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The global COVID-19 pandemic has challenged nurse leaders in ways that one could not imagine six months ago. Along with ongoing priorities of providing high quality, cost-effective and safe care, nurse leaders are also committed to creating environments that support excellence in patient and family experience. This article will provide exemplars of how nurse leaders used decisive decision-making, adapted to novel situations and issues, ensured reliable and safe delivery of care and engaged patients, families and their workforce to create excellent experiences of care during the pandemic. Throughout this crisis, nurse leaders have learned how to grapple with quick and often uncertain decision-making, adapted ways to engage patient and family amidst new care situations and operational policies, delivered care reliably with ever changing metrics and measures and created environments to support and bring smiles to nurses and other health care staff. New opportunities to care for and positively engage patients and families have emerged. Experience Framework This article is associated with the Culture & Leadership lens of The Beryl Institute Experience Framework. (http://bit.ly/ExperienceFramework) Access other PXJ articles related to this lens. Access other resources related to this lens

Anne Arundel Medical Center has been on a 3-year journey to improve employee well-being with the assumption that employee well-being and employee engagement are interconnected. Improvements in employee well-being will result in increased employee engagement and will be a pivotal driver to assist the health system meet its goals. Historically, Anne Arundel Medical Center successfully differentiated itself in the market by being the region's high-quality, low-cost provider of health services delivered through intense collaboration with patients and families. The financial, quality, and patient satisfaction results are in the top percentiles nationwide. However, as the pace of change accelerates and the organization faces increased pressure to improve outcomes, keeping employees from becoming burned out and disengaged becomes an increasing concern. The WellBeing framework was developed on the basis of the work of Tom Rath and Jim Harter as the model to support Anne Arundel's WellBeing work. The efforts around well-being are comprehensive and impact all aspects of how work is conducted. Employee well-being has been elevated to an equal third prong along with providing high-quality low-cost care in a patient-centered environment. This focus on leading an employee WellBeing Program has resulted in improved engagement scores at Anne Arundel Medical Center.

Objective We herein examine the role of endogenous miR155 in the development of systemic manifestations in pristane induced lupus. Materials and methods Systemic lupus in miR155-deficient and wild type mice was induced upon injection of pristane and analyzed after 8 months, PBS-injected mice served as controls. Glomerulonephritis and pneumonitis were quantified using the kidney biopsy score and a newly adapted histomorphometric image analysis system; lung tissue was further analyzed by tissue cytometry. Serum levels of anti-dsDNA, anti-histone and anti-chromatin antibodies were measured by ELISA. Frequencies of B cells, activated and regulatory CD4+ T cells as well as Th1, Th2, Th17 cells were measured by flow cytometry. RT-qPCR was used to measure expression levels of interferon-signature and T-cell subset related as well as miR155-associated genes. Results After induction of lupus, miR155-deficient mice had significant less pulmonary involvement (perivascular inflammatory area in mm2/mm2 lung area 0.00092±0.00015 vs. 0.0027±0.00075, p = 0.0347) and renal disease (glomerular activity score 1.95±0.19 vs 3±0.26, p = 0.0029) compared to wild types. MiR155-deficient mice had significantly lower serum levels of disease-associated auto-antibodies and decreased frequencies of activated CD4+CD25+ (Foxp3-) cells. Upon restimulation, CD4+ cells showed a less pronounced Th2 and Th17 and a slightly decreased Th1 response in mir155-deficient mice. Pristane-treated wild types showed significantly up-regulated expression of genes related to the INF-signature (MX1, IP10, IRF7, ISG15). Conclusions MiR155-deficient mice had less severe organ involvement, lower serum auto-antibody levels, a less prominent T cell response and lower expressions of genes jointly responsible for disease development. Thus, antagonizing miR155 might be a future approach in treating SLE.

Since sodium stibogluconate (SSG) inhibited phosphatases including SHP-1 and augmented anti-tumor actions of IFN-α2b in vitro and in mice, two Phase I trials of SSG/IFN-α2b combination were undertaken to evaluate safety and target inhibition. Escalating doses of SSG (200-1200 mg/m2) and fixed doses of IFN-α2b (3x106 units/m2) with or without chemotherapy (dacarbazine, vinblastine, cisplatin) were evaluated for side effects and impact on SHP-1 phospho-substrates and IFNα-stimulated-genes (ISGs) in peripheral blood in 40 patients with metastatic melanoma, soft tissue sarcomas, gastrointestinal stromal tumors, and breast or colorectal carcinomas who did not have other established treatment options. Common adverse events were bone marrow suppression, fatigue, gastrointestinal upset, and asymptomatic lipase elevation (n=13); the latter was dose related and mostly after 10d of SSG/IFN-α2b in combination. Levels of SHP-1 substrates (pSTAT1, pSTAT3, pLck and pSlp76) were increased (up to 3x) in peripheral blood cells following SSG with no potentiation by combination with IFN-α2b. Representative ISGs in peripheral blood were induced after IFN-α2b at 4 and 24 hrs with selective modulations by combination. The median time on trials was 2.3 months (10-281d) with no objective regression of disease. Alive at 1y were 17/40 (43%) patients and after 2y were 8/40 (20%) following treatment initiation. These data demonstrate that SSG impacted signal molecules consistent with PTP inhibition and was tolerated in combination with IFN-α2b. Phase II investigations of SSG could safely utilize doses of up to 1200 mg/m2 of SSG for up to 10d alone or in combination with IFN-α2b with or without chemotherapy.

In this paper, the authors review empirical evidence on the effects of peer groups on social, emotional and behavioural functioning. The paper shows that an understanding of the ways in which peer groups can influence the development of deviance and subvert the positive effects of interventions can be exploited in the promotion of positive social and emotional functioning.

Purpose/objectives Readmission rates for heart failure patients are a Center for Medicare & Medicaid and Joint Commission core measure. At this urban Midwestern medical center, the 6-month baseline skilled nursing facility (SNF) readmission rate was 30%. Nurse case management implemented a process to decrease the rate for this population. Follow-up phone calls were in place for patients discharged to home, but a gap remained in those discharged to SNFs. Nurse case management developed a follow-up phone call process within 48 hours of discharge to the registered nurse/licensed practical nurse in the SNFs to verify that: 1. Daily morning weights were ordered. 2. Parameters to contact primary care provider if weight gain was greater than 3 pounds per day or 5 pounds per week. 3. 2 gram sodium restricted diet was ordered. 4. Appropriate diuretic was ordered and reconciled. 5. Follow-up provider visits were made, for patient to be seen within 3 to 5 days following discharge. Primary practice setting Acute inpatient care settings. Findings/conclusions The phone calls resulted in improved continuity of care and clarification of discharge orders. The opportunity for question-and-answer time between the hospital and the SNF nurse provided just-intime education; relationships have also been strengthened. Recent data show that the current readmission rate averages 11.32% (a decrease from 30%). This nurse case management–driven process of follow-up phone calls between the hospital and SNF staff to reduce readmission rates in heart failure patients resulted in improved continuity of care and clarification of discharge orders. Implications for cm practice This simple, innovative process allowed for improved continuity of care and partnerships between inpatient hospitalization and the SNF, thereby reduced transcription errors and improved patient health outcomes. Enhanced communication between providers allowed for a significant reduction in readmissions from SNFs to the hospital.

Managing the risk posed by violent and sexual offenders who have a personality disorder is a key priority in forensic mental health services. An important element of service delivery is to maintain client engagement with the care team in order to promote positive change. Service‐user involvement in multi‐method evaluations has been shown to increase involvement and ownership of services and thereby increase engagement. This study presents the findings from a qualitative service user evaluation of a pilot project known as the Forensic Intensive Psychological Treatment Service (FIPTS). The main findings highlight the importance of a good therapeutic relationship and good communication with the care team, how therapy work offers insight and understanding into behaviour, encouraging service users to make positive changes, and how returning to work gives hope, independence and confidence. Service users generally feel supported and able to approach the team with any concerns of escalating risk and also highlight certain areas of improvement.

Objective: There is limited evidence regarding effective smoking cessation interventions in deprived communities. This study explored what factors are considered most important in smoking cessation, from the perspective of a group of NHS Stop Smoking Service users from a deprived community. Design: A qualitative study. Setting: A deprived community in Brighton and Hove City, Southeast England. Methods: Fifteen adults who had used the local NHS Stop Smoking Service were recruited to the focus groups. Thematic analysis was used to identify key themes regarding factors that were considered most helpful during the smoking cessation attempt. Results: Factors deemed most important for a successful smoking cessation attempt were counsellors’ attitude and knowledge, flexibility of appointments, personalized one-to-one support including additional support between sessions, all provided in an accessible local community setting. Individuals were most likely to decide to quit smoking for health reasons, and support from family and friends was important during the quit attempt. Conclusion: This study shows that smokers from deprived communities require more intensive, flexible and personalized support from a stop smoking service which should ideally be located in their community setting. A more innovative, tailored and less prescriptive approach to providing stop smoking services may help to improve cessation rates among smokers in deprived communities.

Level of consciousness at the end of life in critically ill patients is poorly characterized. We report a case series of seven patients who were neurologically intact before the decision to withdraw care due to extensive systemic critical illness. As part of our end-of-life care protocol, bispectral index (BIS) monitor (Aspect Medical Systems, Newton, MA) or SEDline (Hospira, Lake Forest, IL) monitoring devices are placed on each patient to ensure adequate comfort. Both monitoring systems use an integer-based system (BIS or PSI, respectively) to reflect the level of consciousness/effect of anesthesia. In each case, loss of blood pressure, as monitored by indwelling arterial line, was followed by a decline is BIS/PSI activity followed by a transient spike in BIS/PSI activity that approached levels normally associated with consciousness. This spike in electroencephalogram (EEG) activity had short duration and the activity then declined to a level of activity associated with burst suppression. In one case of a patient who had a SEDLine device, we were able to capture and analyze the raw EEG signal, and confirm that the EEG waveform was not artifact, and in fact a high frequency waveform was present during the spike activity. We speculate that this level of BIS/SEDline activity is related to the cellular loss of membrane polarization due to hypoxemia. We further speculate that since this increase in electrical activity occurred when there was no discernable blood pressure, patients who suffer "near death" experiences may be recalling the aggregate memory of the synaptic activity associated with this terminal but potentially reversible hypoxemia.

New intravenous pumps help increase safety measures and improve cost-effectiveness.

The range of empirically based evidence on interventions for meeting the needs of students with social, emotional and behavioural difficulties (SEBD) in mainstream schools is rich and varied. This paper is based on an international literature search and review of studies that were published between 1980 and 2012. Particular attention is given to evidence that define the qualities and skills of effective teachers and the value of behavioural and cognitive behavioural interventions.

The immunobiology of tumor-infiltrating dendritic cells (DCs) can be strongly influenced by the cytokine environment present in the malignant tissue. We have previously identified discrete melanoma lines, inducing E-cadherin expression on monocyte-derived DCs in vitro. We demonstrate here that this effect, independent of cell contact, is not inducible in the presence of tumor lysates and requires the constitutive expression of IFN stimulated gene 15 (ISG15) by malignant cells. High-density oligonucleotide arrays were used to investigate the expression pattern of 7000 genes in RNA from two melanoma cell clones competent for E-cadherin induction and two clones devoid of DC-modulating capacity. A total of 13 genes encoding soluble proteins were expressed at higher magnitude in melanomas able to induce E-cadherin expression on DCs. Combining those data with quantitative protein assays, we could narrow our investigation down to three factors: the chemokine CCL5 and the cytokines ISG15 and type I IFNs. Strikingly,7 ng/ml of ISG15 could be detected in the corresponding melanoma-conditioned medium and induction of E-cadherin on DCs failed in the presence of antibodies neutralizing ISG15 protein. Most importantly, strong cytoplasmic expression of ISG15 was detected by immunohistochemistry in the original tumor specimen from which the melanoma cell lines under investigation were derived. These data describe a novel property of ISG15 targeting induction of E-cadherin on DCs and possibly influencing their migratory behavior.

The primary goal of this study was to evaluate increased platelet membrane fluidity as a putative risk factor for Alzheimer's disease and its relationship to the APOE epsilon4 genotype.This report describes the results of a prospective, longitudinal study of 330 initially asymptomatic, first-degree relatives of probands with Alzheimer's disease.Nine incident cases of Alzheimer's disease were detected during the first 2,220 subject-years of the follow-up period. Age, increased platelet membrane fluidity, and the APOE epsilon4 allele made significant independent contributions to the risk of developing Alzheimer's disease, while sex and years of education did not. Increased platelet membrane fluidity was associated with incident Alzheimer's disease cases between the ages of 64 and 71, while the epsilon4 allele was associated with incident Alzheimer's disease cases from age 64 until at least age 80.These results indicate that increased platelet membrane fluidity is not produced by the APOE epsilon4 allele. Instead, increased platelet membrane fluidity and the epsilon4 allele appear to make significant independent contributions to the risk of developing Alzheimer's disease among the first-degree relatives of patients with this disorder. Moreover, the age ranges over which these risk factors operate appear to be different.

We studied the effect of interferons on the expression of class II histocompatibility (HLA-DR) antigens by cultured adult human astrocytes. Cultures were derived from brain tissue resected for surgical treatment of intractable epilepsy. Cultured astrocytes did not spontaneously display HLA-DR antigen as determined by immunocytochemistry and flow cytometry with antibody to HLA-DR. Astrocytes cultured for 72 h with recombinant or natural interferon-gamma (IFN gamma) demonstrated a dose-dependent increase in HLA-DR expression with optimal stimulation by 100 U/ml IFN gamma. HLA-DR expression was not detectable in astrocytes cultured with IFN gamma for less then 48 h, and peak HLA-DR expression (over 80% of cells) was seen at 120 h of culture. Optimal HLA-DR expression required continuous presence of IFN gamma. Exposure of astrocytes to recombinant or natural interferon-beta (IFN beta) did not induce HLA-DR and pretreatment of astrocytes with IFN beta or interferon-alpha (IFN alpha) significantly inhibited subsequent induction of HLA-DR expression by IFN gamma. These observations suggest that interferons may function in regulating human astrocyte HLA-DR expression within the central nervous system.

A linear regression for a short and long sequence of hydrologic events is used to lengthen the short sequence. The lengthened sequence consists of the original observations and regressed values plus noise, where the noise is a random variable with zero mean and variance proportional to the variance of the observations for the short sequence about the line of regression. Estimates of the mean and variance for the lengthened sequence are shown to be unbiased. If the correlation coefficient, which measures the strength of the linear regression, exceeds about 0.5, then the estimates of the mean and variance based on the lengthened sequence are better estimators of the population values of the mean and variance than the estimates based on the observations for the short sequence. If noise is not added to the regressed values, the correlation coefficient must exceed about 0.8 to obtain improvement in the estimates by use of correlated values. INTRODUCTION In statistical studies of hydrology, the assumption is made that a sequence of a finite number of observed events represents a random sample from an infinite population of such events, where the outcome of each event is governed by some probability distribution. Any change hi the hydrologic regime with which a given sequence is associated is reflected in a change of the probability distribution. Although various parameters may be used to describe a probability distribution, the mean, variance, and skewness are three parameters which provide information about the most useful properties of any probability distribution. The mean is a measure of central tendency, a value about which the events tend to cluster, whereas the variance measures the dispersion or average spread of the events about the mean. The skewness is a measure of the asymmetry of the distribution of the events about the mean. These three parameters cannot define a probability distribution uniquely, except in special cases; nevertheless, they do provide characteristics which may be used to describe and compare various hydrologic phenomena. The population values of these parameters are generally unknown, but the values may be estimated from a sequence of observations. How reliable these estimates are depends primarily upon the period or length of the sequence the total number of observations. If the estimates are unbiased, their reliability increases with an increase of the sequence length. To increase a sequence length by making additional observations in time in order to obtain more reliable estimates of the mean, variance, and skewness is not always operationaUy or economically feasible. If not, recourse must be had to other procedures for increasing a sequence length. One such procedure, which is the topic of discussion in this paper, is to utilize the relations among hydrologic phenomena. A relation among the concurrent observations for a short and a long sequence can be used to obtain estimates of the nonobserved events for the short sequence which correspond to the observed events for the nonconcurrent portion of the long sequence. In this manner the short sequence is lengthened. The observed and estimated events for the lengthened sequence can be used to obtain estimates of the mean, variance, and skewness. Whether or not the reliability of these estimates is greater than that for the estimates of these parameters based only on the observations depends mainly upon the strength of the relation between the concurrent observations for the short and long sequences. A mathematical evaluation of this procedure has been made by several investigators under the assumptions that (1) the events are independently distributed in time, (2) the concurrent events for two sequences have a joint normal distribution, (3) the relation between the concurrent events is defined by a linear regression, and (4) no changes occur hi the hydrologic regimes with which the sequences are associated. The strength of the linear regression is measured by the productmoment correlation coefficient. Under the assumption of normality, only the mean and variance need to be considered because these two parameters uniquely define a normal probability distribution. For this distribution, the skewness is zero. El E2 STATISTICAL STUDIES IN HYDROLOGY H. A. Thomas, Jr. (written commun. 1956), showed that the lengthened sequence yields an unbiased estimate of the mean, and if the product-moment correlation coefficient exceeds lf-yNi 2 where NI is the length of the concurrent period, the reliability of this estimate of the mean is greater than that based only on the observations for the short sequence. These results also were obtained by W. G. Cochran (1953) in an earlier and independent study of a double sampling problem. J. R. Rosenblatt (1959) showed that the lengthened sequence yields a biased estimate of the variance, and that the reliability of this estimate is greater than that based only on the observations for the short sequence if the product-moment correlation coefficient exceeds about 0.8. M. B. Fiering (1963) obtained somewhat similar results for the estimates of the mean and variance when more than one long sequence is related to a short sequence by a multiple linear regression. In the studies cited above, the estimated events in the lengthened sequence were regression estimates, that is, estimates which correspond to values on the line of regression. These estimates tend to yield a smaller variance than would the real observations. In order to "preserve" the variance inherent with the observations, a random component must be added to the regression estimates. This component, often referred to as noise, is normally distributed with zero mean and variance proportional to the variance of the observations for the short sequence about the line of regression. This paper reports the results of an investigation made to determine the reliability of estimates of the mean and variance computed from a lengthened sequence when noise is added to the regression values. Noise is shown to have no effect on the reliability of the estimate of the mean. However, the addition of noise is shown to lead to an unbiased estimate of the variance for the lengthened sequence. The reliability of this estimate is greater than that when no noise is added to the regression values. STATISTICAL MODEL The long and short sequences for a pair of hydrologic phenomena are denoted by x and y. In general, the two phenomena need not be the same. If, for example, y denotes streamflow, x may denote streamflow, precipitation, temperature, or a geochronologic phenomena such as tree-ring widths. The observed events for the long and short sequences are represented as where NI is the length of the short sequence and (Ni-+-Na) is the length of the long sequence. For this representation of the two sequences, NI also denotes the concurrent period of observation. In practice, the NI observations for the short sequence need not correspond to the first NI observations of the long sequence, nor need the NI concurrent observations of x and y occur consecutively. However, there is no loss of generality if the two sequences are represented as above. The concurrent observations x and y are assumed to have a joint normal probability distribution with parameters nx, ny, a2., a2,, and p=ft