Navigating the Healthcare Conundrum: Leadership Perspective from a Premier Healthcare Organization in Loma Linda's Blue Zone.

Navigating the healthcare conundrum in the Blue Zone of Loma Linda, California, requires understanding the unique factors that make this region stand out in terms of health and longevity. But more important is understanding the healthcare system sustaining the Blue Zone in Loma Linda, California. In an era marked by soaring healthcare costs and diminishing reimbursement rates, hospitals and physicians face an unprecedented challenge: providing excellent patient care while maintaining financial sustainability. This leadership perspective publication paper delves into the multifaceted struggles encountered by healthcare and hospital leaders, exploring the root causes, implications, and potential solutions for this complex issue. As we examine the evolving healthcare landscape, we aim to shed light on the critical need for innovative approaches to sustain the future of healthcare excellence in one of the five original Blue Zones.

Targeting a highly repetitive genomic sequence for sensitive and specific molecular detection of the filarial parasite Mansonella perstans from human blood and mosquitoes.

BACKGROUND: Mansonella perstans is among the most neglected of the neglected tropical diseases and is believed to cause more human infections than any other filarial pathogen in Africa. Based largely upon assumptions of limited infection-associated morbidity, this pathogen remains understudied, and many basic questions pertaining to its pathogenicity, distribution, prevalence, and vector-host relationships remain unanswered. However, in recent years, mounting evidence of the potential for increased Mansonella infection-associated disease has sparked a renewal in research interest. This, in turn, has produced a need for improved diagnostics, capable of providing more accurate pictures of infection prevalence, pathogen distribution, and vector-host interactions. METHODOLOGY/PRINCIPAL FINDINGS: Utilizing a previously described pipeline for the discovery of optimal molecular diagnostic targets, we identified a repetitive DNA sequence, and developed a corresponding assay, which allows for the sensitive and species-specific identification of M. perstans in human blood samples. Testing also demonstrated the ability to utilize this assay for the detection of M. perstans in field-collected mosquito samples. When testing both sample types, our repeat-targeting index assay outperformed a ribosomal sequence-targeting reference assay, facilitating the identification of additional M. perstans-positive samples falsely characterized as "negative" using the less sensitive detection method. CONCLUSIONS/SIGNIFICANCE: Through the development of an assay based upon the systematic identification of an optimal DNA target sequence, our novel diagnostic assay will provide programmatic efforts with a sensitive and specific testing platform that is capable of accurately mapping M. perstans infection and determining prevalence. Furthermore, with the added ability to identify the presence of M. perstans in mosquito samples, this assay will help to define our knowledge of the relationships that exist between this pathogen and the various geographically relevant mosquito species, which have been surmised to represent potential secondary vectors under certain conditions. Detection of M. perstans in mosquitoes will also demonstrate proof-of-concept for the mosquito-based monitoring of filarial pathogens not vectored primarily by mosquitoes, an approach expanding opportunities for integrated surveillance.

Integrating blue: How do we make nationally determined contributions work for both blue carbon and local coastal communities?

Blue Carbon Ecosystems (BCEs) help mitigate and adapt to climate change but their integration into policy, such as Nationally Determined Contributions (NDCs), remains underdeveloped. Most BCE conservation requires community engagement, hence community-scale projects must be nested within the implementation of NDCs without compromising livelihoods or social justice. Thirty-three experts, drawn from academia, project development and policy, each developed ten key questions for consideration on how to achieve this. These questions were distilled into ten themes, ranked in order of importance, giving three broad categories of people, policy & finance, and science & technology. Critical considerations for success include the need for genuine participation by communities, inclusive project governance, integration of local work into national policies and practices, sustaining livelihoods and income (for example through the voluntary carbon market and/or national Payment for Ecosystem Services and other types of financial compensation schemes) and simplification of carbon accounting and verification methodologies to lower barriers to entry.

Healthcare professionals' views of a new second-level nursing associate role: A qualitative study exploring early implementation in an acute setting.

AIM: The study aimed to establish the views of a range of stakeholders about their experiences of the newly implemented nursing associate role in England and its potential to contribute to patient care. BACKGROUND: Second-level nursing roles are increasingly used internationally within the healthcare workforce. In response to registered nurse workforce deficits, a new nursing associate role has been introduced in England to augment care provided by registered nurses and enable career progression of support workers. DESIGN: Qualitative descriptive design. METHODS: Semi-structured interviews and a focus group were conducted with a range of healthcare professionals in a large inner city acute secondary care healthcare organisation in England. Interviews were guided by the Consolidated Framework for Implementation Research and analysed using Framework Analysis. The study was reported according to COREQ guidelines. RESULTS: 33 healthcare professionals were interviewed-directors of nursing, ward managers, nursing associates and multidisciplinary team members. Participants perceived the role was broadly adaptable to different healthcare settings and provided a positive professional development mechanism for healthcare support workers. Managers felt training commitments made implementing the role complex and costly. Participants argued the role had limitations, particularly with intravenous medicine management. Implementation was impeded by rapid pace and consequent lack of clear communication and planning. CONCLUSIONS: The nursing associate role was perceived as an inclusive pathway into nursing but with limitations when working with high-acuity patients. Further evaluation is needed to investigate how the role has embedded over time. RELEVANCE TO CLINICAL PRACTICE: The role should be seen as both a stepping stone into registered nursing positions and valued as part of the nursing workforce. Consideration must be given to how the role can be safely implemented in different settings. Findings have relevance to healthcare leaders internationally, who continue to work in a climate of economic pressure and staffing shortages.

Healthcare professionals' perspectives on enrolled nurses, practical nurses and other second-level nursing roles: A systematic review and thematic synthesis.

BACKGROUND: Significant workforce shortages and economic pressures have led to the expanded scope and reintroduction of new roles for second-level nurses in many Organization for Economic Co-operation and Development countries. Given this, there is a need to understand the emic and etic perspectives of second-level nurses, to ensure collaborative teamwork and safe patient care. OBJECTIVE: This review aimed to systematically identify, appraise, and synthesize qualitative research evidence on healthcare professionals' perspectives on second-level nursing roles in the healthcare workforce. These findings inform recommendations that would influence the development and implementation of these roles in healthcare organisations. DESIGN: A systematic review and thematic synthesis of qualitative research was conducted. Six databases were systematically searched and forward and backwards searching completed. Included studies focused on healthcare professionals' perspectives (including views of second-level nurses themselves) on second-level nursing roles. All included articles were from Organization for Economic Co-operation and Development countries. The Critical Appraisal Skills Programme checklist for qualitative research was used to assess the evidence quality. The results section of each included article was coded and descriptive themes were developed. An interpretative and iterative process led to the final analytic themes. FINDINGS: Twenty-six qualitative studies were identified from five countries over 26 years. Four analytic themes were identified: undifferentiated role; efficient but limited; subordinated task-doers; and broadening scope and strengthened identity. The synthesis demonstrated dichotomies wherein some second-level nursing roles were devalued, and others had increasing scope and responsibility. Role and boundary confusion was evident and had not decreased over time. Hierarchies in nursing practice underlined the split between critical thinking and hands-on approaches to care which, in some cases, debased the second-level nursing role because of its association with practical hands-on care. CONCLUSIONS: The analytic themes in this synthesis suggest that second-level nurses have faced the same issues over decades with little change. Perceptions of second-level nursing roles are primarily influenced by meso (organisational level) factors and micro (individual, behavioural) factors. The synthesis concludes that a cultural shift in valuing the hands-on care provided by second-level nursing is necessary, along with systems-level shift that clarifies the role of second-level nursing within healthcare teams to enhance collaborative practice. Further research should attend to macro-level influences on perceptions of second-level nurses, the work they do, and how this is valued or institutionally embedded. Tweetable abstract: Healthcare professionals' perspectives on second-level nursing roles: a systematic review and thematic synthesis.

Healthcare students interprofessional critical event/disaster response course.

OBJECTIVE: Numerous disasters confirm the need for critical event training in healthcare professions. However, no single discipline works in isolation and interprofessional learning is recognized as a necessary component. An interprofessional faculty group designed a learning curriculum crossing professional schools. DESIGN: Faculty members from four healthcare schools within the university (nursing, pharmacy, allied health, and medicine) developed an interdisciplinary course merging both published cross-cutting competencies for critical event response and interprofessional education competencies. SETTING: Students completed a discipline-specific online didactic course. Interdisciplinary groups then participated in a 4-hour synchronous experience. This live course featured high-fidelity medical simulations focused on resuscitation, as well as hands-on modules on decontamination and a mass casualty triage incorporating moulaged standardized patients in an active shooter scenario. PARTICIPANTS: Participants were senior students from allied health, medicine, nursing, and pharmacy. MAIN OUTCOME MEASURES: Precourse and postcourse assessments were conducted online to assess course impact on learning performance, leadership and team development, and course satisfaction. RESULTS: Students participated were 402. Precourse and postcourse evaluations showed improvement in team participation values, critical event knowledge, and 94 percent of participants reported learning useful skills. Qualitative responses evidenced positive response; most frequent recurring comments concerned value of interprofessional experiences in team communication and desire to incorporate this kind of education earlier in their curriculum. Students demonstrated improvement in both knowledge and attitudes in a critical event response course that includes interprofessional instruction and collaboration. Further study is required to demonstrate sustained improvement as well as benefit to clinical outcomes.

Effect of Educational Debt on Emergency Medicine Residents: A Qualitative Study Using Individual Interviews.

STUDY OBJECTIVE: In 2001, less than 20% of emergency medicine residents had more than $150,000 of educational debt. Our emergency medicine residents anecdotally reported much larger debt loads. Surveys have reported that debt affects career and life choices. Qualitative approaches are well suited to explore how and why such complex phenomena occur. We aim to gain a better understanding of how our emergency medicine residents experience debt. METHODS: We conducted individual semistructured interviews with emergency medicine residents. We collected self-reported data related to educational debt and asked open-ended questions about debt influence on career choices, personal life, future plans, and financial decisions. We undertook a structured thematic analysis using a qualitative approach based in the grounded theory method. RESULTS: Median educational debt was $212,000. Six themes emerged from our analysis: (1) debt influenced career and life decisions by altering priorities; (2) residents experienced debt as a persistent source of background stress and felt powerless to change it; (3) residents made use of various techniques to negotiate debt in order to focus on day-to-day work; (4) personal debt philosophy, based on individual values and obtained from family, shaped how debt affected each individual; (5) debt had a normative effect and was acculturated in residency; and (6) residents reported a wide range of financial knowledge, but recognized its importance to career success. CONCLUSION: Our emergency medicine residents' debt experience is complex and involves multiple dimensions. Given our current understanding, simple solutions are unlikely to be effective in adequately addressing this issue.

Allosensitization does not alter post-transplant outcomes in pediatric patients bridged to transplant with a ventricular assist device.

Patients supported with a VAD are at increased risk for sensitization. We aimed to determine risk factors for sensitization as well as the impact of sensitization on post-transplant outcomes. The UNOS database (January 2004-June 2014) was used to identify patients (≤18 yrs) supported with a durable VAD. Rates and degree of sensitization in the VAD cohort were calculated. Post-transplant survival was determined comparing outcomes of sensitized vs. non-sensitized patients. There were 3097 patients included in the study; 19% (n = 579) were bridged with a VAD. Of these, 41.8% were sensitized vs. 29.9% of the patients who were not bridged with a VAD (p < 0.001). VAD was an independent predictor of sensitization (OR 2.05 [1.63-2.57]; p < 0.001). There was no difference in sensitization based on device type (continuous vs. pulsatile flow, p = 0.990). Post-transplant survival rates between the sensitized and non-sensitized VAD patients were not different, including patients with a PRA >50% and VAD patients with a positive DSC (p = 0.280 and 0.160, respectively). In conclusion, pediatric VAD patients are more likely to be sensitized, but there was no difference in sensitization based on device type. In addition, sensitization does not appear to impact outcomes.

Arrhythmia as a cardiac manifestation in MELAS syndrome.

A 44-year-old female with a diagnosis of mitochondrial myopathy, encephalopathy and stroke-like episodes (MELAS) syndrome had progressive left ventricular hypertrophy (LVH) on echocardiogram. A Holter monitor demonstrated episodes of non-sustained atrial tachycardia, a finding not been previously described in this population. This unique case of MELAS syndrome demonstrates the known associated cardiac manifestation of LVH and the new finding of atrial tachycardia which may represent the potential for subclinical arrhythmia in this population.

The Development of a Physician Vitality Program: A Brief Report.

We describe the development of an innovative program to support physician vitality. We provide the context and process of program delivery which includes a number of experimental support programs. We discuss a model for intervention and methods used to enhance physician resilience, support work-life balance, and change the culture to one that explicitly addresses the physician's biopsychosocial-spiritual needs. Recommendations are given for marriage and family therapists (MFTs) who wish to develop similar support programs for healthcare providers. Video Abstract.

The use of a Berlin Heart EXCOR LVAD in a child receiving chemotherapy for Castleman's disease.

We present the unique case of a pediatric patient who received chemotherapy for a diagnosis of CD, while mechanically supported with a Berlin EXCOR LVAD secondary to restrictive cardiomyopathy. A four-yr-old previously healthy male with restrictive cardiomyopathy required MCS after cardiac arrest but was diagnosed with multicentric CD, a non-malignant lymphoproliferative disorder fueled by excessive IL-6 production. Treatment with IL-6 blockade (tocilizumab) every two wk and methylprednisolone had no effect on his lymph nodes or cardiac function while on temporary RotaFlow. A Berlin LVAD was placed for treatment with rituximab, COP, vincristine, and methylprednisolone. After three courses of chemotherapy, his inflammatory markers normalized and his lymphadenopathy decreased but cardiac function remained severely depressed. He tolerated chemotherapy on the Berlin but required frequent titrations of his anti-coagulation regimen and he did suffer a hemorrhagic stroke. His clinical status improved significantly with rehabilitation, and he tolerated heart transplantation without further complications. MCS is a feasible option as a bridge to recovery or heart transplant eligibility for patients with hemodynamic collapse requiring chemotherapy but it does necessitate close titration of the anti-coagulation regimen to coincide with changes in the inflammatory state.

Autonomic dysfunction: a driving force for myocardial fibrosis in young Duchenne muscular dystrophy patients?

Cardiac manifestations of Duchenne muscular dystrophy (DMD) include progressive cardiac dysfunction and an elevated resting heart rate (HR). We hypothesized this elevated HR reflects autonomic dysfunction that can be identified by heart rate variability (HRV) analyses which will be associated with myocardial fibrosis by cardiac magnetic resonance imaging (cMR). DMD patients (N = 74) and controls (N = 17) had time and frequency domain HRV analyses calculated via Holter monitoring. Cardiac magnetic resonance imaging was performed on DMD cases only. χ (2) test, T test, ANOVA, and logistic regression were used to perform comparisons between groups. A p value of <0.05 was used for statistical significance. DMD cases had higher resting average HR than controls (99.4 ± 8.9, 85.4 + 6.2, p < 0.001). Among HRV variables, decreases were seen in the following: standard deviation of R to R intervals, the percent RR intervals differing by >50 ms from previous RR interval, the root-meansquare of successive differences of RR intervals, the standard deviation of the mean R to R segment (SDANN), low frequency, and high frequency domain, all p values 0.001. Maximum HR and SDANN most significantly associated with positive LGE on cMR (p = 0.008, p = 0.016). DMD cases on beta blocker had an average HR lower than those not on beta blocker (p = 0.009), but with no difference in HRV analysis. DMD patients have reduced HRV and therefore autonomic dysfunction prior to the onset of heart failure which is associated with myocardial fibrosis.

The flipped classroom: a modality for mixed asynchronous and synchronous learning in a residency program.

INTRODUCTION: A "flipped classroom" educational model exchanges the traditional format of a classroom lecture and homework problem set. We piloted two flipped classroom sessions in our emergency medicine (EM) residency didactic schedule. We aimed to learn about resident and faculty impressions of the sessions, in order to develop them as a regular component of our residency curriculum. METHODS: We evaluated residents' impression of the asynchronous video component and synchronous classroom component using four Likert items. We used open-ended questions to inquire about resident and faculty impressions of the advantages and disadvantages of the format. RESULTS: For the Likert items evaluating the video lectures, 33/35 residents (94%, 95% CI 80%-99%) responded that the video lecture added to their knowledge about the topic, and 33/35 residents felt that watching the video was a valuable use of their time. For items evaluating the flipped classroom format, 36/38 residents (95%, 95% CI 82%-99%) preferred the format to a traditional lecture on the topic, and 38/38 residents (100%, 95% CI 89%-100%) felt that the small group session was effective in helping them learn about the topic. Most residents preferred to see the format monthly in our curriculum and chose an ideal group size of 5.5 (first session) and 7 (second session). Residents cited the interactivity of the sessions and access to experts as advantages of the format. Faculty felt the ability to assess residents' understanding of concepts and provide feedback were advantages. CONCLUSION: Our flipped classroom model was positively received by EM residents. Residents preferred a small group size and favored frequent use of the format in our curriculum. The flipped classroom represents one modality that programs may use to incorporate a mixture of asynchronous and interactive synchronous learning and provide additional opportunities to evaluate residents.

Prompt recognition and percutaneous coronary intervention leads to favorable myocardial recovery after ST-segment elevation myocardial infarction secondary to acute promyelocytic leukemia: pediatric case report.

Acute myocardial infarction (AMI) is extremely rare in children, and unlike the adult disease, the etiology of the infarction is rarely due to atherosclerotic coronary disease. This unique reported case involved a 15-year-old boy with severe chest pain who presented with an ST-segment-elevation myocardial infarction secondary to in situ thrombus formation in the left anterior descending (LAD) coronary artery. The initial electrocardiogram (ECG) had a Q-wave pattern in V6 and ST depression in the inferior leads with ST-segment elevation in reciprocal leads. The cardiac enzymes and routine labs showed evidence of myocardial damage. The boy was urgently taken to the cardiac catheterization laboratory for percutaneous coronary intervention, where complete occlusion of the LAD was found and successfully stented. Eventually, a peripheral blood smear showed pancytopenia with 38 % hypergranular blast-like cells consistent with acute myeloid leukemia (AML), and chemotherapy with all-transretinoic acid was implemented. This first pediatric case report of an AML-associated AMI emphasizes the benefit resulting from expedient reperfusion of the ischemic myocardium by quick reestablishment of coronary perfusion. It also emphasizes the limitations of existing noninvasive technologies in detecting myocardial viability.

Correlation of heart rate and cardiac dysfunction in Duchenne muscular dystrophy.

Sinus tachycardia is common in cases of Duchenne muscular dystrophy (DMD). The authors hypothesized that an elevated heart rate would herald cardiomyopathy onset. A retrospective case-control study was performed with 55 DMD boys and 150 age-matched control boys. The variables were age, heart rate, shortening fraction, and left ventricular end-diastolic dimension. Cardiomyopathy was defined as a shortening fraction less than 28%. The DMD boys had a higher initial heart rate with no baseline echocardiographic evidence of cardiomyopathy. The control subjects showed a statistically significant age-related decline in heart rate (p = 0.001) but not the DMD boys. Cardiomyopathy developed in 17 of the 55 DMD boys over a period of 4.6 ± 1.6 years. The DMD upper and lower heart rate groups were similar in age, follow-up time, and initial shortening fraction, yet cardiomyopathy developed in 14 (42%) of 33 upper quartile boys but only 3 (14%) of 22 lower quartile DMD boys (odds ratio, 6.5 (95% confidence interval, 1.15-18.92; p < 0.05). Compared with the control subjects, the DMD boys had a higher resting heart rate and a lack of age-related heart rate decline. The DMD boys in the upper heart rate quartile were more likely to progress to cardiomyopathy than those in the lower quartiles. This study establishes heart rate elevation as a statistically significant risk factor for cardiomyopathy. Further studies may define heart rate cutoffs for early pharmacologic intervention for incipient cardiomyopathy.

Starting out-training in Finland made me crave starting out greater responsibility in the UK.

On a recent three-month educational exchange programme in Finland, I was intrigued by the differences in the opportunities offered to nursing students between Finland and the UK.

Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache.

This clinical policy from the American College of Emergency Physicians is an update of a 2002 clinical policy on the evaluation and management of adult patients presenting to the emergency department (ED) with acute, nontraumatic headache. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following 5 critical questions: (1) Does a response to therapy predict the etiology of an acute headache? (2) Which patients with headache require neuroimaging in the ED? (3) Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain computed tomography (CT) scans are interpreted as normal? (4) In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study? (5) Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.