comblées dans des domaines cliniques spécifiques (médecine obstétrique et périopératoire) et par rapport à des compétences spécifiques (tests de stress à l'effort); dans certains domaines, comme les troubles liés à l'utilisation de substances psychoactives, les efforts doivent être poursuivis. Il est important de noter que des lacunes subsistent dans la préparation à certains rôles intrinsèques (par exemple, les compétences de gestionnaire). Conclusion: L'élaboration d'un programme national de formation en MIG a permis de combler certaines lacunes en matière de formation, mais des carences subsistent. Notre étude fournit les données nécessaires pour répondre aux besoins évolutifs de nos diplômés.

Negative Regulation of Innate Immune Signaling by Components of the Button Mushroom Agaricus bisporus.

SCOPE: Mushrooms are valued as an edible and medical resource for millennia. As macrofungi, they possess conserved molecular components recognized by innate immune cells like macrophages, yet unlike pathogenic fungi, they do not trigger the immune system in the same way. That these well-tolerated foods both avoid immuno-surveillance and have positive health benefits, highlights the dearth of information on the interactions of mushroom-derived products with the immune system. METHODS AND RESULTS: Using powders produced from the common white button mushroom, Agaricus bisporus, it is observed that pre-treatment of mouse and human macrophages with mushroom powders attenuates innate immune signaling triggered by microbial ligands like LPS and  ß-glucans, including NFκB activation and pro-inflammatory cytokine production. This effect of mushroom powders is observed at lower doses of TLR ligands, suggesting a model of competitive inhibition whereby mushroom compounds bind and occupy innate immune receptors, precluding activation by microbial stimuli. This effect is preserved following simulated digestion of the powders. Moreover, in vivo delivery of mushroom powders attenuates the development of colitis in a DSS-mouse model. CONCLUSION: This data highlights an important anti-inflammatory role for powdered A. bisporus mushrooms, which can be further utilized to develop complementary approaches to modulate chronic inflammation and disease.

Revitalizing the Muddiest Point for Formative Assessment and Student Engagement in a Large Class.

BACKGROUND: Ascertaining student understanding can be challenging in large-enrollment and hybrid or asynchronous courses. PROBLEM: Instructors needed an innovative instructional strategy to encourage student engagement and support learning in a large-enrollment, mixed-format pathophysiology class. APPROACH: A weekly, graded assignment was created by merging the formative assessment commonly referred to as the muddiest point (MP) with an asynchronous discussion board activity within the learning management system. Each week, students were required to submit a question and respond to a peer. Instructors created a remediation lecture based on the most common student questions. OUTCOMES: The majority of students reported they benefitted from the MP discussion boards and remediation lectures. CONCLUSIONS: The MP discussion board activity is a flexible, instructional strategy to determine areas of confusion, increase student engagement, and facilitate learning in large-enrollment classes offered in multiple formats.

Mobile Health Application and Hypertension Management in Rural, Middle-Aged Adults: A Quality Improvement Project.

Over 29% of the adult population in the United States are diagnosed with hypertension, and rates are significantly higher in those adults who live in rural areas. Hypertension is recognized as the most prevalent comorbidity and modifiable risk factor leading to premature death. The purpose of this quality improvement project was to determine if using a mobile phone-based health application called Medisafe could enhance medication adherence and improve blood pressure control in rural-dwelling adults. A small group (N = 14) of middle-aged (45-64 years old) patients with hypertension were recruited to download the free Medisafe phone-based health application. Patients utilized the Medisafe application between their initial visit and a 4- to 6-week follow-up. At the follow-up visit, 64% (n = 9) of participants improved their level of hypertension control by blood pressure classification and improved their scores on the medication adherence questionnaire. The findings from this quality improvement project suggest the Medisafe application is useful to enhance medication adherence and blood pressure control. Future research and quality improvement initiatives are necessary to determine the broader efficacy of phone-based health applications in the rural adult population.

Assessing and Addressing Fundamentals of Social Determinants of Health Factors in Kidney Transplant Candidates and Recipients.

Non-medical factors can have a positive or negative effect on health outcomes and equity. These social determinants of health can play a role in patients' risk of developing kidney failure, as well as their access to kidney transplantation and long-term allograft survival. Nephrology nurses have the opportunity to identify and address negative social determinants of health factors in their patients because they are often patients' first contact in the nephrology setting. The purpose of this article is to promote nephrology nurses' and other nephrology health care providers' understanding of social determinants of health factors, and the fundamental practices for addressing them among kidney transplant candidates and kidney transplant recipients.

Quality of virtual care for ambulatory care sensitive conditions: Patient and provider experiences.

BACKGROUND: The COVID-19 pandemic and the need for physical distancing has led to rapid uptake of virtual visits to deliver ambulatory health care. Despite widespread adoption, there has been limited evaluation of the quality of care being delivered through virtual modalities for ambulatory care sensitive conditions (ACSCs). OBJECTIVE: To characterize patients' and providers' experiences with the quality and sustainability of virtual care for ACSCs. DESIGN: This was a multi-method study utilizing quantitative and qualitative data from patient surveys, provider surveys, and provider focus groups at a large academic ambulatory care hospital between May 2020 and June 2021. We included patients and providers utilizing telephone or video visits for the following ACSCs: hypertension, angina, heart failure, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, or asthma. MAIN MEASURES: Quantitative and qualitative patient and provider survey responses were mapped to the Six Domains of Healthcare Quality framework. Provider focus groups were coded to identify themes within each quality domain. KEY RESULTS: Surveys were completed by 110/352 (31%) consenting patients and 20/61 (33%) providers. 5 provider focus groups were held with 14 participants. Patients found virtual visits to be generally more convenient than in-person visits for ACSCs. The perceived effectiveness of virtual visits was dependent on the clinical and social complexity of individual encounters. Respondents reported difficulty forming effective patient-provider relationships in the virtual environment. Patients and providers felt that virtual care has potential to both alleviate and exacerbate structural barriers to equitable access to care. CONCLUSIONS: In a large academic ambulatory care hospital, patients and providers experienced the quality of virtual visits for the management of ACSCs to be variable depending on the biopsychosocial complexity of the individual encounter. Our findings in each quality domain highlight key considerations for patients, providers and institutions to uphold the quality of virtual care for ACSCs.

Outpatient visit trends for internal medicine ambulatory care sensitive conditions after the COVID-19 pandemic: a time-series analysis.

BACKGROUND: The COVID-19 pandemic led to a dramatic shift in the delivery of outpatient medicine with reduced in-person visits and a transition to predominantly virtual visits. We sought to understand trends in visit patterns for ambulatory care sensitive conditions (ACSCs) commonly seen in internal medicine clinics. METHODS: We included adult outpatients seen for an ACSC between March 15th, 2017 and March 14th, 2021 at a single-centre in Ontario, Canada. Monthly visits were assessed by visit type (new consultation, follow-up), diagnosis, and clinic. Time series analyses compared visit volumes pre- and post-pandemic. Proportion of virtual visits were compared before and during the pandemic. Patient and visit factors were compared between in-person and virtual visits. RESULTS: 8274 patients with 34,021 visits were included. Monthly visits increased by 15% during the pandemic (p <  0.0001). New consultations decreased by 10% (p = 0.0053) but follow-up visits increased by 21% (p <  0.0001). Monthly heart failure visits increased by 43% (p <  0.0001) whereas atrial fibrillation visits decreased. Pre- pandemic, < 1% of visits were virtual compared to 82% during the pandemic (p <  0.0001). Less than half of heart failure visits were virtual whereas > 95% of diabetes visits were virtual. CONCLUSIONS: We found a significant increase in overall visits to internal medicine clinics driven by increased volumes of follow-up visits, which more than offset decreased new consultations. There was variability in visit trends and uptake of virtual care by visit diagnosis, which may indicate challenges with delivery of virtual care for certain conditions.

Obstructive sleep apnea and nocturnal attacks of paroxysmal atrial fibrillation.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is commonly seen in patients with atrial fibrillation (AF), but it is unclear to what extent this relationship is one of causation or association. We examined a cohort of patients with paroxysmal AF to determine whether the presence of OSA (apnea-hypopnea index ≥ 15 events/h) affects the time of onset of symptomatic AF episodes. METHODS: Patients with a recent emergency department visit for a symptomatic episode of paroxysmal AF were recruited from an AF clinic. The time of onset of the AF attack was classified as occurring in "sleeping hours" or "waking hours" based on direct history from the patient and emergency department visit documentation. RESULTS: Of 152 patients with paroxysmal AF, 67 underwent polysomnography; 1 (1.5%) had central sleep apnea, 46 (68.7%) had mild or no OSA, and 20 (29.8%) had OSA. In the OSA group, 14/20 (70.0%) had their symptomatic AF attack during sleeping hours compared to 12/46 (26.1%) in the mild or no OSA group (P = .001). Compared with those who had a paroxysmal AF attack during waking hours, and adjusting for confounders, those who had a paroxysmal AF attack during sleeping hours had almost 6 times the odds of having OSA (odds ratio, 5.53; P = .007). CONCLUSIONS: Compared to patients with paroxysmal AF with mild or no OSA, those with OSA were far more likely to have a symptomatic AF attack during sleeping hours, supporting a causal role for OSA in the pathogenesis of AF in this population. These findings strongly suggest that patients who have nocturnal AF attacks should be evaluated for OSA. CITATION: Lin C-H, Timofeeva M, O'Brien T, Lyons OD. Obstructive sleep apnea and nocturnal attacks of paroxysmal atrial fibrillation. J Clin Sleep Med. 2022;18(5):1279-1286.

Lessons Learned for Training a Research Team and Teaching Kidney Transplant Recipients How to Use a Mobile Health Technology for Dietary Intake and Physical Activity via a Virtual Platform.

Kidney transplant centers and other health care organizations historically have struggled to merge lifestyle management for diet and physical activity into clinical practice. The use of mobile health (mHealth) applications has the potential for kidney transplant recipients to track calorie intake and physical activity in real time. Few studies have reported how they trained their research team and participants how to use mHealth technology in real time. The purpose of this study was to describe lessons learned for training a research team and teaching kidney transplant recipients how to use mHealth technology utilizing a virtual format. Findings suggest that time and educational materials, and using verbal, written, and visual information are critical when conducting a research study using a virtual format.

Maintenance phase of a physical activity intervention in older kidney transplant recipients: A 12-month follow-up.

Daily walking activities are associated with improving cardiovascular outcomes in older kidney transplant recipients. However, little is known regarding physical activity adherence outcomes in older kidney recipients. The purpose of this randomized controlled trial 12-month follow-up study was to evaluate the feasibility of the intervention (SystemCHANGE™ + activity tracker) during the maintenance period (7-12 months), compared to an attention-control group (activity tracker only) in older kidney recipients (age 60 and older). The sample included 60 participants (n = 30 IG; n = 30 ACG). Adherence rates for wearing the activity tracker daily were 96.5% in the IG and 80.8% in the ACG. The IG demonstrated within-group improvements for blood pressure at 12 months. Overall, there was a decrease in the average daily steps observed in both groups. These data suggest this intervention is feasible and additional boosters should be considered during the maintenance period to encourage physical activity.

Older Adults' Views and Attitudes on Physical Activity; Reasons to Participate and Abstain.

Purpose: Despite numerous established benefits of exercise, many older adults do not get enough. The purpose of this study was to identify facilitators and barriers to physical activity/exercise; gain greater understanding of older adults' physical activity self-efficacy; and increase understanding of how to reduce sedentary behavior.Design: Cross-sectional descriptiveMethods: Quantitative with convenience sample of 66 older adultsFindings: Nearly one third of participants reported engaging in regular physical activity. They tended to have rather strong physical activity self-efficacy and limited barriers to being active.Conclusions: The sample had limited involvement in physical activity or exercise, despite feeling confident in their ability to be active. There could be additional barriers or motivating factors that are preventing them from being more active.Clinical Evidence: Honest and directed conversation about older adults' understanding and attitudes towards exercise, paired with an individualized plan tailored to their interests and lifestyle could help increase physical activity/exercise.

SystemCHANGE™ Solutions to Improve Medication Adherence in Kidney Transplant Recipients: A Secondary Data Analysis.

The SystemCHANGE™ intervention has led to great improvements in medication adherence, which is a challenge for nearly one-third of kidney transplant recipients. This secondary data analysis sought to measure the frequency of individual solutions utilized by participants in a previously conducted randomized controlled trial of the SystemCHANGE™ intervention and to determine which classes of solutions had greatest impact on improved medication adherence. Solutions that were significant predictors of improving medication adherence to the 85% or higher level included alarm cues (p ≤ 0.0001), time cues (p = 0.006), restructuring the physical environment (p = 0.048), and social support (p = 0.023). Alarm and time cues, restructuring the environment, and social support were successful solutions largely influenced by personal routine and environment consideration that might be prioritized in future studies when implementing SystemCHANGE™.