From Competency to Capability

Abstract Nursing students may experience difficulty tmnsitioning from being competent in the campus lab environment to being capable in a clinical environment when the campus lab experience does not offer realistic challenges. Students have the knowledge of how to safely perform the skills but cannot demonstrate the skills, utilizing clinical reasoning, in the unstable and unpredictable hospital environment. Traditional campus lab instruction for medication administration includes small group practice that is task oriented in a stable and predictable environment. Progressive simulation challenges the student with utilization of multiple levels of simulation incorporating clinical reasoning .. The goal of this project was enabling the Associate Degree Nursing student to develop capability of medication administration in the unstable and unpredictable environment of the clinical setting This capstone project evaluated the cuniculum change of introducing progressive simulation involving an unstable and unpredictable environment in the campus lab. The students practiced administering parenteral medications with planned instructional methodology based on replicating a portion of a study done by Brydges, Carnahan, Rose, and Dubrowski (2010). According to Brydges et aI. (2010), progressive simulation is described as an environment where the student makes the decision of when to progress from one simulation station level to the next. The progressive simulation for this project was in the format of three stations with each station increasing in complexity that requires clinical reasoning during the medication administration process, utilizing mUltiple levels of simulation. A total of21 students completed the progressive simulation process. Self-efficacy surveys completed by participants prior to and follqwing the intervention revealed a statistically significant differenc:e with an increase in self-scoring (p= .00 I). In the clinical setting, 95.3% of the participants scored a passing score, successfully demonstrating capability in medication administration and clinical reasoning but the statistical analysis was not significant (p=O.5]). Faculty surveys did not reveal a statistically significant increase in satisfttction with the curriculum change (p=.060), but the evaluations included positive comments supporting maintaining the curriculum change

Ecology and physiology of the aphid pathogenic fungus Erynia neoaphidis

A thesis submitted to the Faculty of Health and Social Science, University of Luton, in partial fulfillment of the requirements for the degree of Doctor of Philosophy.Erynia neoaphidis Remaudiere and Hennebert (Zygomycetes: Entomophthorales) is an obligate pathogen of invertebrates, especially aphids, and has therefore been studied as a possible biological control agent for a number of years. However, a number of important physiological and ecological questions regarding optimal conditions for conidial production and transmission 0 f the fungus through an aphid population had to be answered. This thesis investigated some of these aspects. Solid and liquid media were used to culture the fungus, and E. neoaphidis was cultured on a fully defined medium for the first time. A sporulation monitor and digital image analysis was used to quantify conidial production from E. neoaphidis biomass produced in vivo and in vitro. This was a completely novel method and is useful for gathering data on large numbers of conidia, 50 that size distributions can be constructed and the physiological status of the conidia inferred from this. E. neoaphidis infected aphid cadavers produced more, smaller conidia when grown in vitro. Biomass harvested from exponential growth phase in fed batch culture produced significantly more conidia than biomass harvested from any other growth phase although further work on the nutritional requirements of E. neoaphidis in vitro is required. The duration of the conidial discharge was also greatest from biomass harvested at the exponential phase and therefore. biomass harvested from the exponential phase should be used if the fungus is to be applied as a control agent. E. neoaphidis biomass kept at low humidity during simulated winter conditions produced infective conidia after 24 weeks, indicating that mycosed cadavers may act as a reservoir to infect the next season's hosts. Pesticides adversely affected the growth and production of conidia by E. neoaphidis, with herbicides having the least deleterious effects, and therefore being most compatible in an integrated pest management program. Laboratory and field studies were used to assess the transmission of E. neoaphidis through aphid populations. Position of the inoculum on the host plant affected the primary transmission of the fungus through aphid populations in the laboratory and in the field, and secondary transmission of the fungus in the laboratory. It is therefore important to apply the fungus to where it will maximally spread. There was some evidence for effects of host and inoculum density on the transmission of the fungus, especially in the laboratory, indicating that, in practice, the fungus is unlikely to spread rapidly through low densities of aphids and therefore to achieve control of such populations, a high inoculum density may be required. There was also very Iittle transmission of the fungus via aphid vectors to susceptible aphid populations on different host, although as a general observation, vectoring of conidia by the wind may be very important. The smaller conidia produced by in vivo biomass may be vectored more easily by wind than the large conidia produced in vitro

Efficacy and safety of erenumab in women with a history of menstrual migraine

Background We performed a post hoc, subgroup analysis of a phase 3, randomized, double-blind, placebo-controlled study of erenumab for prevention of episodic migraine (STRIVE) to determine the efficacy and safety of erenumab in women with self-reported menstrual migraine. Methods Patients received placebo, erenumab 70 mg, or erenumab 140 mg subcutaneously once monthly during the 6-month double-blind treatment phase of STRIVE. Women who reported history of menstrual migraine and who were = 50% reduction from baseline in MMD, and incidence of adverse events. Results Among 814 women enrolled in STRIVE, 232 (28.5%) reported a history of menstrual migraine and were 5, suggesting a high proportion of women with attacks outside of the 5-day perimenstrual window (2 days before and 3 days after the start of menstruation). Information on "migraine days" includes (and does not discriminate between) perimenstrual and intermenstrual migraine attacks. Between-group differences from placebo over months 4-6 for erenumab 70 mg and 140 mg were - 1.8 (P = 0.001) and - 2.1 (P = 50% reduction from baseline in MMD over months 4-6 were 2.2 (P = 0.024) and 2.8 (P = 0.002) times greater for erenumab 70 mg and 140 mg, respectively, than for placebo. Erenumab had an overall safety profile comparable to placebo. Conclusion Data from this subgroup analysis of women with menstrual migraine are consistent with data from the overall STRIVE episodic migraine population, supporting the efficacy and safety of erenumab in women who experience menstrual migraine. Trial registration: ClinicalTrials.gov, NCT02456740. Registered 28 May 2015

Non-steroidal anti-inflammatory drugs (NSAIDs) and breast cancer risk: differences by molecular subtype.

Use of non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with reduced risk of breast cancer, though findings have been inconsistent. This inconsistency may result from differences in etiology for breast tumors of different subtypes. We examined the association between NSAID use and breast cancer characterized by molecular subtypes in a population-based case-control study in Western New York. Cases (n = 1,170) were women with incident, primary, histologically confirmed breast cancer. Controls (n = 2,115) were randomly selected from NY Department of Motor Vehicles records (<65 years) or Medicare rolls (≥ 65 years). Participants answered questions regarding their use of aspirin and ibuprofen in the year prior to interview and their use of aspirin throughout their adult life. Logistic regression models estimated odds ratios (OR) and 95% confidence intervals (95% CI). Recent and lifetime aspirin use was associated with reduced risk, with no differences by subtype. Recent use of ibuprofen was significantly associated with increased risk of ER+/PR+(OR 1.33, 95% CI: 1.09-1.62), HER2- (OR 1.27, 95% CI: 1.05-1.53), and p53- breast cancers (OR 1.28, 95% CI: 1.04-1.57), as well as luminal A or B breast cancers. These findings support the hypothesis of heterogeneous etiologies of breast cancer subtypes and that aspirin and ibuprofen vary in their effects

Analysing and Recommending Options for Maintaining Universal Coverage with Long-Lasting Insecticidal Nets: The Case of Tanzania in 2011.

Tanzania achieved universal coverage with long-lasting insecticidal nets (LLINs) in October 2011, after three years of free mass net distribution campaigns and is now faced with the challenge of maintaining high coverage as nets wear out and the population grows. A process of exploring options for a continuous or "Keep-Up" distribution system was initiated in early 2011. This paper presents for the first time a comprehensive national process to review the major considerations, findings and recommendations for the implementation of a new strategy. Stakeholder meetings and site visits were conducted in five locations in Tanzania to garner stakeholder input on the proposed distribution systems. Coverage levels for LLINs and their decline over time were modelled using NetCALC software, taking realistic net decay rates, current demographic profiles and other relevant parameters into consideration. Costs of the different distribution systems were estimated using local data. LLIN delivery was considered via mass campaigns, Antenatal Care-Expanded Programme on Immunization (ANC/EPI), community-based distribution, schools, the commercial sector and different combinations of the above. Most approaches appeared unlikely to maintain universal coverage when used alone. Mass campaigns, even when combined with a continuation of the Tanzania National Voucher Scheme (TNVS), would produce large temporal fluctuations in coverage levels; over 10 years this strategy would require 63.3 million LLINs and a total cost of $444 million USD. Community mechanisms, while able to deliver the required numbers of LLINs, would require a massive scale-up in monitoring, evaluation and supervision systems to ensure accurate application of identification criteria at the community level. School-based approaches combined with the existing TNVS would reach most Tanzanian households and deliver 65.4 million LLINs over 10 years at a total cost of$449 million USD and ensure continuous coverage. The cost of each strategy was largely driven by the number of LLINs delivered. The most cost-efficient strategy to maintain universal coverage is one that best optimizes the numbers of LLINs needed over time. A school-based approach using vouchers targeting all students in Standards 1, 3, 5, 7 and Forms 1 and 2 in combination with the TNVS appears to meet best the criteria of effectiveness, equity and efficiency

Design, implementation and evaluation of a national campaign to distribute nine million free LLINs to children under five years of age in Tanzania.

BACKGROUND\ud \ud After a national voucher scheme in 2004 provided pregnant women and infants with highly subsidized insecticide-treated nets (ITNs), use among children under five years (U5s) in mainland Tanzania increased from 16% in 2004 to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned a catch-up campaign to rapidly and equitably deliver a free long-lasting insecticidal net (LLIN) to every child under five years in Tanzania.\ud \ud METHODS\ud \ud The ITN Cell, a unit within the National Malaria Control Programme (NMCP), coordinated the campaign on behalf of the Ministry of Health and Social Welfare. Government contractors trained and facilitated local government officials to supervise village-level volunteers on a registration of all U5s and the distribution and issuing of LLINs. The registration results formed the basis for the LLIN order and delivery to village level. Caregivers brought their registration coupons to village issuing posts during a three-day period where they received LLINs for their U5s. Household surveys in five districts assessed ITN ownership and use immediately after the campaign.\ud \ud RESULTS\ud \ud Nine donors contributed to the national campaign that purchased and distributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including all campaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented one zone at a time from March 2009 until May 2010. ITN ownership at household level increased from Tanzania's 2008 national average of 45.7% to 63.4%, with significant regional variations. ITN use among U5s increased from 28.8% to 64.1%, a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions.\ud \ud CONCLUSION\ud \ud A national-level LLIN distribution strategy that fully engaged local government authorities helped avoid additional burden on the healthcare system. Distribution costs per net were comparable to other public health interventions. Particularly among rural residents, ITN ownership and use increased significantly for the intended beneficiaries. The upcoming universal LLIN distribution and further behaviour change communication will further improve ITN ownership and use in 2010-2011

Considering Intra-individual Genetic Heterogeneity to Understand Biodiversity

In this chapter, I am concerned with the concept of Intra-individual Genetic Hetereogeneity (IGH) and its potential influence on biodiversity estimates. Definitions of biological individuality are often indirectly dependent on genetic sampling -and vice versa. Genetic sampling typically focuses on a particular locus or set of loci, found in the the mitochondrial, chloroplast or nuclear genome. If ecological function or evolutionary individuality can be defined on the level of multiple divergent genomes, as I shall argue is the case in IGH, our current genetic sampling strategies and analytic approaches may miss out on relevant biodiversity. Now that more and more examples of IGH are available, it is becoming possible to investigate the positive and negative effects of IGH on the functioning and evolution of multicellular individuals more systematically. I consider some examples and argue that studying diversity through the lens of IGH facilitates thinking not in terms of units, but in terms of interactions between biological entities. This, in turn, enables a fresh take on the ecological and evolutionary significance of biological diversity

Quality Control Autophagy Degrades Soluble ERAD-Resistant Conformers of the Misfolded Membrane Protein GnRHR

Molecular chaperones triage misfolded proteins via action as substrate selectors for quality control (QC) machines that fold or degrade clients. Herein, the endoplasmic reticulum (ER) associated Hsp40 JB12 is reported to participate in partitioning mutant conformers of GnRHR, a G-protein coupled receptor, between ER-associated degradation (ERAD) and a novel ERQC-autophagy pathway for membrane proteins. ERQC-autophagy degrades E90K-GnRHR because pools of its partially folded and detergent soluble degradation intermediates are resistant to ERAD. S168R-GnRHR is globally misfolded and disposed of via ERAD, but inhibition of p97, the protein retrotranslocation motor, shunts S168R-GnRHR from ERAD to ERQC autophagy. Partially folded and grossly misfolded forms of GnRHR associate with JB12 and Hsp70. Elevation of JB12 promotes ERAD of S168R-GnRHR, with E90K-GnRHR being resistant. E90K-GnRHR elicits association of the Vps34 autophagy initiation complex with JB12. Interaction between ERassociated Hsp40s and the Vps34 complex permits the selective degradation of ERAD-resistant membrane proteins via ERQC-autophagy

Upfront Biology-Guided Therapy in Diffuse Intrinsic Pontine Glioma: Therapeutic, Molecular, and Biomarker Outcomes from PNOC003

PURPOSE PNOC003 is a multicenter precision medicine trial for children and young adults with newly diagnosed diffuse intrinsic pontine glioma (DIPG). PATIENTS AND METHODS Patients (3-25 years) were enrolled on the basis of imaging consistent with DIPG. Biopsy tissue was collected for whole-exome and mRNA sequencing. After radiotherapy (RT), patients were assigned up to four FDA-approved drugs based on molecular tumor board recommendations. H3K27M-mutant circulating tumor DNA (ctDNA) was longitudinally measured. Tumor tissue and matched primary cell lines were characterized using whole-genome sequencing and DNA methylation profiling. When applicable, results were verified in an independent cohort from the Children's Brain Tumor Network (CBTN). RESULTS Of 38 patients enrolled, 28 patients (median 6 years, 10 females) were reviewed by the molecular tumor board. Of those, 19 followed treatment recommendations. Median overall survival (OS) was 13.1 months [95% confidence interval (CI), 11.2-18.4] with no difference between patients who followed recommendations and those who did not. H3K27M-mutant ctDNA was detected at baseline in 60% of cases tested and associated with response to RT and survival. Eleven cell lines were established, showing 100% fidelity of key somatic driver gene alterations in the primary tumor. In H3K27-altered DIPGs, TP53 mutations were associated with worse OS (TP53mut 11.1 mo; 95% CI, 8.7-14; TP53wt 13.3 mo; 95% CI, 11.8-NA; P = 3.4e-2), genome instability (P = 3.1e-3), and RT resistance (P = 6.4e-4). The CBTN cohort confirmed an association between TP53 mutation status, genome instability, and clinical outcome. CONCLUSIONS Upfront treatment-naïve biopsy provides insight into clinically relevant molecular alterations and prognostic biomarkers for H3K27-altered DIPGs