Using ‘think aloud’ as a strategy for improving clinical reasoning in high fidelity case-based simulation for undergraduate nursing students.

Theme Paper for Curriculum innovation and enhancement theme AIM: This paper reports on a research project that trialled an educational strategy implemented in an undergraduate nursing curriculum. The project aimed to explore the effectiveness of ‘think aloud’ as a strategy for improving clinical reasoning for students in simulated clinical settings. BACKGROUND: Nurses are required to apply and utilise critical thinking skills to enable clinical reasoning and problem solving in the clinical setting (Lasater, 2007). Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students (Banning, 2008, Lee and Ryan-Wenger, 1997). This project used the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students were assisted to uncover cognitive approaches to assist in making effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection about their practice. MEHODS: In semester 2 2011 at QUT, third year nursing students undertook high fidelity simulation (some for the first time), commencing in September of 2011. There were two cohorts for strategy implementation (group 1= used think aloud as a strategy within the simulation, group 2= no specific strategy outside of nursing assessment frameworks used by all students) in relation to problem solving patient needs. The think aloud strategy was described to students in their pre-simulation briefing and allowed time for clarification of this strategy. All other aspects of the simulations remained the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials). Ethics approval has been obtained for this project. RESULTS: Results of a qualitative analysis (in progress- will be completed by March 2012) of student and facilitator reports on students’ ability to meet the learning objectives of solving patient problems using clinical reasoning and experience with the ‘think aloud’ method will be presented. A comparison of clinical reasoning learning outcomes between the two groups will determine the effect on clinical reasoning for students responding to patient problems. CONCLUSIONS: In an environment of increasingly constrained clinical placement opportunities, exploration of alternate strategies to improve critical thinking skills and develop clinical reasoning and problem solving for nursing students is imperative in preparing nurses to respond to changing patient needs.

Histological and morphometric lesions in the pre-clinical, developmental phase of insulin-induced laminitis in Standardbred horses

Lamellar pathology in experimentally-induced equine laminitis associated with euglycaemic hyperinsulinaemia is substantial by the acute, clinical phase (∼48 h post-induction). However, lamellar pathology of the developmental, pre-clinical phase requires evaluation. The aim of this study was to analyse lamellar lesions both qualitatively and quantitatively, 6, 12 and 24 h after the commencement of hyperinsulinaemia. Histological and histomorphometrical analyses of lamellar pathology at each time-point included assessment of lamellar length and width, epidermal cell proliferation and death, basement membrane (BM) pathology and leucocyte infiltration. Archived lamellar tissue from control horses and those with acute, insulin-induced laminitis (48 h) was also assessed for cellular proliferative activity by counting the number of cells showing positive nuclear immuno labelling for TPX2. Decreased secondary epidermal lamellar (SEL) width and increased histomorphological evidence of SEL epidermal basal (and supra-basal) cell death occurred early in disease progression (6 h). Increased cellular proliferation in SELs, infiltration of the dermis with small numbers of leucocytes and BM damage occurred later (24 and 48 h). Some lesions, such as narrowing of the SELs, were progressive over this time period (6–48 h). Cellular pathology preceded leucocyte infiltration and BM pathology, indicating that the latter changes may be secondary or downstream events in hyperinsulinaemic laminitis.

Analysis of higher-order aberrations in a large clinical population

Purpose: To use a large wavefront database of a clinical population to investigate relationships between refractions and higher order aberrations and between aberrations of right and left eyes. Methods: Third and fourth-order aberration coefficients and higher-order root-mean-squared aberrations (HO RMS), scaled to a pupil size of 4.5 mm diameter, were analysed in a population of about 24,000 patients from Carl Zeiss Vision's European wavefront database. Correlations were determined between the aberrations and the variables of refraction, near addition and cylinder. Results: Most aberration coefficients were significantly dependent upon these variables, but the proportions of aberrations that could be explained by these factors were less than 2% except for spherical aberration (12%), horizontal coma (9%) and HO RMS (7%). Near addition was the major contributor for horizontal coma (8.5% out of 9.5%) and spherical equivalent was the major contributor for spherical aberration (7.7% out of 11.6%). Interocular correlations were highly significant for all aberration coefficients, varying between 0.16 and 0.81. Anisometropia was a variable of significance for three aberrations (vertical coma, secondary astigmatism and tetrafoil), but little importance can be placed on this because of the small proportions of aberrations that can be explained by refraction (all less than 1.0 %). Conclusions: Most third- and fourth-order aberration coefficients were significantly dependent upon spherical equivalent, near addition and cylinder, but only horizontal coma (9%) and spherical aberration (12%) showed dependencies of greater than 2%. Interocular correlations were highly significant for all aberration coefficients, but anisometropia had little influence on aberration coefficients.

Rod and cone pathway signaling and interaction under mesopic illumination

This study investigates the time-course and post-receptoral pathway signaling of photoreceptor interactions when the rod (R) and three cone (L, M, S) photoreceptor classes contribute to mesopic vision. A four-primary photostimulator independently controls photoreceptor activity in human observers. The first experiment defines the temporal adaptation response of receptoral (L-, S-cone, rod) and post-receptoral (LMS, LMSR,+L-M) signaling and interactions. Here we show that nonopponent cone-cone interactions (L-cone, LMS, LMSR) have monophasic temporal response patterns whereas opponent signals (+L-M, S-cone) show biphasic response patterns with slower recovery. By comparison, rod-cone interactions with nonopponent signals have faster adaptation responses and reduced sensitivity loss whereas opponent rod-cone interactions are small or absent. Additionally, the rod-rod interaction differs from these interaction types and acts to increase rod sensitivity due to temporal summation but with a slower time course. The second experiment shows that the temporal profile of the rod signal alters the relative rod contributions to the three primary post-receptoral pathways. We demonstrate that rod signals generate luminance (þLþM) signals mediated via the MC pathway with all rod temporal profiles and chromatic signals (L/LþM, S/LþM) in both the PC and KC pathways with durations .75 ms. Thus, we propose that the change in relative weighting of rod signals within the post-receptoral pathways contributes to the sensitivity and temporal response of rod and cone pathway signaling and interactions.

The key regulatory roles of the PI3K/Akt signalling pathway in the functionalities of mesenchymal stem cells and applications in tissue regeneration

Mesenchymal stem cells (MSCs) are multi-potent cells that can differentiate into various cell types and have been used widely in tissue engineering application. In tissue engineering, a scaffold, MSCs and growth factors are used as essential components and their interactions have been regarded to be important for regeneration of tissues. A critical problem for MSCs in tissue engineering is their low survival ability and functionality. Most MSCs are going to be apoptotic after transplantation. Therefore, increasing MSC survival ability and functionalities is the key for potential applications of MSCs. Several approaches have been studied to increase MSC tissue forming capacity including application of growth factors, overexpression of stem cell regulatory genes and improvement of biomaterials for scaffolds. The effects of these approaches on MSCs have been associated with the activation of the PI3K/Akt signaling pathway. The pathway plays central regulatory roles in MSC survival, proliferation, migration, angiogenesis, cytokine production and differentiation. In this review, we summarize and discuss the literatures related to the roles of the PI3K/Akt pathway in the functionalities of MSCs and the involvement of the pathway in biomaterials-increased MSC functinalities. Biomaterials have been modified in their properties, surface structure and loaded with growth factors to increase MSC functionalities. Several studies demonstrated that the biomaterials-increased MSC functionalities are mediated by the activation of the PI3K/Akt pathway.

Human milk xanthine oxidase and neonatal salivary nucleotide precursors generate hydrogen peroxide; a novel pathway with potential role in regulating oral microflora

Background: Xanthine oxidase (XO) is a complex molybdeno-flavoprotein occurring with high activity in the milk fat globule membrane (MFGM) in all mammalian milk and is involved in the final stage of degradation of purine nucleotides. It catalyzes the sequential oxidation of hypoxanthine to xanthine and uric acid, accompanied by production of hydrogen peroxide and superoxide anion. Human saliva has been extensively described for its composition of proteins, electrolytes, cortisol, melatonin and some metabolites such as amino acids, but little is known about nucleotide metabolites. Method: Saliva was collected with swabs from babies; at full-term 1-4 days, 6-weeks, 6-months and 12-months. Unstimulated fasting (morning) saliva samples were collected directly from 77 adults. Breast milk was collected from 24 new mothers. Saliva was extracted from swabs and ultra-filtered. Nucleotide metabolites were analyzed by RP-HPLC with UV-photodiode array and ESI-MS/MS. XO activity was measured as peroxide production from hypoxanthine. Bacterial inhibition over time was assessed using CFU/mL or OD. Results: Median concentrations (μmol/L) of salivary nucleobases and nucleosides for neonates/6-weeks/6-months/12-months/adult respectively were: uracil 5.3/0.8/1.4/0.7/0.8, hypoxanthine 27/7.0/1.1/0.8/2.0, xanthine 19/7.0/2.0/2.0/2.0, adenosine 12/7.0/0.9/0.8/0.1, inosine 11/5.0/0.3/0.4/0.2, guanosine 7.0/6.0/0.5/0.4/0.1, uridine 12/0.8/0.3/0.9/0.4. Deoxynucleosides and dihydropyrimidines concentrations were essentially negligible. XO activity (Vmax:mean ± SD) in breast milk was 8.9 ± 6.2 μmol/min/L and endogenous peroxide was 27 ± 12 μmol/L; mixing breast milk with neonate saliva generated ~40 μmol/L peroxide,which inhibited Staphylococcus aureus. Conclusions: Salivary metabolites, particularly xanthine/hypoxanthine, are high in neonates, transitioning to low adult levels between 6-weeks to 6-months (p < 0.001). Peroxide occurs in breast milk and is boosted during suckling as an antibacterial system.

Risk modelling in quality clinical registries : Monitoring lesion treatment failure rate in percutaneous coronary interventions

Aims: This paper describes the development of a risk adjustment (RA) model predictive of individual lesion treatment failure in percutaneous coronary interventions (PCI) for use in a quality monitoring and improvement program. Methods and results: Prospectively collected data for 3972 consecutive revascularisation procedures (5601 lesions) performed between January 2003 and September 2011 were studied. Data on procedures to September 2009 (n = 3100) were used to identify factors predictive of lesion treatment failure. Factors identified included lesion risk class (p < 0.001), occlusion type (p < 0.001), patient age (p = 0.001), vessel system (p < 0.04), vessel diameter (p < 0.001), unstable angina (p = 0.003) and presence of major cardiac risk factors (p = 0.01). A Bayesian RA model was built using these factors with predictive performance of the model tested on the remaining procedures (area under the receiver operating curve: 0.765, Hosmer–Lemeshow p value: 0.11). Cumulative sum, exponentially weighted moving average and funnel plots were constructed using the RA model and subjectively evaluated. Conclusion: A RA model was developed and applied to SPC monitoring for lesion failure in a PCI database. If linked to appropriate quality improvement governance response protocols, SPC using this RA tool might improve quality control and risk management by identifying variation in performance based on a comparison of observed and expected outcomes.

The ionic products from bredigite bioceramics induced cementogenic differentiation of periodontal ligament cells via activation of the Wnt/β-catenin signalling pathway

Periodontitis results from the destructive inflammatory reaction of the host elicited by a bacterial biofilm adhering to the tooth surface and if left untreated, may lead to the loss of the teeth and the surrounding tissues, including the alveolar bone. Cementum is a specialized calcified tissue covering the tooth root and an essential part of the periodontium which enables the attachment of the periodontal ligament to the root and the surrounding alveolar bone. Periodontal ligament cells (PDLCs) represent a promising cell source for periodontal tissue engineering. Since cementogenesis is the critical event for the regeneration of periodontal tissues, this study examined whether inorganic stimuli derived from bioactive bredigite (Ca7MgSi4O16) bioceramics could stimulate the proliferation and cementogenic differentiation of PDLCs, and further investigated the involvement of the Wnt/β-catenin signalling pathway during this process via analysing gene/protein expression of PDLCs which interacted with bredigite extracts. Our results showed that the ionic products from bredigite powder extracts led to significantly enhanced proliferation and cementogenic differentiation, including mineralization–nodule formation, ALP activity and a series of bone/cementum-related gene/protein expression (ALP, OPN, OCN, BSP, CAP and CEMP1) of PDLCs in a concentration dependent manner. Furthermore, the addition of cardamonin, a Wnt/β-catenin signalling inhibitor, reduced the pro-cementogenesis effect of the bredigite extracts, indicating the involvement of the Wnt/β-catenin signalling pathway in the cementogenesis of PDLCs induced by bredigite extracts. The present study suggests that an entirely inorganic stimulus with a specific composition of bredigite bioceramics possesses the capacity to trigger the activation of the Wnt/β-catenin signalling pathway, leading to stimulated differentiation of PDLCs toward a cementogenic lineage. The results indicate the therapeutic potential of bredigite ceramics in periodontal tissue engineering application.

Suspected mechanisms in the cause of overuse running injuries : A clinical review

Context: Various epidemiological studies have estimated that up to 70% of runners sustain an overuse running injury each year. Although few overuse running injuries have an established cause, more than 80% of running-related injuries occur at or below the knee, which suggests that some common mechanisms may be at work. The question then becomes, are there common mechanisms related to overuse running injuries? Evidence Acquisition: Research studies were identified via the following electronic databases: MEDLINE, EMBASE PsycInfo, and CINAHL (1980–July 2008). Inclusion was based on evaluation of risk factors for overuse running injuries. Results: A majority of the risk factors that have been researched over the past few years can be generally categorized into 2 groups: atypical foot pronation mechanics and inadequate hip muscle stabilization. Conclusion: Based on the review of literature, there is no definitive link between atypical foot mechanics and running injury mechanisms. The lack of normative data and a definition of typical foot structure has hampered progress. In contrast, a large and growing body of literature suggests that weakness of hip-stabilizing muscles leads to atypical lower extremity mechanics and increased forces within the lower extremity while running.

Alcohol and other drugs in the Australian construction industry : a pathway for safety focused cultural change

Background: Anecdotal evidence from the infrastructure and building sectors highlights issues of alcohol and other drugs (AODs) and its association with safety risk on construction sites. Currently, there is no clear evidence on the prevalence and risk of AOD use among Australian construction workers and there is limited evidential guidance regarding how to effectively address such an issue. Aims: The current research aims to scientifically evaluate the use of AODs within the Australian construction industry in order to reduce the potential resulting safety and performance impacts and engender a cultural change in the workforce. A nationally consistent and collaborative approach across the workforce will be adopted. Methods: A national assessment of the use of AODs was conducted in participating organisations across three states. The World Health Organisation’s Alcohol Use Disorders Identification Test (AUDIT) was used to measure alcohol use. Illicit drug use, ‘readiness to change’, impediments to reducing impairment, feasibility of proposed interventions, and employee attitudes and knowledge regarding AOD was also measured through a combination of survey items and interviews. Through an educative approach and consultation with employers, employees, union groups and leaders in applied AOD research, this assessment was used to inform and support cultural change management of AOD use in the industry. Results: Results (n=494) indicate that as in the general population, a proportion of those sampled in the construction sector may be at risk of hazardous alcohol consumption. A total of 286 respondents (58%) scored above the cut-off cumulative score for risky or hazardous alcohol use. Other drug use was also identified as a major issue. Interview responses and input from all project partners is presented within a guiding principle framework for cultural change. Conclusions: Results support the need for evidence-based, comprehensive and tailored responses in the workplace. This paper will discuss the final results in the context of facilitating cultural change in the construction industry.

Clinical data integration approach using SAS clinical data integration server (CDI) tools

The decisions people make about medical treatments have a great impact on their lives. Health care practitioners, providers and patients often make decisions about medical treatments without complete understanding of the circumstances. The main reason for this is that medical data are available in fragmented, disparate and heterogeneous data silos. Without a centralised data warehouse structure to integrate these data silos, it is highly unlikely and impractical for the users to get all the information required on time to make a correct decision. In this research paper, a clinical data integration approach using SAS Clinical Data Integration Server tools is presented.

Data warehousing model for integrating fragmented electronic health records from disparate and heterogeneous clinical data stores

This research was a step forward in developing a data integration framework for Electronic Health Records. The outcome of the research is a conceptual and logical Data Warehousing model for integrating Cardiac Surgery electronic data records. This thesis investigated the main obstacles for the healthcare data integration and proposes a data warehousing model suitable for integrating fragmented data in a Cardiac Surgery Unit.

Preparing culturally and linguistically diverse nursing students for clinical practice in the health care setting

The number of culturally and linguistically diverse (CALD) students seeking enrollment in higher education courses in Western countries where English is the predominant language has grown considerably in the past decade, especially in undergraduate health care courses. When enrolled in nursing courses, students are required to complete clinical placements. Such experiences can create significant challenges for CALD students where language, cultural differences, and interpretation of cultural norms complicate the learning process. To assist CALD nursing students to transition successfully, an extracurricular integrated curriculum program was developed and implemented at a university in Queensland, Australia. The program is a series of interactive workshops based on the principles of caring pedagogy and student-centered learning. The program applies strategies that combine small-group discussions with peers, role-plays, and interactions with final-year nursing student volunteers. Evaluation of the program suggests it has assisted most of the students surveyed to be successful in their clinical studies.

Proteomics science and society :the role of knowledge translation in moving towards clinical applications

Gaining support for proteomics science requires effective knowledge translation. Knowledge translation (KT) processes turn the evidence generated by scientific discovery into recommendations for clinical applications, funding priorities, and policy/regulatory reforms. Clinicians, regulators, and funders need to understand why emerging proteomics knowledge is relevant, and what are the potential applications of that knowledge. A lack of clarity remains about what KT means.