Prospective Physician Assistant Student Perspectives on an In-Person vs. Virtual Admissions Interview Process.

PURPOSE: The pandemic strained many usual methods of communication and training, forcing changes to selection processes for health professions programs. The purpose of this study was to determine, through interviewee feedback, the effectiveness of a virtual interview process when compared with a previous in-person interview process at one physician assistant (PA) program. METHODS: During the pandemic, the PA program adapted to a virtual holistic interview process to include interaction with current students and faculty. The effectiveness of the virtual platform was measured comparatively using the program's existing interviewee evaluation format for previous in-person experiences. RESULTS: Prepandemic data showed high ratings from interviewees regarding the interview process. Intrapandemic data suggest an interview process can be duplicated in a virtual format without compromising experience and goals of the program. CONCLUSIONS: Through virtual interviews during a pandemic, the PA program mirrored the effectiveness of their previous in-person experience.

The Impact of COVID-19 on Transportation of Adults With Visual Impairments.

Introduction: Access to efficient and affordable transportation options has long been a challenge for many individuals with vision loss. In spring 2020, the COVID-19 pandemic caused a quick shift in the availability and safety of transportation. Methods: Using the constant comparison method, open-ended responses from 1,162 participants in the Flatten Inaccessibility study were coded. Responses were from participants who had concerns about transportation. Results: Ten themes and corresponding subthemes emerged from the data. Themes were interdependent in that the extent of concerns differed based on respondents' support networks, transportation availability, and financial circumstances. Discussion: The COVID-19 pandemic brought to the forefront both systemic and COVID-19 transportation challenges about which those with visual impairments experienced or had concerns or both. Implications for Practitioners: It is imperative that professionals support those with visual impairments to develop alternative plans for when their typical transportation options are disrupted.

The effects of mood and retrieval cues on semantic memory and metacognition.

We investigated whether the previously established effect of mood on episodic memory generalizes to semantic memory and whether mood affects metacognitive judgments associated with the retrieval of semantic information. Sixty-eight participants were induced into a happy or sad mood by viewing and describing IAPS images. Following mood induction, participants saw a total of 200 general knowledge trivia items (50 open-ended and 50 multiple-choice after each of two mood inductions) and were asked to provide a metacognitive judgment about their knowledge for each item before providing a response. A sample trivia item is: Author - - To kill a mockingbird. Results indicate that mood affects the retrieval of semantic information, but only when the participant believes they possess the requested semantic information; furthermore, this effect depends upon the presence of retrieval cues. In addition, we found that mood does not affect the likelihood of different metacognitive judgments associated with the retrieval of semantic information, but that, in some cases, having retrieval cues increases accuracy of these metacognitive judgments. Our results suggest that semantic retrieval processes are minimally susceptible to the influence of affective state but does not preclude the possibility that affective state may influence encoding of semantic information.

Transforming RN Roles in Community-Based Integrated Primary Care (TRIP): Background and Content.

Given the large body of evidence linking physical and mental health and the impetus provided by health care reform and the Affordable Care Act, the time is ripe to engage nurses in community based, integrated primary care teams to holistically address psychiatric, mental health and substance abuse needs. There is a compelling need for curricular redesign and clinical innovation to prepare an RN workforce for practice in community based integrated primary care teams. To that end, a faculty team of primary care, interprofessional education and content experts developed the Transforming RN Roles in Community Based Integrated Primary Care (TRIP) program for BSN students in a large university in the southeastern United States. The primary goals of the TRIP program are to build/implement an innovative BSN curriculum and expand our academic practice partnership by enhancing student clinical experiences with the goal of preparing an RN workforce for practice in community based integrated care teams. The TRIP program incorporates didactic, simulation and clinical components. Our first student cohort began the TRIP program in the fall of 2018 and will complete the program in spring 2020. In this paper, we provide details about the background, content and activities of this 4-semester (2 year) program.

Clinical Consequences of Cardiomyopathy in Children With Biliary Atresia Requiring Liver Transplantation.

Cirrhotic cardiomyopathy (CCM), a comorbidity of end-stage cirrhotic liver disease, remains uncharacterized in children, largely because of a lack of an established pediatric definition. The aim of this retrospective cohort analysis is to derive objective two-dimensional echocardiographic (2DE) criteria to define CCM associated with biliary atresia (BA), or BA-CCM, and correlate presence of BA-CCM with liver transplant (LT) outcomes in this population. Using receiver operating characteristic (ROC) curve analysis, optimal cut-off values for left ventricular (LV) geometrical parameters that were highly sensitive and specific for the primary outcomes: A composite of serious adverse events (CSAE) and peritransplant death were determined. These results were used to propose a working definition for BA-CCM: (1) LV mass index (LVMI) ≥95 g/m2.7 or (2) relative wall thickness of LV ≥0.42. Applying these criteria, BA-CCM was found in 34 of 69 (49%) patients with BA listed for LT and was associated with increased multiorgan dysfunction, mechanical and vasopressor support, and longer intensive care unit (ICU) and hospital stays. BA-CCM was present in all 4 waitlist deaths, 7 posttransplant deaths, and 20 patients with a CSAE (P < 0.01). On multivariable regression analysis, BA-CCM remained independently associated with both death and a CSAE (P < 0.01). Utilizing ROC analysis, LVMI was found to be a stronger predictor for adverse outcomes compared with current well-established markers, including Pediatric End-Stage Liver Disease (PELD) score. Conclusion: BA-CCM is highly sensitive and specific for morbidity and mortality in children with BA listed for LT. 2DE screening for BA-CCM may provide pertinent clinical information for prioritization and optimal peritransplant management of these children.

Hepatobiliary Dysfunction and Disseminated Intravascular Coagulation Increase Risk of Mortality in Pediatric Hemophagocytic Lymphohistiocytosis.

OBJECTIVES: Hemophagocytic lymphohistiocytosis poses significant challenges due to limited tools to guide clinical decisions in a population at high risk of death. We sought to assess whether disseminated intravascular coagulation and hepatobiliary dysfunction, significant comorbidities seen in critical care settings, would identify hemophagocytic lymphohistiocytosis patients with increased risk of mortality. DESIGN: Retrospective chart review. SETTING: Single-center PICU. PATIENTS: All patients admitted to a tertiary care children's hospital diagnosed with hemophagocytic lymphohistiocytosis from 2005 to 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-three patients were diagnosed with hemophagocytic lymphohistiocytosis with median age of 61 months. The 5-year overall survival was 51% (22/43). Univariate analyses revealed ferritin levels greater than 10,000 (ng/mL), international normalized ratio greater than 1.5, or platelet counts less than 100,000/µL at initiation of dexamethasone were individually associated with mortality. Development of disseminated intravascular coagulation, hepatobiliary dysfunction, or both increased the likelihood of death in hemophagocytic lymphohistiocytosis patients (relative risk; 95% CI) (6; 1.4-34; p < 0.05), (4.1; 1.8-10; p < 0.05), and (7.5; 1.8-42; p < 0.05). Of 12 autopsies performed, 75% had at least one active infection, 66% had chronic lymphopenia, 50% had lymphocyte depletion in the spleen, thymus, or bone marrow, 42% had evidence of microvascular thrombosis, and 92% had evidence of hepatocellular injury. CONCLUSIONS: Hemophagocytic lymphohistiocytosis continues to have high mortality with hemophagocytic lymphohistiocytosis-1994/2004 (dexamethasone/etoposide), the current standard of care for all children with hemophagocytic lymphohistiocytosis. Hemophagocytic lymphohistiocytosis patients who developed disseminated intravascular coagulation, hepatobiliary dysfunction, or both had higher risk of death with mortalities of 60%, 77%, and 77%, respectively. Phenotypic classifications are urgently needed to guide individualized treatment strategies to improve outcomes for children with hemophagocytic lymphohistiocytosis.

Empiric weight-based vancomycin in intensive care unit patients with methicillin-resistant Staphylococcus aureus bacteremia.

BACKGROUND: Previous studies were conducted in all hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia to determine safety and effectiveness of guideline-recommended, weight-based dosing of vancomycin. In these studies, it was observed that severely ill patients (Pitt bacteremia score ≥4 or intensive care unit [ICU] patients) were at an increased risk of mortality and/or nephrotoxicity. Therefore, a subanalysis of the effect of guideline-recommended vancomycin dosing on in-hospital mortality and nephrotoxicity in ICU patients with MRSA bacteremia was conducted. METHODS: This multicenter, retrospective, cohort study was conducted in a subset of ICU patients from a previous MRSA bacteremia study. Patients were ≥18 years old and received ≥48 hours of empiric vancomycin from July 1, 2002, to June 30, 2008. The incidence of nephrotoxicity and in-hospital mortality was compared in patients who received guideline-recommended dosing (at least 15 mg/kg per dose) to patients who received non-guideline-recommended dosing of vancomycin. Multivariable generalized linear mixed-effects models were constructed to determine independent risk factors for in-hospital mortality and nephrotoxicity. RESULTS: Guideline-recommended dosing was received by 34% of patients (n = 137). Nephrotoxicity occurred in 35% of patients receiving guideline-recommended dosing and 39% receiving non-guideline-recommended dosing (P = 0.67). In-hospital mortality rate was 24% among patients who received guideline-recommended dosing compared with 31% for non-guideline-recommended dosing (P = 0.40). Guideline-recommended dosing was not associated with nephrotoxicity (odds ratio: 1.10; 95% confidence interval: 0.43-2.79) or in-hospital mortality (odds ratio: 0.54; 95% confidence interval: 0.22-1.36) in the multivariable analysis. CONCLUSIONS: Guideline-recommended dosing of vancomycin in ICU patients with MRSA bacteremia is not significantly associated with nephrotoxicity or in-hospital mortality. However, the 7% absolute difference for in-hospital mortality suggests that larger studies are needed.

Common questions about Clostridium difficile infection.

Clostridium difficile infection is a common cause of antibiotic-associated diarrhea. It causes no symptoms in more than one-half of infected patients, but can also cause a wide spectrum of illnesses and death. The incidence and severity have increased in recent years. The most important modifiable risk factor for C. difficile infection is antibiotic exposure; this risk is dose-related and higher with longer courses and combination therapy. C. difficile infection is also associated with older age, recent hospitalization, multiple comorbidities, use of gastric acid blockers, inflammatory bowel disease, and immunosuppression. It has become more common in younger, healthier patients in community settings. The most practical testing options are rapid testing with nucleic acid amplification or enzyme immunoassays to detect toxin, or a two-step strategy. Treatment includes discontinuing the contributing antibiotic, if possible. Mild C. difficile infection should be treated with oral metronidazole; severe infection should be treated with oral vancomycin. Fidaxomicin may be an effective alternative. Recurrences of the infection should be treated based on severity. Tapering and the pulsed-dose method of oral vancomycin therapy for second recurrences are effective. Prevention includes responsible antibiotic prescribing and vigilant handwashing. Probiotics prevent antibiotic-associated diarrhea, but are not recommended specifically for preventing C. difficile infection.

Reliability and validity of the postepidural fall risk assessment score.

The purpose of this study was to establish the interrater reliability and face validity of the postepidural fall risk assessment score instrument for the obstetric patient. The sample consisted of 207 healthy mothers at an inner-city level 1 trauma center. Kappa coefficients ranged from 0.54 to 0.83. Face validity of the tool was determined by participating nurses (n = 25). Results indicated that the tool was reliable and required modification to increase face validity.

Nitric oxide synthase gene transfer restores activity of circulating angiogenic cells from patients with coronary artery disease.

Circulating angiogenic cells (CACs), represent a potential new therapeutic tool for the treatment of cardiovascular diseases, but their regenerative function is impaired in patients with coronary artery disease (CAD) and cardiac risk factors. The objective of this study is to assess the effect of lentiviral overexpression of endothelial nitric oxide synthase (eNOS) on the activity of CACs from patients with CAD and cardiac risk factors. In vitro and in vivo assays were employed to evaluate the regenerative capacity of the cells compared to CACs derived from healthy volunteers. Lentiviral eNOS transduction of cells from CAD patients significantly improved chemotactic migration compared with sham transduction, and increased the ability of CACs to induce angiogenic tube formation when cocultured with human umbilical vein endothelial cells (HUVECs) on Matrigel. In addition, eNOS transduction restored the ability of patient-derived CACs to enhance neovascularization and improve ischemic hind limb perfusion, approaching the efficacy of cells from healthy donors. These data indicate that CAC dysfunction seen in high-risk patients can be partially reversed by eNOS overexpression, suggesting that ex vivo gene delivery may improve the efficacy of autologous cell therapy for cardiovascular disease.

Antibody to ovalbumin and delayed-type hypersensitivity to Candida albicans and mycobacteria in lactating Holstein cows using Quil A or Freund's complete adjuvant.

Antibody-mediated immune response (AMIR) to ovalbumin (OVA) or hen-egg white lysozyme (HEWL) and cell-mediated immune response (CMIR) such as delayed-type hypersensitivity (DTH) to mycobacteria have been proposed as quantitative traits for selective breeding to improve animal health. However, DTH to mycobacteria may confound diagnosis of tuberculosis in cattle. Candida albicans, a yeast also known to induce DTH, was tested as an alternative for DTH induction and testing since it is not a target of regulatory diagnostic tests. Other objectives were to determine if both AMIR and CMIR in cattle receiving Quil A as adjuvant were equivalent to corresponding responses induced by Freund's complete adjuvant (FCA). Forty lactating Holstein cows were randomly assigned to two treatment groups, which received ovalbumin (OVA) and C. albicans adjuvanted with FCA and Freund's incomplete adjuvant (FIA) on days 0 and 14, respectively, or Quil A on days 0 and 14. The FCA was used as adjuvant and as a source of Mycobacterium tuberculosis-induced DTH. Testing for DTH was performed on day 21 with killed C. albicans whole cell (CaWC), a purified extract from C. albicans (candin) and M. phlei purified protein (phlein). Both primary and secondary antibody responses to OVA were statistically significant and similar in both FCA and Quil A treatment groups. No significant differences were detected in immunoglobulin G (IgG) isotypic-mediated responses to OVA or candin between groups. C. albicans adjuvanted with Quil A induced DTH reaction similar to those induced by C. albicans and mycobacteria in FCA.

Stigma and public health policy for schizophrenia.

Few families seem to be preparing adequately for the future with respect to financial planning or caregiving responsibilities. The consequences of schizophrenia on siblings and sibling relationships can be significant. Exploring how the chaos and confusion that typically accompanies the onset of the illness may have adversely affected family members and family relationships can offer an opportunity to build proactive partnerships toward future planning for continuity of care for the mentally ill. The Schizophrenia Society of Saskatchewan facilitates family involvement in fostering a sibling support strategy focused on the specific issues faced by siblings of people with schizophrenia. Support groups and the provision of concrete family financial and caregiving planning are tangible ways siblings can prepare better for the future. Strengthening lobbying capacities is also important to advocate partnerships between integrative community-based, client-centered services and family members of the severely mentally ill.