Evaluation of an ambulatory care pathway for patients with nitrous oxide-induced myeloneuropathy.

Introduction: Cases of nitrous oxide (N2O)-induced myeloneuropathy are increasing at UK hospitals. At our centre, a dedicated ambulatory care pathway, endorsed nationally, was established to treat and monitor patients with N2O-myeloneuropathy in 2021 and refined through three audit cycles. We analysed the outcomes of patients on this pathway to better understand factors associated with non-engagement. Alongside, a novel approach using WhatsApp for questionnaire delivery was trialled in an attempt to improve engagement with treatment. Methods: Patients on the N2O ambulatory care pathway were identified from MDT meeting lists from 9 September 2022 to 25 April 2023. Clinical data were collected via electronic clinical records, including the most recent neurological examination and reason for discharge from the pathway. Patients identified from MDT lists from 27 January 2023 to 14 March 2023 were approached to participate in weekly 12-item surveys, delivered via WhatsApp. This was approved as a service development project with approval for WhatsApp use given by the chief clinical information officer. Results: 35/56 (62.5%) patients were discharged from ambulatory care due to non-attendance and 17/56 (30.4%) completed their treatment course. The median time from initial presentation to discharge was 49 days. 24/40 (60.0%) of patients with a final neurological examination documented had a residual deficit, with objective sensory deficits most common. 12 patients were approached to receive weekly questionnaires via WhatsApp. 5/8 who expressed interest returned a consent form. All participants were withdrawn due to non-response or participant choice. 1/5 returned more than two surveys. Conclusion: Despite poor participation in surveys delivered via WhatsApp, novel approaches are needed to improve engagement with patients on the N2O ambulatory care pathway.

Insomnia Symptoms Are Associated with Measures of Functional Deterioration and Dementia Status in Adults with Down Syndrome at High Risk for Alzheimer's Disease.

Background: While obstructive sleep apnea (OSA) and insomnia symptoms in neurotypical populations are associated with Alzheimer's disease (AD), their association with dementia in adults with Down syndrome (DS) remains less clear, even though these symptoms are prevalent and treatable in DS. Understanding their associations with AD-related dementia status, cognitive impairment, and functional deterioration may lead to interventions to slow decline or disease progression in adults with DS. Objective: To characterize differences in OSA and insomnia symptom expression by dementia status, and to determine which sleep factors support dementia diagnosis. Methods: Multimodal consensus conference was used to determine dementia status in 52 adults with DS (52.2 ±â€Š6.4 years, 21 women). Cognitive impairment, adaptive behavior skills, and symptoms of OSA and insomnia were quantified using validated assessments for adults with DS and their primary informants. Results: A sex by dementia status interaction demonstrated that older women with DS and dementia had more severe terminal insomnia but not OSA symptoms relative to older women with DS who were cognitively stable (CS). Greater insomnia symptom severity was associated with greater functional impairments in social and self-care domains adjusting for age, sex, premorbid intellectual impairment, and dementia status. Conclusions: Insomnia symptoms are more severe in women with DS with dementia than in women with DS and no dementia, and regardless of dementia status or sex, more severe insomnia symptoms are associated with greater impairment in activities of daily living. These findings underscore the potential importance of early insomnia symptom evaluation and treatment in women with DS at risk of developing AD.

Protodefluorinated Selectfluor® Aggregatively Activates Selectfluor® for Efficient Radical C(sp3)-H Fluorination Reactions.

Efficient fluorination reactions are key in the late-stage functionalization of complex molecules in medicinal chemistry, in upgrading chemical feedstocks, and in materials science. Radical C(sp3)-H fluorinations using Selectfluor® - one of the most popular fluorination agents - allow to directly engage unactivated precursors under mild photochemical or thermal catalytic conditions. However, H-TEDA(BF4)2 to date is overlooked and discarded as waste, despite comprising 95% of the molecular weight of Selectfluor®. We demonstrate that the addition of H-TEDA(BF4)2 at the start of fluorination reactions markedly promotes their rates and accesses higher overall yields of fluorinated products (~3.3x higher on average across the cases studied) than unpromoted reactions. Several case studies showcase generality of the promotor, for photochemical, photocatalytic and thermal radical fluorination reactions. Detailed mechanistic investigations reveal the key importance of aggregation changes in Selectfluor® and H-TEDA(BF4)2 to fill gaps of understanding in how radical C(sp3)-H fluorination reactions work. This study exemplifies an overlooked reaction waste product being upcycled for a useful application.

Big data study using health insurance claims to predict multidisciplinary low vision service uptake.

SIGNIFICANCE: There is a lack of research from high-income countries with various health care and funding systems regarding barriers and facilitators in low vision services (LVS) access. Furthermore, very few studies on LVS provision have used claims data. PURPOSE: This study aimed to investigate which patient characteristics predict receiving multidisciplinary LVS (MLVS) in the Netherlands, a high-income country, based on health care claims data. METHODS: Data from a Dutch national health insurance claims database (2015 to 2018) of patients with eye diseases causing potentially severe visual impairment were retrieved. Patients received MLVS (n = 8766) and/or ophthalmic treatment in 2018 (reference, n = 565,496). MLVS is provided by professionals from various clinical backgrounds, including nonprofit low vision optometry. Patient characteristics (sociodemographic, clinical, contextual, general health care utilization) were assessed as potential predictors using a multivariable logistic regression model, which was internally validated with bootstrapping. RESULTS: Predictors for receiving MLVS included prescription of low vision aids (odds ratio [OR], 8.76; 95% confidence interval [CI], 7.99 to 9.61), having multiple ophthalmic diagnoses (OR, 3.49; 95% CI, 3.30 to 3.70), receiving occupational therapy (OR, 2.32; 95% CI, 2.15 to 2.51), mental comorbidity (OR, 1.17; 95% CI, 1.10 to 1.23), comorbid hearing disorder (OR, 1.98; 95% CI, 1.86 to 2.11), and receiving treatment in both a general hospital and a specialized ophthalmic center (OR, 1.23; 95% CI, 1.10 to 1.37), or by a general practitioner (OR, 1.23; 95% CI, 1.18 to 1.29). Characteristics associated with lower odds included older age (OR, 0.30; 95% CI, 0.28 to 0.32), having a low social economic status (OR, 0.91; 95% CI, 0.86 to 0.97), physical comorbidity (OR, 0.87; 95% CI, 0.82 to 0.92), and greater distance to an MLVS (OR, 0.95; 95% CI, 0.92 to 0.98). The area under the curve of the model was 0.75 (95% CI, 0.75 to 0.76; optimism = 0.0008). CONCLUSIONS: Various sociodemographic, clinical, and contextual patient characteristics, as well as factors related to patients' general health care utilization, were found to influence MLVS receipt as barriers or facilitators. Eye care practitioners should have attention for socioeconomically disadvantaged older patients when considering MLVS referral.

Performance of restorations in primary molars over a seven-year period.

OBJECTIVE: The aim of this study was to evaluate the use and reintervention rate of fillings compared to preformed metal crowns in the everyday clinical practice of German dentists. METHODS: In this retrospective, longitudinal analysis, fee codes from the Kassenzahnärztliche Vereinigung Westfalen-Lippe for restorations placed in primary molars between 2012 and 2015 in children until 7 years of age followed for a 7-year period (latest until December 2022) were filtered and analyzed with the Fine and Gray competing risk regression and Cox proportional hazards regression to calculate the risk of reintervention divided into the main outcomes "Successful", "Minor Failure/Repair" and "Major Failure/Endodontic Treatment/Extraction". 367,139 primary molars (one-surface fillings: n = 117,721; two-surface fillings n = 198,815; three-surface fillings n = 36,695; more than three-surface fillings n = 8,267 and preformed metal crowns n = 5,641 were included in this study. RESULTS: Teeth treated with preformed crowns needed significantly less re-interventions. Subdistribution hazard ratio for minor events was 0.117 (95 %-CI: 0.097 to 0.141) and hazard ratio of major events (HR=0.786; 95 %-CI: 0.695 to 0.890) when compared to one-surface fillings in multivariable adjusted analysis. Within 7-year follow-up preformed crowns required less repairs (80.6 % success rate, minor failure 4.4 %, major failure 16.3 %) than the teeth treated with composite fillings (46.2 %-52.6 % success rate, minor failure 27.0 %-39.5 %, major failure 15.5 %-28.4 %, p < 0.001). CONCLUSION: Within the German healthcare system fillings are the first choice for treating primary molars despite considerably higher reintervention rates. This encourages a discussion on the indication of fillings and the more durable preformed metal crowns to reduce unnecessary reintervention in young children. CLINICAL SIGNIFICANCE: This study gives an unprecedented insight into the German healthcare system regarding the reintervention rates of the most relevant treatment techniques for caries in primary molars.

A programmable seekRNA guides target selection by IS1111 and IS110 type insertion sequences.

IS1111 and IS110 insertion sequence (IS) family members encode an unusual DEDD transposase type and exhibit specific target site selection. The IS1111 group include identifiable subterminal inverted repeats (sTIR) not found in the IS110 type1. IS in both families include a noncoding region (NCR) of significant length and, as each individual IS or group of closely related IS selects a different site, we had previously proposed that an NCR-derived RNA was involved in target selection2. Here, we find that the NCR is usually downstream of the transposase gene in IS1111 family IS and upstream in the IS110 type. Four IS1111 and one IS110 family members that target different sequences are used to demonstrate that the NCR determines a short seeker RNA (seekRNA) that co-purified with the transposase. The seekRNA is essential for transposition of the IS or a cargo flanked by IS ends from and to the preferred target. Short sequences matching both top and bottom strands of the target are present in the seekRNA but their order in IS1111 and IS110 family IS is reversed. Reprogramming the seekRNA and donor flank to target a different site is demonstrated, indicating future biotechnological potential for these systems.

Integrative Review of Sources of Baccalaureate Nursing Students' Clinical Practice Anxiety.

BACKGROUND: Nursing education research and anecdotal literature has revealed that undergraduate nursing students report anxiety related to clinical practice. Most published studies have focused on the effectiveness of interventions to reduce anxiety; only a few identify specific sources of clinical practice anxiety. METHOD: We conducted an integrative literature review to understand the sources of nursing students' practice-related anxiety and how this anxiety has been measured. RESULTS: We classified sources of practice-related anxiety into nine themes grouped into five categories: consequences of making a mistake; fear of the unknown; incivility of staff members or teachers; threat to self-concept, image, or health; and theory-practice gap. Practice-related anxiety was measured quantitatively with various surveys and qualitatively using semistructured individual or group interviews and students' journal entries. CONCLUSION: Different sources of practice-related anxiety likely require distinct interventions. Further research is recommended to identify effective interventions to reduce anxiety related to each of the identified themes. [J Nurs Educ. 2024;63(6):349-355.].

Highly acidic N-triflylphosphoramides as chiral Brønsted acid catalysts: the effect of weak hydrogen bonds and multiple acceptors on complex structures and aggregation.

N-Triflylphosphoramides (NTPAs) represent an important catalyst class in asymmetric catalysis due to their multiple hydrogen bond acceptor sites and acidity, which is increased by several orders of magnitude compared to conventional chiral phosphoric acids (CPAs). Thus, NTPAs allow for several challenging transformations, which are not accessible with CPAs. However, detailed evidence on their hydrogen bonding situation, complex structures and aggregation is still lacking. Therefore, this study covers the hydrogen bonding behavior and structural features of binary NTPA/imine complexes compared to their CPA counterparts. Deviating from the single-well potential hydrogen bonds commonly observed in CPA/imine complexes, the NTPA/imine complexes exhibit a tautomeric equilibrium between two proton positions. Low-temperature NMR at 180 K supported by computer simulations indicates a OHN hydrogen bond between the phosphoramide oxygen and the imine, instead of the mostly proposed NHN H-bond. Furthermore, this study finds no evidence for the existence of dimeric NTPA/NTPA/imine complexes as previously suggested for CPA systems, both synthetically and through NMR studies.

"Intramuscular Breast Augmentation in Secondary Mastopexy Augmentation."

BACKGROUND: Breast augmentation with implants is one of the most performed aesthetic surgical procedures performed worldwide. We describe this new option for breast implant secondary procedures, the intra pectoralis major pocket, as a feasible and reproducible surgical technique. METHODS: A retrospective chart review was conducted on all patients who underwent revision augmentation or mastopexy augmentation procedure between 2005 and 2022 by the senior author. The intramuscular pocket is dissected between the pectoral muscle fascicles where almost is not bleeding. RESULTS: Patients were followed for an average of 21.5 months. A total of 319 patients underwent revisionary breast augmentation/mastopexies performed by the senior author. Indications for reoperation were based both on specific patient dissatisfaction with their original surgery and surgeon's physical examination and assessment. In 196 cases we performed the intramuscular pocket. None of the intramuscular had capsular contracture or animation deformity in the follow up period. CONCLUSIONS: The intramuscular technique is a valuable and safe technique for secondary breast augmentation.

Untangling the genetics of beta cell dysfunction and death in type 1 diabetes.

Type 1 diabetes (T1D) is a complex multi-system disease which arises from both environmental and genetic factors, resulting in the destruction of insulin-producing pancreatic beta cells. Over the past two decades, human genetic studies have provided new insight into the etiology of T1D, including an appreciation for the role of beta cells in their own demise. Here, we outline models supported by human genetic data for the role of beta cell dysfunction and death in T1D. We highlight the importance of strong evidence linking T1D genetic associations to bona fide candidate genes for mechanistic and therapeutic consideration. To guide rigorous interpretation of genetic associations, we describe molecular profiling approaches, genomic resources, and disease models that may be used to construct variant-to-gene links and to investigate candidate genes and their role in T1D. We profile advances in understanding the genetic causes of beta cell dysfunction and death at individual T1D risk loci. We introduce genetic risk prediction models and discuss how they can be used to address disease heterogeneity. Finally, we present areas where investment will be critical for future use of genetics to address open questions and to develop new treatment and prevention strategies for T1D.

Unpacking workplace stress and forensic expert decision-making: From theory to practice.

Workplace stress can affect forensic experts' job satisfaction and performance, which holds financial and other implications for forensic service providers. Therefore, it is important to understand and manage workplace stress, but that is not simple or straightforward. This paper explores stress as a human factor that influences forensic expert decision-making. First, we identify and highlight three factors that mitigate decisions under stress conditions: nature of decision, individual differences, and context of decision. Second, we situate workplace stress in forensic science within the Challenge-Hindrance Stressor Framework. We argue that stressors in forensic science workplaces can have a positive or a negative impact, depending on the type, level, and context of stress. Developing an understanding of the stressors, their sources, and their possible impact can help forensic service providers and researchers to implement context-specific interventions to manage stress at work and optimize expert performance.

Early-pregnancy sex steroid and thyroid function hormones, thyroid autoimmunity, and maternal papillary thyroid cancer incidence in the Finnish Maternity Cohort.

Thyroid cancer more commonly affects women than men and is the third most frequently diagnosed cancer among women of reproductive age. We conducted a nested case-control study within the Finnish Maternity Cohort to evaluate pre-diagnostic sex steroid and thyroid function markers in relation to subsequent maternal papillary thyroid cancer. Cases (n = 605) were women ages 18-44 years, who provided an early-pregnancy (<20 weeks gestation) blood sample and were diagnosed with papillary thyroid cancer up to 11 years afterward. Controls (n = 1185) were matched to cases 2:1 by gestational age, mother's age, and date at blood draw. Odds ratios (ORs) for the associations of serum thyroid peroxidase antibodies (TPO-Ab), thyroglobulin antibodies (Tg-Ab), thyroid stimulating hormone (TSH), free thyroxine (fT4), free triiodothyronine (fT3), progesterone, and estradiol with papillary thyroid cancer were estimated using conditional logistic regression. TPO-Ab and Tg-Ab positivity (>95th percentile among controls) were associated with more than 3-fold (OR = 3.32, 95% confidence interval [CI] 2.33-4.72) and 2-fold (OR = 2.03, 95% CI 1.41-2.93) increased odds of papillary thyroid cancer, respectively. These associations were similar by time since blood draw, parity, gestational age, smoking status, and age and stage at diagnosis. In models excluding TPO-Ab or Tg-Ab positivity, TPO-Ab (quartile 4 vs. 1: OR = 1.66, 95% CI 1.17-2.37, p-trend = .002) and Tg-Ab (quartile 4 vs. 1: OR = 1.74, 95% CI 1.22-2.49, p-trend = .01) levels were positively associated with papillary thyroid cancer. No associations were observed for estradiol, progesterone, TSH, fT3, or fT4 overall. Our results suggest that thyroid autoimmunity in early pregnancy may increase the risk of maternal papillary thyroid cancer.

Medical Image sharing: What do the public see when reviewing radiographs? A pilot study.

INTRODUCTION: Policymakers wish to extend access to medical records, including medical imaging. Appreciating how patients might review radiographs could be key to establishing future training needs for healthcare professionals and how image sharing could be integrated into practice. METHOD: A pilot study in the UK using a survey was distributed to adult participants via the online research platform Prolific. All subjects were without prior professional healthcare experience. Participants reviewed ten radiographs (single projection only) and were asked a two-stage question. Firstly, if the radiograph was 'normal' or 'abnormal' and secondly, if they had answered 'abnormal', to identify the abnormality from a pre-determined list featuring generic terms for pathologies. RESULTS: Fifty participants completed the survey. A mean of 65.8 % of participants were able to correctly identify if radiographs were normal or abnormal. Results in relation to the identification of a pathology were not as positive, but still notable with a mean of 46.4 % correctly identifying abnormalities. Qualitative data demonstrated that members of the public are enthralled with reviewing radiographs and intrigued to understand their performance in identifying abnormalities. CONCLUSION: In the pilot, members of the public could identify if a radiograph is normal or abnormal to a reasonable standard. Further detailed interpretation of images requires supportive intervention. This pilot study suggests that patients can participate in image sharing as part of their care. Image sharing may be beneficial to the therapeutic relationship, aiding patient understanding and enhancing consultations between healthcare professional and patient. Further research is indicated.

Statin use is not associated with inflammation among Chilean women of Mapuche and non-Mapuche ancestry with gallstones.

Aim: Statins are associated with lower risk of gallstones due to anti-inflammatory effects. We assessed whether statins impact circulating inflammation among Chilean women with gallstones. Materials & methods: 200 Mapuche women were matched on statin use and age to 200 non-Mapuche women in the Chile Biliary Longitudinal Study. We analyzed 92 inflammatory biomarkers using multivariable-adjusted regression models, random forests and pathway analyses. Results: Statins were not significantly associated with any inflammation marker when women were analyzed jointly or stratified by ancestry. No significant associations were found through random forest methods and pathway analyses. Discussion: We did not find significant associations between statin use and inflammation markers in women with gallstones, suggesting that statins do not reduce inflammation once gallstones have formed.

Statins are prescribed to lower cholesterol and can also decrease the risk of gallstone formation by reducing inflammation. We assessed whether statin use reduces inflammation among women who have already developed gallstones. We analyzed 92 inflammation markers among 400 women in Chile, including 200 women with Mapuche Amerindian ancestry and 200 women of Latina/European ancestry. We found that statin use was not correlated with inflammation in this group of women overall nor by ancestry. This may mean that statin use does not reduce inflammation in women who already were diagnosed with gallstones.

A Web-Based Peer Support Network to Help Care Partners of People With Serious Illness: Co-Design Study.

BACKGROUND: Care partners of people with serious illness experience significant challenges and unmet needs during the patient's treatment period and after their death. Learning from others with shared experiences can be valuable, but opportunities are not consistently available. OBJECTIVE: This study aims to design and prototype a regional, facilitated, and web-based peer support network to help active and bereaved care partners of persons with serious illness be better prepared to cope with the surprises that arise during serious illness and in bereavement. METHODS: An 18-member co-design team included active care partners and those in bereavement, people who had experienced serious illness, regional health care and support partners, and clinicians. It was guided by facilitators and peer network subject-matter experts. We conducted design exercises to identify the functions and specifications of a peer support network. Co-design members independently prioritized network specifications, which were incorporated into an early iteration of the web-based network. RESULTS: The team prioritized two functions: (1) connecting care partners to information and (2) facilitating emotional support. The design process generated 24 potential network specifications to support these functions. The highest priorities included providing a supportive and respectful community; connecting people to trusted resources; reducing barriers to asking for help; and providing frequently asked questions and responses. The network platform had to be simple and intuitive, provide technical support for users, protect member privacy, provide publicly available information and a private discussion forum, and be easily accessible. It was feasible to enroll members in the ConnectShareCare web-based network over a 3-month period. CONCLUSIONS: A co-design process supported the identification of critical features of a peer support network for care partners of people with serious illnesses in a rural setting, as well as initial testing and use. Further testing is underway to assess the long-term viability and impact of the network.

Associations of tubal ligation and hysterectomy with serum androgen and estrogen metabolites among postmenopausal women in the Women's Health Initiative Observational Study.

PURPOSE: Hysterectomy is associated with subsequent changes in circulating hormone levels, but the evidence of an association for tubal ligation is unclear. We evaluated whether circulating concentrations of androgens and estrogens differ by tubal ligation or hysterectomy status in postmenopausal women from the Women's Health Initiative (WHI)-Observational Study (OS). METHODS: Serum androgens and estrogens were measured in 920 postmenopausal women who did not use menopausal hormone therapy at the time of blood draw, of whom 139 self-reported a history of tubal ligation and 102 reported hysterectomy (with intact ovaries). Geometric mean hormone concentrations (GMs) and 95% confidence intervals (CIs) associated with a history of tubal ligation or hysterectomy (ever/never), as well as time since procedures, were estimated using adjusted linear regression with inverse probability of sampling weights to account for selection. RESULTS: Circulating levels of 12 androgen/androgen metabolites and 20 estrogen/estrogen metabolites did not differ by tubal ligation status. Among women reporting prior hysterectomy compared to women without hysterectomy, we observed lower levels of several androgens (e.g., testosterone (nmol/L): GMyes 0.46 [95% CI:0.37-0.57] vs. GMno 0.62 [95% CI:0.53-0.72]) and higher levels of estrogen metabolites, for example, 2-hydroxyestrone-3-methyl ether (GMyes 11.1 [95% CI:8.95-13.9] pmol/L vs. GMno 8.70 [95% CI:7.38-10.3]) and 4-methoxyestrone (GMyes 6.50 [95% CI:5.05-8.37] vs. GMno 4.92 [95% CI:4.00-6.05]). CONCLUSION: While we did not observe associations between prior tubal ligation and postmenopausal circulating hormone levels, our findings support that prior hysterectomy was associated with lower circulating testosterone levels and higher levels of some estrogen metabolites, which may have implications for future hormone-related disease risks.

Arcus Experience: Bridging the Data Science Gap for Nurse Researchers.

BACKGROUND: For years, nurse researchers have been called upon to engage with "big data" in the electronic health record (EHR) by leading studies focusing on nurse-centric patient outcomes and providing clinical analysis of potential outcome indicators. However, the current gap in nurses' data science education and training pose a significant barrier. OBJECTIVES: We aimed to evaluate the viability of conducting nurse-led, big-data research projects within a custom-designed computational lab and examine the support required by a team of researchers with little to no big-data experience. METHODS: Four nurse-led research teams developed a research question reliant on existing EHR data. Each team was given its own virtual computational lab populated with raw data. A data science education team provided instruction in coding languages-primarily structured query language and R-and data science techniques to organize and analyze the data. RESULTS: Three research teams have completed studies, resulting in one manuscript currently undergoing peer-review and two manuscripts in progress. The final team is performing data analysis. Four barriers and four facilitators to big-data projects were identified. DISCUSSION: As the data-science learning curve is steep, organizations need to help bridge the gap between what is currently taught in doctoral nursing programs and what is required of clinical nurse researchers to successfully engage in big-data methods. Additionally, clinical nurse researchers require protected research time and a data science infrastructure that supports novice efforts with education, mentorship, and computational lab resources.

Understanding Breast Cancer Images in Art History as a Form of Health Communication.

Can art and visual images meant for public consumption (museums, galleries, social media platforms) serve as a critical form of health communication for breast cancer patients? For their clinicians? For the population at large? Art history research methods are applied to a range of breast cancer images in western art in order to understand what the images communicate to us about patient experience, agency, and inequity in health care at the time of their construction. The following is a selective look at western art as it reflects and informs our understanding of breast cancer over time.