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OBJECTIVE To identify the source of a pseudo-outbreak of Mycobacterium gordonae DESIGN Outbreak investigation. SETTING University Hospital in Chicago, Ilinois. PATIENTS Hospital patients with M. gordonae-positive clinical cultures. METHODS An increase in isolation of M. gordonae from clinical cultures was noted immediately following the opening of a newly constructed hospital in January 2012. We reviewed medical records of patients with M. gordonae-positive cultures collected between January and December 2012 and cultured potable water specimens in new and old hospitals quantitatively for mycobacteria. RESULTS Of 30 patients with M. gordonae-positive clinical cultures, 25 (83.3%) were housed in the new hospital; of 35 positive specimens (sputum, bronchoalveolar lavage, gastric aspirate), 32 (91.4%) had potential for water contamination. M. gordonae was more common in water collected from the new vs. the old hospital [147 of 157 (93.6%) vs. 91 of 113 (80.5%), P=.001]. Median concentration of M. gordonae was higher in the samples from the new vs. the old hospital (208 vs. 48 colony-forming units (CFU)/mL; P<.001). Prevalence and concentration of M. gordonae were lower in water samples from ice and water dispensers [13 of 28 (46.4%) and 0 CFU/mL] compared with water samples from patient rooms and common areas [225 of 242 (93%) and 146 CFU/mL, P<.001]. CONCLUSIONS M. gordonae was common in potable water. The pseudo-outbreak of M. gordonae was likely due to increased concentrations of M. gordonae in the potable water supply of the new hospital. A silver ion-impregnated 0.5-μm filter may have been responsible for lower concentrations of M. gordonae identified in ice/water dispenser samples. Hospitals should anticipate that construction activities may amplify the presence of waterborne nontuberculous mycobacterial contaminants.

Diabetes is a complex disease, and patients face barriers to reaching glycosylated hemoglobin (HgbA1c) goals. A retrospective cohort chart review evaluated if the cost of diabetes medications is a barrier to glycemic goals in uninsured patients receiving reduced-cost medications. Thirty-five patients were followed over 6 months to determine the association between HgbA1c and medication possession, monthly income, drug costs/month/patient, and poverty level. Higher HgbA1c was associated with higher drug cost/month (P = 0.005), but better medication possession was not associated with lower HgbA1c levels. Providers should tailor care to address factors (other than cost) known to influence HgbA1c.

Difficulties encountered in the retrieval of evidence-based nursing (EBN) literature and recognition of terminology, research focus, and design differences between evidence-based medicine and nursing led to the realization that nursing needs its own filter strategies for evidence-based practice. This article describes the development and evaluation of filters that facilitate evidence-based nursing searches. An inductive, multistep methodology was employed. A sleep search strategy was developed for uniform application to all filters for filter development and evaluation purposes. An EBN matrix was next developed as a framework to illustrate conceptually the placement of nursing-sensitive filters along two axes: horizontally, an adapted nursing process, and vertically, levels of evidence. Nursing diagnosis, patient outcomes, and primary data filters were developed recursively. Through an interface with the PubMed search engine, the EBN matrix filters were inserted into a database that executes filter searches, retrieves citations, and stores and updates retrieved citations sets hourly. For evaluation purposes, the filters were subjected to sensitivity and specificity analyses and retrieval set comparisons. Once the evaluation was complete, hyperlinks providing access to any one or a combination of completed filters to the EBN matrix were created. Subject searches on any topic may be applied to the filters, which interface with PubMed. Sensitivity and specificity for the combined nursing diagnosis and primary data filter were 64% and 99%, respectively; for the patient outcomes filter, the results were 75% and 71%, respectively. Comparisons were made between the EBN matrix filters (nursing diagnosis and primary data) and PubMed's Clinical Queries (diagnosis and sensitivity) filters. Additional comparisons examined publication types and indexing differences. Review articles accounted for the majority of the publication type differences, because \"review\" was accepted by the CQ but was \"NOT'd\" by the EBN filter. Indexing comparisons revealed that although the term \"nursing diagnosis\" is in Medical Subject Headings (MeSH), the nursing diagnoses themselves (e.g., sleep deprivation, disturbed sleep pattern) are not indexed as nursing diagnoses. As a result, abstracts deemed to be appropriate nursing diagnosis by the EBN filter were not accepted by the CQ diagnosis filter. The EBN filter capture of desired articles may be enhanced by further refinement to achieve a greater degree of filter sensitivity. Retrieval set comparisons revealed publication type differences and indexing issues. The EBN matrix filter \"NOT'd\" out \"review,\" while the CQ filter did not. Indexing issues were identified that explained the retrieval of articles deemed appropriate by the EBN filter matrix but not included in the CQ retrieval. These results have MeSH definition and indexing implications as well as implications for clinical decision support in nursing practice.

Purpose To develop a vision for the future of disaster nursing, identify barriers and facilitators to achieving the vision, and develop recommendations for nursing practice, education, policy, and research. Design and Methods A series of semistructured conference calls were conducted with 14 national subject matter experts to generate relevant concepts regarding national nursing workforce preparedness. An invitational daylong workshop hosted by the Veterans Emergency Management Evaluation Center, U.S. Department of Veterans Affairs, was held in December 2014 to expand and refine these concepts. Workshop participants included 70 nurses, emergency managers, and a broad range of public health professionals. Conference call notes and audiotapes of the workshop were transcribed and thematic analysis conducted to outline a vision for the future of nursing in disaster preparedness and response, and to articulate an agenda for nursing practice, education, policy, and research to achieve that vision. Findings The group developed a vision for the future of disaster nursing, and identified current barriers and opportunities to advance professional disaster nursing. A broad array of recommendations for nursing practice, education, policy, and research, as well as implementation challenges, are summarized in this article. Conclusions This project represents an important step toward enhancing nurses’ roles as leaders, educators, responders, policymakers, and researchers in disaster preparedness and response. Nurses and the health and human service organizations that employ them are encouraged to engage in an expansive national dialogue regarding how to best incorporate the vision and recommendations into their individual lives and the organizations for which they work. Clinical Relevance Nurses comprise the largest healthcare workforce, and opportunities exist to strengthen disaster readiness, enhance national surge capacity, and build community resiliency to disasters.

The isomerase activity of Cyclophilin A is important for midbody abscission during cell division, however, to date, midbody substrates remain unknown. In this study, we report that the GTP-binding protein Septin 2 interacts with Cyclophilin A. We highlight a dynamic series of Septin 2 phenotypes at the midbody, previously undescribed in human cells. Furthermore, Cyclophilin A depletion or loss of isomerase activity is sufficient to induce phenotypic Septin 2 defects at the midbody. Structural and molecular analysis reveals that Septin 2 proline 259 is important for interaction with Cyclophilin A. Moreover, an isomerisation-deficient EGFP-Septin 2 proline 259 mutant displays defective midbody localisation and undergoes impaired abscission, which is consistent with data from cells with loss of Cyclophilin A expression or activity. Collectively, these data reveal Septin 2 as a novel interacting partner and isomerase substrate of Cyclophilin A at the midbody that is required for abscission during cytokinesis in cancer cells.

Background Therapeutic antibiotic dose monitoring can be particularly challenging in septic patients requiring renal replacement therapy. Our aim was to conduct an exploratory population pharmacokinetic (PK) analysis on PK of vancomycin following intermittent infusion in critically ill patients receiving continuous venovenous haemodiafiltration (CVVHDF); focussing on the influence of dialysis-related covariates. Methods This was a retrospective single-centre tertiary level intensive care unit (ICU) study, which included patients treated concurrently with vancomycin and CVVHDF between January 2015 and July 2016. We extracted clinical, laboratory and dialysis data from the electronic healthcare record (EHR), using strict inclusion criteria. A population PK analysis was conducted with a one-compartment model using the PMetrics population PK modelling package. A base structural model was developed, with further analyses including clinical and dialysis-related data to improve model prediction through covariate inclusion. The final selected model simulated patient concentrations using probability of target attainment (PTA) plots to investigate the probability of different dosing regimens achieving target therapeutic concentrations. Results A total of 106 vancomycin dosing intervals (155 levels) in 24 patients were examined. An acceptable 1-compartment base model was produced (Plots of observed vs. population predicted concentrations (Obs–Pred) R 2  = 0.78). No continuous covariates explored resulted in a clear improvement over the base model. Inclusion of anticoagulation modality and vasopressor use as categorical covariates resulted in similar PK parameter estimates, with a trend towards lower parameter estimate variability when using regional citrate anti-coagulation or without vasopressor use. Simulations using PTA plots suggested that a 2 g loading dose followed by 750 mg 12 hourly as maintenance dose, commencing 12 h after loading, is required to achieve adequate early target trough concentrations of at least 15 mg/L. Conclusions PTA simulations suggest that acceptable trough vancomycin concentrations can be achieved early in treatment with a 2 g loading dose and maintenance dose of 750 mg 12 hourly for critically ill patients on CVVHDF.

The following article discusses the challenges associated with the teaching and learning of the language of mathematics. Because this specialized language is critical in communicating, recording, and reasoning mathematically, we begin by describing the components of mathematical language. [...]valid mathematical arguments depend on truth alone. [...]we decided to create our own disciplinary language tasks by revising several available English Language Arts (ELA) lessons and extending our search to social media. Because mathematically gifted students \"need greater depth and breadth and open-ended opportunities\" (Sheffield, 1994), we combined best practices for language instruction with best practices for gifted education. Encourage students to write and illustrate a humorous poem, children's book, or comic that centers on the use (or misuse) of mathematical homonyms (see National Council of Teachers of Mathematics, 2011, for a list of homonyms).

IntroductionIntraneural perineurioma (IP) classically causes a progressive, painless mononeuropathy, usually in young adults, and most frequently affecting the sciatic nerve or its branches. Pathological features are pathognomonic, but the radiological findings are also diagnostic; focal fusiform hypertro- phy and high signal on T2 MRI, with avid homogeneous enhancement. We present two cases of diffuse disease causing upper-limb plexopathy.MethodsPatients were evaluated at two specialist neuromuscular centres.ResultsPatient 1, a 20 year-old male, presented with a 12-year history of progressive distal then proximal, bilateral upper limb amyotrophy and sensory loss. Neurophysiology suggested an axonal process without evidence of conduction block or dispersion. MRI showed bilateral brachial plexus hypertrophy with avid enhancement. Dorsal ulnar nerve biopsy confirmed IP. Patient 2, a 41 year-old male, presented with more than a 20-year history of right lower cranial nerve palsies and right shoulder girdle amyotrophy, with distal left upper limb amyotrophy. Imaging was near identical to Patient 1, and brachial plexus biopsy confirmed IP, which in this case extended to the cranial nerves.ConclusionsDiffuse IP is extremely rare. We report cases of progressive upper-limb disease confirmed on distal and proximal biopsy. The phenotype and radiological findings should prompt consideration of the diagnosis.

Purpose Climate change, human conflict, and emerging infectious diseases are inexorable actors in our rapidly evolving healthcare landscape that are triggering an ever‐increasing number of disaster events. A global nursing workforce is needed that possesses the knowledge, skills, and abilities to respond to any disaster or large‐scale public health emergency in a timely and appropriate manner. The purpose of this article is to articulate a compelling mandate for the advancement of disaster nursing education within the United States with clear action steps in order to contribute to the achievement of this vision. Design and Methods A national panel of invited disaster nursing experts was convened through a series of monthly semistructured conference calls to work collectively towards the achievement of a national agenda for the future of disaster nursing education. Findings National nursing education experts have developed consensus recommendations for the advancement of disaster nursing education in the United States. This article proposes next steps and action items to achieve the desired vision of national nurse readiness. Conclusions Novel action steps for expanding disaster educational opportunities across the continuum of nursing are proposed in response to the current compelling need to prepare for, respond to, and mitigate the impact of disasters on human health. U.S. educational institutions and health and human service organizations that employ nurses must commit to increasing access to a variety of quality disaster‐related educational programs for nurses and nurse leaders. Clinical Relevance Opportunities exist to strengthen disaster readiness and enhance national health security by expanding educational programming and training for nurses.

IntroductionStrachan’s syndrome was originally described in Jamaican plantation workers in 1887. Affected individuals exhibit sensory, optic and auditory neuropathy. A nutritional cause has been suggested, and supported given its similarities to other endemic neuropathies, including in Cuba, Tanzania and Somalia. It is commonly seen in British Black African and Caribbean individuals, including siblings, following dietary restriction or acute illness leading to catabolic stress.MethodsThis study aims to characterise the clinical features and genetic profiles of a cohort of UK patients with Strachan’s syndrome and to increase recognition of the syndrome amongst UK neurologists.ResultsThirty patients including two sets of unrelated siblings were identified with a clinical diagnosis of Strachan’s syndrome. Plasma acylcarnitine and urine organic acid profiles measured acutely revealed elevated short, medium and long chain acyl carnitines. Muscle biopsies revealed a reduction in mito- chondrial DNA copy number and ragged red fibres in some individuals. Perivascular inflammatory cell infiltrate was evident in sural nerve biopsies.ConclusionStrachan’s syndrome may result from riboflavin deficiency. The occurrence of the syndrome in siblings and high prevalence in the UK Jamaican community suggests a genetic predisposition. We propose a low index of suspicion and early treatment with high dose B vitamins and riboflavin.