Comparability between wearable inertial sensors and an electronic walkway for spatiotemporal and relative phase data in young children aged 6-11 years

BACKGROUND

Approaches to gait analysis are evolving rapidly and now include a wide range of options: from e-patches to video platforms to wearable inertial measurement unit systems. Newer options for gait analysis are generally more inclusive for the assessment of children, more cost effective and easier to administer. However, there is limited data on the comparability of newer systems with more established traditional approaches in young children.

RESEARCH QUESTION

To determine comparability between the Physilog®5 wearable inertial sensor and GAITRite® electronic walkway for spatiotemporal (stride length, time and velocity, cadence) and relative phase (double support time, stance, swing, loading, foot flat and push off) data in young children.

METHODS

A total 34 typically developing participants (41% female) aged 6-11 years old median age 8.99 years old (interquartile range 2.83) were assessed walking at self-selected speed over the GAITRite® electronic walkway while concurrently wearing shoe-attached Physilog®5 IMU sensors. Level of agreement was analysed by Lin's concordance correlation coefficient (CCC), Bland-Altman plots and 95% limit of agreement. Systematic bias was assessed using 95% confidence interval of the mean difference.

RESULTS

Excellent to almost perfect agreement was observed between systems for spatiotemporal metrics: cadence (CCC=0.996), stride length (CCC=0.993), stride time (CCC=0.996), stride velocity (CCC=0.988). The relative phase metrics adjusted for stride velocity showed improved comparability when compared to the unadjusted metrics: swing adjusted (adj) (CCC=0.635); stance adj (CCC: 0.879); loading adj: (CCC=0.626).

SIGNIFICANCE

Spatiotemporal metrics are highly compatible across GAITRite® electronic walkway and Physilog®5 IMU systems in young children. Relative phase metrics were somewhat compatible between systems when adjusted for stride velocity.

The Neuman Systems Model: A Framework for Aggression and Violence Prevention

Aggression and violence influence nurse-client relationships and the quality of care provided, and just as important, they also influence the nurses' physical and emotional well-being. The Neuman systems model is utilized to define and understand factors that contribute to aggressive and violent behavior and for the purposes of providing a systematic approach to the prevention and management of stressors leading to aggression and violence.

Truth for the Moment and Importance to Nursing

In the article that follows the authors present information focused on nursing care delivery involving Neuman systems theory and improving the stress and stability. The authors then follow up with a clinical scenario which utilizes the Neuman system model as a means to prevent and ameliorate aggression and violence. The structure and evidence guided by Betty Neuman's systems model centers on managing and reducing stresses and working towards reconstitution. The thoughts contained in this article highlight some considerations regarding the importance of truth and truth for the moment for the nursing discipline.

Impact of Blood Culture Contamination on Antibiotic Use, Resource Utilization, and Clinical Outcomes: A Retrospective Cohort Study in Dutch and US Hospitals

Background

Blood culture contamination (BCC) has been associated with prolonged antibiotic use (AU) and increased health care utilization; however, this has not been widely reevaluated in the era of increased attention to antibiotic stewardship. We evaluated the impact of BCC on AU, resource utilization, and length of stay in Dutch and US patients.

Methods

This retrospective observational study examined adults admitted to 2 hospitals in the Netherlands and 5 hospitals in the United States undergoing ≥2 blood culture (BC) sets. Exclusion criteria included neutropenia, no hospital admission, or death within 48 hours of hospitalization. The impact of BCC on clinical outcomes-overall inpatient days of antibiotic therapy, test utilization, length of stay, and mortality-was determined via a multivariable regression model.

Results

An overall 22 927 patient admissions were evaluated: 650 (4.1%) and 339 (4.8%) with BCC and 11 437 (71.8%) and 4648 (66.3%) with negative BC results from the Netherlands and the United States, respectively. Dutch and US patients with BCC had a mean ± SE 1.74 ± 0.27 (P < .001) and 1.58 ± 0.45 (P < .001) more days of antibiotic therapy than patients with negative BC results. They also had 0.6 ± 0.1 (P < .001) more BCs drawn. Dutch but not US patients with BCC had longer hospital stays (3.36 days; P < .001). There was no difference in mortality between groups in either cohort. AU remained higher in US but not Dutch patients with BCC in a subanalysis limited to BC obtained within the first 24 hours of admission.

Conclusions

BCC remains associated with higher inpatient AU and health care utilization as compared with patients with negative BC results, although the impact on these outcomes differs by country.

Living the Art of Nursing

The article that follows reflects on the importance, the precision, and the guidance provided through theoretical foundations, science, and art of nursing as directed by these paradigmatic theoretical frameworks and their corresponding practice methodologies. The mainstay element common across all frameworks is the precise essentials contained within the nursing theoretical frameworks that, in turn, guide the contributions of the nursing discipline. The humanbecoming paradigm serves as the primary highlighted focus of the article.

Paradoxes and Patterns in Nursing Practice

In the article that follows the authors present information focused on nursing care delivery involving intimate partner violence and how to structure, evaluate, and improve nursing care. The authors chose the structure of Virginia Henderson's nature of nursing to evaluate nursing care and review the paradoxes and patterns lived in a journey of improving nursing care. This brings to light the importance of paradoxes and patterns of nursing care and the importance of utilizing a nursing theory-based approach.

Application of Virginia Henderson's Theory Within an Intimate Partner Violence Scenario

The practice column focuses on incorporating a nursing theoretical framework into nursing care in a clinical scenario involving intimate partner violence. Accordingly, as exemplified by utilizing Virginia Henderson's theory, there is guidance to define, focus, and evaluate nursing care in these multifaceted clinical cases.

Insights and Power of Storytelling

This practice column focuses on the insights and power of storytelling. Storytelling reflects a unique narrative that uncovers meaning in such a manner that new insights arise for the both the storyteller and beholder of a story. The importance of storytelling is illustrated with the light stories shine on meanings, value priorities, and choices. Accordingly, the honoring of storytelling within nursing's theoretical frameworks and practices transforms the individual nurse, informs the discipline, and provides service to persons, families, and communities.

Wisdom in Nursing Practice

This column on practice applications focuses on wisdom and the critical nature wisdom serves within the nursing discipline. Wisdom conveys an awareness, judgement, and a diligent engagement with important persons, ideas, and others; therefore, wisdom has implications for nursing in the areas of practice, education, leadership, and research. Even broader and more importantly, wisdom connects to nursing's theoretical conceptualizations and informs the why and value of the nursing discipline.

Virginia Henderson's Writings on the Nature of Nursing: An Exemplar of Nursing Practice

Virginia Henderson's views on the nature of nursing continues to serve patients. Henderson emphasized that with the increasing complexity and technology in healthcare, nursing has never had a more important opportunity to contribute to the placement of the patient in the best conditions to achieve health. The aim of this article is to highlight a case study that employed Henderson's principles and plan of care to assist a child with a diagnosis of hemolytic uremic syndrome (HUS) through the performance of activities centering on achieving health and recovery.

Language That Respects Dignity in Nursing Practice

Language provides an opportunity to understand, to bring meaning, and to disregard. Increased reports of incivility disrespect the basic dignity of persons whether these actions and language occur in or outside the workplace. The author of this article reviews the defining elements of civility and incivility and proposes a theoretically based humanbecoming approach.

Differing approaches to analyse on-treatment cardiovascular events comparing daprodustat with darbepoetin: results from the ASCEND-ND trial

Background

Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) represent a potential new therapeutic option to treat anaemia of chronic kidney disease (CKD).

Purpose

In the recent ASCEND-ND trial (NCT02876835)1, conducted in patients with anaemia of CKD not requiring dialysis, the HIF-PHI daprodustat was non-inferior to darbepoetin for cardiovascular (CV) events in the primary intention-to-treat analysis (HR 1.03; 95% CI 0.89, 1.19); however, a prespecified on-treatment analysis raised concerns about a higher risk of CV events associated with daprodustat compared to darbepoetin (HR 1.40; 95% CI 1.17, 1.68). Our analysis explored potential reasons to explain the differences between on-treatment and intention-to-treat analyses in ASCEND-ND.

Methods

Overall, 3872 patients were randomised to receive either oral daprodustat (daily) or darbepoetin alfa given weekly, every 2 weeks, or every 4 weeks in an open-label fashion (last dosing frequency for darbepoetin was 7% weekly, 15% every 2 weeks, and 78% every 4 weeks). Patients were followed for development of the composite CV outcome (all-cause death, first non-fatal myocardial infarction, or first non-fatal stroke). The prespecified on-treatment approach included CV events up to 28 days following the last non-zero dose date of randomised therapy (Figure 1). Post-hoc analyses used Cox regression models to assess the impact of different follow-up periods (indexed to last non-zero dose date, treatment stop (discontinuation) date, and dosing intervals) on the treatment effect estimate.

Results

Different definitions of “on-treatment” using alternative censoring approaches resulted in hazard ratios for the CV composite outcome for daprodustat vs. darbepoetin that ranged from 1.06 (95% CI 0.89, 1.27) censored at treatment stop date; 1.09 (95% CI 0.89, 1.33) censored at last non-zero dose date + dosing interval; 1.54 (95% CI 1.20, 1.97) censored at the last non-zero dose date (Figure 2). As a result of the differential dosing interval, the gap between the last non-zero dose date and CV event date was 15 [1 to 134] days in the daprodustat arm, and 35 [13 to 134] days prior in the darbepoetin arm. This resulted in identical patients (i.e., identical treatment stop dates and event dates) being more likely to count as “on-treatment” in the daprodustat arm (Figure 1). This artefactual difference was not observed in analyses that were indexed to the treatment stop date, nor in analyses that accounted for the different dosing intervals for darbepoetin.

Conclusion

In the ASCEND-ND trial, different dosing frequencies introduced longer intervals between the last non-zero dose date and date of CV outcomes in the darbepoetin arm, compared with daprodustat. This artefact led to inappropriate undercounting of CV events in the darbepoetin arm. Accounting for the differential intervals resulted in neutral effect estimates, which were consistent with those observed with intention-to-treat approaches.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): ASCEND-ND was funded by GlaxoSmithKline

Causes of death in patients with chronic kidney disease: insights from the ASCEND-D and ASCEND-ND cardiovascular outcomes trials

Background

There are limited contemporary data available regarding adjudicated causes of death in patients with chronic kidney disease (CKD). Prior studies have indicated that cardiovascular (CV) events are one of the most common causes of death among patients with CKD, with previous reports stating approximately 30% of patients died from CV causes [1]. Here, we report the adjudicated causes of death in two recently completed large-scale randomised controlled trials (RCTs) with ∼14,200 person years of follow-up: ASCEND-D [2] (median follow-up: 2.5 years; NCT02879305) and ASCEND-ND [3] (median follow-up: 1.9 years; NCT02876835). These trials investigated the safety and efficacy of daprodustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI), in correcting anaemia in patients with CKD.

Purpose

This study assessed the causes of death in patients with CKD in the ASCEND-D and ASCEND-ND trials.

Methods

ASCEND-D and ASCEND-ND were global, randomised, open-label, CV outcome trials in adult patients with CKD-related anaemia undergoing maintenance dialysis (ASCEND-D) or with pre-dialysis CKD (ASCEND-ND) who received daily oral daprodustat or conventional erythropoiesis-stimulating agents (ESAs). Cause of death was systematically and centrally adjudicated in a blinded fashion to the study treatment assignment by an independent committee.

Results

In ASCEND-D and ASCEND-ND, respectively, 2964 and 3872 patients were randomised, of which 92% and 97% completed the study. Baseline characteristics were well-balanced across treatment groups within each trial. Adjudicated causes of death for the ASCEND-D and -ND trials are shown in the Table. All-cause mortality was similar in patients treated with daprodustat as compared with those treated with conventional ESA in both the ASCEND-D and -ND trials. Overall mortality in the ASCEND-D and -ND trials was 20.0% and 15.5%, respectively, and CV causes accounted for approximately 30–40% of all deaths and infection accounted for 25–30% of all deaths in both trials.

Conclusion

Although CV events were the most common cause of death in the ASCEND-D and ASCEND-ND trials (30–40% of cases), the risk of death due to infection was also high, accounting for approximately 25–30% of all deaths across all study arms. Sudden death accounted for most CV deaths, particularly in the ASCEND-D trial. Infection as a cause of death was more frequent than previously reported in other RCTs or disease registries. Causes of death did not differ significantly between ASCEND-D and ASCEND-ND, or between treatments. However, as this is a selected population for a CV trial, it may not be representative of a real-life CKD population. Our results provide important data to inform the design of future studies in this population.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This study was funded by GlaxoSmithKline. Medical writing support was provided Natasha Tracey, PhD (Ashfield MedComms, Macclesfield, UK) and was funded by GlaxoSmithKline.

Value Priorities, Honoring the Dignity of Persons, and Living the Art of Nursing

Values and expression of values reflect an explicit-tacit coming to know, and value priorities sculpt theoretical knowledge and practice. The author in this article proposes that values, theory, and practice provide a connectedness among persons, families, and communities that promotes the dignity of persons. The promotion of dignity of persons goes beyond a framework that only focuses on the critical elements of missed or incomplete nursing care.

Human Colon Cancer-Derived Clostridioides difficile Strains Drive Colonic Tumorigenesis in Mice

Defining the complex role of the microbiome in colorectal cancer and the discovery of novel, protumorigenic microbes are areas of active investigation. In the present study, culturing and reassociation experiments revealed that toxigenic strains of Clostridioides difficile drove the tumorigenic phenotype of a subset of colorectal cancer patient-derived mucosal slurries in germ-free ApcMin/+ mice. Tumorigenesis was dependent on the C. difficile toxin TcdB and was associated with induction of Wnt signaling, reactive oxygen species, and protumorigenic mucosal immune responses marked by the infiltration of activated myeloid cells and IL17-producing lymphoid and innate lymphoid cell subsets. These findings suggest that chronic colonization with toxigenic C. difficile is a potential driver of colorectal cancer in patients.

SIGNIFICANCE

Colorectal cancer is a leading cause of cancer and cancer-related deaths worldwide, with a multifactorial etiology that likely includes procarcinogenic bacteria. Using human colon cancer specimens, culturing, and murine models, we demonstrate that chronic infection with the enteric pathogen C. difficile is a previously unrecognized contributor to colonic tumorigenesis. See related commentary by Jain and Dudeja, p. 1838. This article is highlighted in the In This Issue feature, p. 1825.

Roy Adaptation Model: Theory-Based Knowledge and Nursing Care With a Person Experiencing COVID-19

Nursing theories shed light and guide nursing care through provision of care to persons based on the specialized knowledge base of the profession. Nurses utilizing Roy's adaptation model deliver holistic care by accounting for people, processes, and the environments. The aim of this article is to illustrate the value of utilizing the Roy adaptation model in the care of a patients by reviewing nursing care provided to a patient diagnosed with COVID-19.

Power with Presence: Connecting Theory and Knowledge to Nursing Practice

Theory and knowledge connect and constitute disciplinary-centered practice. Nursing theories and knowledge thus propel nursing practice through leading-following processes cocreated with and directed toward the betterment of persons, families, and communities amid changing social and healthcare contexts. In the article that follows, the Roy adaptation model provides a guiding light and structure to focus on emerging healthcare requisites expressed by persons and communities.

Valuing Originality in Nursing Practice

Originality brings forth the idea of envisioning something novel and requires enculturating disciplinary knowledge. Originality ideally initiates within nurse education and extends throughout all areas in which nurses practice, the goal of which is to advance future directions of disciplinary knowledge and practice.

Validation of shoe-worn Gait Up Physilog®5 wearable inertial sensors in adolescents

BACKGROUND

Gait Up Physilog® wearable inertial sensors are a powerful alternative to traditional laboratory-based gait assessment for children with gait impairment. To build clinician trust in these devices and ultimately facilitate their use outside confined spaces, studies have examined performance of previous versions of Physilog® wearable inertial sensors but predominant focus has been on older adults. Despite their different gait patterns and behavioural/cognitive profiles, there are limited studies in children.

RESEARCH QUESTION

To determine whether key spatiotemporal gait parameters (stride length, time and velocity) collected by shoe-worn Physilog®5 sensors in a hallway assessment protocol are a valid method of gait assessment in typically developing adolescents aged 12-15 years.

METHODS

A total 30 typically developing participants (50 % female) median age 13.7 (interquartile range 2.34) were assessed in an exploratory study whilst walking at self-selected speed over the GAITRite® electronic walkway, concurrently wearing Physilog®5 sensors. Concurrent validity was analysed by Lin's concordance correlation coefficient (CCC), Bland-Altman plots and 95 % limit of agreement. Systematic bias was assessed using 95 % confidence interval of the mean difference.

RESULTS

Mean stride data demonstrated substantial agreement for stride length (CCC = 0.975) and stride velocity (CCC = 0.979) to almost perfect agreement for stride time (CCC > 0.996). Agreement between the technologies for individual stride-to-stride data remained high for stride time (CCC = 0.952); yet reduced for stride length (CCC = 0.868) and stride velocity (CCC = 0.877). Male/female differences in performance of the technology were observed for stride velocity, favouring females.

SIGNIFICANCE

Physilog®5 inertial sensors accurately measure walking in adolescents, with stride time the most accurately detected parameter. This demonstrates that wearables can be used by researchers and clinicians working with adolescent groups as an alternative to fixed systems. These findings will ultimately pave the way to using wearables for assessments with children outside of the laboratory environment.

Metaphorically Speaking: Living the Art of Nursing and Meaningful Insights

The importance of honoring and attending to human expressions, including metaphor, is more than an exercise in rhetorical flourish. Attending to metaphorical expressions is an inherent whole-in-motion connection of living the art of humanbecoming with the attention to honoring personal values and choices. The humanbecoming paradigm offers a person-centered approach and thus advances the trust of persons within the various communities receiving healthcare.

Organizational structures and processes in nurse-led, evidence-based practice projects that lead to measurable outcomes: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to describe health care organizational structures and processes that support implementation of nurse-led, evidence-based practice projects resulting in improvements in outcome measures.

INTRODUCTION

Many health care organizations claim to support evidence-based practice methodology; however, a gap exists between knowledge generation and its use in routine clinical practice. This scoping review protocol will examine the status of organizational factors impacting implementation of evidence-based practices and reported outcomes.

INCLUSION CRITERIA

This scoping review will consider all literature that includes descriptions of health care organizations' structures or support of evidence-based nursing programs or efforts that include outcomes. Health care organizations are defined as primary/secondary/tertiary, public/private, for profit/non-profit hospitals, medical centers, or multi-hospital systems. Literature will be excluded if the evidence-based practice project does not report the organizational structures that supported the implementation for the project. In addition, literature will be excluded if the program is not inclusive of nursing.

METHODS

Literature published in English from 1992 to present will be included. The databases to be searched include MEDLINE, CINAHL, Cochrane, and Embase. The search for unpublished evidence and gray literature will include ProQuest Dissertations & Theses Global, ANCC Magnet conferences, and government publications. Retrieval of full-text studies and data extraction will be performed independently by two reviewers. The extracted data will be presented in a tabular format with accompanying narrative summary.

Peplau's Theory of Interpersonal Relations: A Case Study

Theoretical frameworks offer guiding principles to guide nursing practice on well-defined nursing knowledge. Peplau's theory of interpersonal relationship empowers nurses in their work for regaining health and well-being for people. Understanding the theory and the connectedness that arises from this theory provides a structure for nurse-patient relations, even working through a language barrier as evidenced by the case scenario detailed in this article.

Advancing Nursing Practice Through Mentoring and Teaching-Learning

In the article that follows this introduction, there are insights into the importance of a theoretical framework for nursing practice. The authors detail the impact to nursing practice a theoretical framework provides by using a case study approach. The introductory thoughts in this article focus on inspiring mentoring models and teaching learning models within theoretically based nursing science and practice.

Cybernetic Communications: Focusing Interactions on Goal-Centered Care

In nursing homes, due to time constraints, lack of communication can influence the quality of information exchanged, which influences the outcomes of healthcare for residents. Nurses' proximity to the nursing home resident, their knowledge, and skill serve as an opportunity to communicate and facilitate patient-centered goals and improve treatment decision-making. Concepts within the cybernetic communication literature entail systemic interactive relationships that enable the sharing of knowledge and expertise. These interactions are based on nursing's theoretical knowledge, clinical judgment, and empowerment and are based on patient-centered goals.

Attentive Presence: Considerations for Focusing on Another

The article that follows provides insight when applying the literature on cybernetic communications and integrating goal-centered nursing care. This introductory piece provides an element of forethought by considering the phenomenon of attentive presence. The critical point emphasized in both commentaries is the significance of working together with the ebb and flow of connections and collaborations within the healthcare context.

Robotics: Considerations for Practice

The term robotics traditionally refers to the utilization of machines to perform a mechanized task or series of tasks automatically. The author in this article traces some ethical precepts from the literature and proposes that future developments include nursing theory. This would provide the opportunity for bringing forth person-centered utilization of technologies within any healthcare context.

Reliability and validity of the FSHD-composite outcome measure in childhood facioscapulohumeral dystrophy

This study aims to investigate intra-rater reliability and construct validity of the Facioscapulohumeral Dystrophy Composite Outcome Measure (FSHD-COM), in childhood FSHD. Participants included eighteen children with FSHD, and matched healthy controls. Reliability data were collected from 15 participants with FSHD over two testing sessions. Validity data were collected from all participants. Participants with FSHD completed; the FSHD-COM (and modified pediatric version), Motor Function Measure-32 (MFM-32), FSHD Severity Scales, Performance of the Upper Limb 2.0, Pediatric Quality of Life™ Neuromuscular Module and pediatric FSHD Health-Index Questionnaire. Both versions of the FSHD-COM showed excellent intra-rater reliability (ICC_1,2 > 0.99, lower 95%CI > 0.98) with a Minimal Detectable Change (MDC95%) of ≤14.5%. The FSHD-COM had robust and widespread correlations with other related outcome measures. The FSHD-COM versions and 6 min walk test effectively discriminated between children with and without FSHD; the MFM-32 and 10 m walk/run test did not. Ceiling effects were not observed on either version of the FSHD-COM. Reliability and validity findings in this childhood FSHD study concord with estimates in adults. Both versions of the FSHD-COM were effective in discriminating disease in children with mild FSHD symptoms. The FSHD-COM has the potential to be a useful measure of function across the life span.

Shaming: Considerations for Practice

Feeling ashamed frequently arises with the experience of being shamed by others. In the initial thoughts put forth in this article and the article that follows, considerations to the feelings of shame arising with the shaming are explored within the context of persons who have experienced sexual violence. This provides insights for nursing practice based on a nursing theoretical perspective.

Sexual Violence: A Review and Case Study Utilizing Watson's Caring Science

The care provided to persons who experience sexual violence is complex and needs to be individualized and account for the person's expressed needs. Nurses have the potential to facilitate the recovery from such traumatic events. Utilizing Watson's theory of human caring science, nursing care practices provide an influence through their utilization of artistry with caring-healing processes and attending to the healing environment for people. The authors in this article present a case study enlightening the applicability, implementation, and outcomes of caring for patients with this experience sensitively and holistically.

Nursing Perspectives and Knowledge With an Acuity Adaptable Model

An acuity adaptable pediatric cardiac care model provides healthcare centered on the practice of having the child remain in the same unit and receive care from the same clinical team from admission to discharge. This means the child is managed as they progress from an acute, intermediate, intensive care, and sometimes even long-term status within the same room. This article highlights the relationship-based care nursing model, a patient-centered care model, and the importance of nursing disciplinary knowledge from the Roy adaptation model and its impact on the healthcare this population receives within a unique environment.

Targeted rapid testing for SARS-CoV-2 in the emergency department is associated with large reductions in uninfected patient exposure time

Opportunity exists to decrease healthcare-related exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), preserve infection control resources, and increase care capacity by reducing the time to diagnosis of coronavirus disease 2019 (COVID-19). A retrospective cohort analysis was undertaken to measure the effect of targeted rapid molecular testing for SARS-CoV-2 on these outcomes. In comparison with standard platform testing, rapid testing was associated with a 65.6% reduction (12.6 h) in the median time to removal from the isolation cohort for patients with negative diagnostic results. This translated to an increase in COVID-19 treatment capacity of 3028 bed-hours and 7500 fewer patient interactions that required the use of personal protective equipment per week.

Language, Simulation, and Human Connectedness: Thoughts During the 2020 Pandemic

Language provides cadences of sounds, silences, and movements that bring to light meaning, which in turn transforms human connections, understanding, and knowledge. When coupled with disciplinary knowledge and opportunities to illuminate with simulation, there are opportunities to influence human connectedness, which is meaningful even in times of a pandemic.

Insights of Silence

Silence represents more than the absence of noise; it is a penetrating stillness that often provides for attentiveness. The author of this article provides some thoughts and implications for the art of humanbecoming on what can be gleaned in understanding and clarifying the discriminating quiet or tumultuous hush of silence as a human experience.

Bringing Nursing Care to Patients Living With Diabetes Mellitus

The author in this article focuses on exploring a brief historical background of the diagnosis labeled diabetes mellitus and honoring persons who seek nursing care through incorporating Orem's self-care deficit theory. The author highlights utilizing a nursing theoretical framework as an important takeaway to enhance congruence among theory, research, practice, and education. This propels the discipline's meaning and interdisciplinary contributions to persons living with this diagnosis.

Nursing Role for Medication Stewardship Within Long-Term Care Facilities

Elderly residents in long-term care facilities (LTCFs) constitute a population noted to have a large number of medications prescribed and administered. The aim of this article is to explore the nursing role for medication management, with an emphasis on antimicrobial stewardship, guided by disciplinary knowledge of King's theory of goal attainment and skill-based medication knowledge. The outcome is a nursing workforce truly engaged in working with interdisciplinary colleagues and focusing on care planning that includes medication management to improve the health status of residents in long-term care facilities.

Hypoglycemic risk exposures in relation to low serum glucose values in ambulatory patients

This study aimed to correlate hypoglycemic risk exposures (HREs) with low blood glucose value (BGV) in ambulatory patients to inform selection of a glucose critical action value (CAV).This was a retrospective study of ambulatory patients with at least 1 serum glucose ≤70 mg/dL obtained at 2 laboratories within the Johns Hopkins Health System over 3.8 years. Multivariable logistic regression was used to evaluate association of BGV cut-offs of <60, <54, <50, and <45 mg/dL with HREs. HREs were classified as "high hypoglycemic risk" (HHR), "moderate hypoglycemic risk" (MHR), "low hypoglycemic risk" (LHR), and "no hypoglycemic risk" (NHR).A total of 5404 patient samples of BG ≤70 mg/dL were analyzed, of which 30.3%, 23.2%, 28.5%, 18.0% occurred in NHR, LHR, MHR, and HHR groups, respectively. An inverse relationship was noted between BGV cut-offs and HHR, but no association was observed for LHR or MHR. After adjusting for age, sex, and race, there was an inverse association between BG thresholds and the odds of HHR. For classification of HHR, BGV cut-offs of <60, <54, <50, and <45 mg/dL correctly classified 71.2%, 69.8%, 68.8%, and 67.2% of BG samples, achieved false-positive rates of 13.6%, 4.7%, 1.7%, and 0.5% and positive likelihood ratios of 3.3, 6.0, 11.2, and 23.4, respectively.Nearly 70% of low BGVs occurred in patients with at least 1 HRE, but only ∼20% occurred in HHR patients. Given their high positive likelihood ratios, BGVs <54 or <50 mg/dL are reasonable candidates for CAVs that would allow sufficient clinician response time while minimizing false-positive alerts.

Living the Art and Science of Nursing: Flow and Transitioning

Nurses, based on their unique disciplinary knowledge and role, serve as key members of interdisciplinary teams to guide assessments and interventions addressing patient’s goals in flow and transitions of care. This introductory column represents selected thoughts on bridging theory and practice with patient flow and transitions.

Evaluation of an in vivo model for ventricular shunt infection: a pilot study using a novel antimicrobial-loaded polymer

OBJECTIVE

Ventricular shunt infection remains an issue leading to high patient morbidity and cost, warranting further investigation. The authors sought to create an animal model of shunt infection that could be used to evaluate possible catheter modifications and innovations.

METHODS

Three dogs underwent bilateral ventricular catheter implantation and inoculation with methicillin-sensitive Staphylococcus aureus (S. aureus). In 2 experimental animals, the catheters were modified with a polymer containing chemical "pockets" loaded with vancomycin. In 1 control animal, the catheters were polymer coated but without antibiotics. Animals were monitored for 9 to 11 days, after which the shunts were explanted. MRI was performed after shunt implantation and prior to catheter harvest. The catheters were sonicated prior to microbiological culture and also evaluated by electron microscopy. The animals' brains were evaluated for histopathology.

RESULTS

All animals underwent successful catheter implantation. The animals developed superficial wound infections, but no neurological deficits. Imaging demonstrated ventriculitis and cerebral edema. Harvested catheters from the control animal demonstrated > 104 colony-forming units (CFUs) of S. aureus. In the first experimental animal, one shunt demonstrated > 104 CFUs of S. aureus, but the other demonstrated no growth. In the second experimental animal, one catheter demonstrated no growth, and the other grew trace S. aureus. Brain histopathology revealed acute inflammation and ventriculitis in all animals, which was more severe in the control.

CONCLUSIONS

The authors evaluated an animal model of ventricular shunting and reliably induced features of shunt infection that could be microbiologically quantified. With this model, investigation of pathophysiological and imaging correlates of infection and potentially beneficial shunt catheter modifications is possible.

Highlighting Collaboration in Living the Art of Nursing

Collaboration is a frequently cited concept and also cited as a call-to-action item required among team members to improve the status of healthcare for persons and communities. With a humanbecoming paradigmatic lens, freedom is established to elevate the idea that community provides an essential component upon which collaboration can be built. Community is conceptualized as oneness of humanuniverse and is highlighted as an artful aspect of providing care to persons by keeping in the forefront the three humanbecoming change concepts of moving-initiating, anchoring-shifting, and pondering-shaping.

Transforming the Art of Nursing: Telehealth Technologies

Telehealth utilizes technology that connects nurses and persons receiving healthcare services. Rather than focusing on telehealth as a financial burden or a disruptive technology, telehealth nursing should be considered an opportunity to operationalize and transform the art of care, especially when it is guided by nursing theory.

Marijuana use and its influence on sperm morphology and motility: identified risk for fertility among Jamaican men

BACKGROUND

The growing international movement legislating medical marijuana has brought renewed interest to the role of marijuana smoking on fertility potential. Although studies have identified that sperm quality can be compromised by marijuana use, little focus has been placed specifically on those trying to conceive. In this study, we aimed to clarify the impact of marijuana use in semen quality in men being investigated for assisted reproduction.

MATERIALS AND METHODS

We conducted a cross-sectional study at a university-based facility in Jamaica. Routine semen analyses were performed on 229 men ages 23-72 years who were new clients. Logistic regression analyses were performed in order to independently predict quantifiable measures of the impact of marijuana use. The main outcome measures were sperm motility, total motile spermatozoa and morphology.

RESULTS

Overall, 47% of the participants reported marijuana use with 21% of these men reporting recent use. Regression analyses showed that recent use and users of large quantities of marijuana were 2.6 times (aOR = 2.6; 95% CI, 1.0-6.8, p = 0.044) and 4.3 times (aOR = 4.3; 95% CI, 1.1-15.9, p = 0.030) at greater risk of being diagnosed with abnormal motility (asthenozoospermia). Additionally, moderate quantity users were 3.4 times (aOR = 3.4; 95% CI, 1.5-7.9, p = 0.004) more likely to be diagnosed with abnormal morphology (teratozoospermia).

DISCUSSION AND CONCLUSION

Recent use of marijuana as well as moderate to large quantities had an impact on sperm motility and morphology in men being investigated for infertility. We recommend therefore that men undergoing fertility investigations be routinely asked about their recreational use of marijuana and in particular recent and heavy users counselled to stop.

Examining Medication Stewardship: A Nursing Perspective

Stewardship equates to the care and management of resources. The outcome of focusing on goal-centered care planning from a nursing theoretical basis includes medication management and goes beyond tasks and guidelines.

Bringing Joy-Sorrow to Light: Informing Practice Utilizing Theoretical and Research Perspectives

This article focuses on the substance of centering on a nursing disciplinary theoretical approach accomplished through a brief review of the phenomena of joy-sorrow from a research and practice perspective. When practice is designed from a theoretical conceptual system, it takes form and provides tangible benefits through the creative conceptualizations and connectedness that arise to influence persons who seek healthcare. Although the article espouses a humanbecoming framework, the take-away is that a nursing disciplinary approach promotes congruence among theory, research, practice, and education, thereby advancing the discipline's meaning and contributions.