It has become a national priority to have an effective care delivery system for the 21st century. Improving the quality of care and ensuring that the care delivered in a patient-centered framework are goals for many organizations. Nursing practice will be at the core of these changes, working at the point of service as well as at the organizational level. In response to the need for nursing to realign our practices in accordance with the new healthcare mandate, the American Association of Colleges of Nursing has developed the clinical nurse leader (CNL) role. The CNL is a master’s-prepared RN educated to enhance the efficiency of care delivery and facilitate the coordination of care at the bedside through effective collaboration with all healthcare providers. Clinical nurse leader competencies align with key messages highlighted in the Institute of Medicine’s 2010 report on The Future of Nursing, including the need for a highly educated nursing workforce practicing at their full scope, and for RNs to become full partners with physicians and other health professionals in redesigning healthcare. The CNL role has been demonstrated to improve patient outcomes, but it has not been widely adopted throughout the country. This article describes how a progressive care unit (PCU) redesigned its care delivery system to implement the CNL role, using Kotter’s Eight Change Phases model as a guide.

In this study, we demonstrate the complexities of performing a sibling analysis with a re-examination of associations between cell phone exposures and behavioral problems observed previously in the Danish National Birth Cohort. Children (52,680; including 5441 siblings) followed up to age 7 were included. We examined differences in exposures and behavioral problems between siblings and non-siblings and by birth order and birth year. We estimated associations between cell phone exposures and behavioral problems while accounting for the random family effect among siblings. The association of behavioral problems with both prenatal and postnatal exposure differed between siblings (odds ratio (OR): 1.07; 95% confidence interval (CI): 0.69-1.66) and non-siblings (OR: 1.54; 95% CI: 1.36-1.74) and within siblings by birth order; the association was strongest for first-born siblings (OR: 1.72; 95% CI: 0.86-3.42) and negative for later-born siblings (OR: 0.63; 95% CI: 0.31-1.25), which may be because of increases in cell phone use with later birth year. Sibling analysis can be a powerful tool for (partially) accounting for confounding by invariant unmeasured within-family factors, but it cannot account for uncontrolled confounding by varying family-level factors, such as those that vary with time and birth order. © 2014 Nature America, Inc. All rights reserved.

Study question

Does parental fertility, measured by time to pregnancy (TTP), or use of medically assisted reproduction (MAR) affect pubertal development in the offspring?

Summary answer

Neither TTP nor type of MAR treatment had clinically relevant implications for mean age at achieving individual pubertal milestones or overall timing of puberty in boys and girls.

What is known already

Parental TTP and MAR have been associated with impaired semen quality in adult sons. Timing of puberty reflects earlier signals of reproductive health, but it remains unclear whether parental fertility or MAR affects pubertal development, especially in the growing generation of children conceived by IVF or ICSI.

Study design, size, duration

In this study, 15 819 children born by mothers in the Danish National Birth Cohort from 2000 to 2003 participated in a nationwide puberty cohort (participation rate = 70%). Parental TTP and use of MAR were reported by mothers in early pregnancy and children's pubertal development data was self-recorded in web-based questionnaires from 11 years of age and 6 monthly throughout puberty (2012-2018).

Participants/materials, setting, methods

Pubertal development in children (of planned pregnancies, n = 13 285) born by untreated subfecund (TTP: 6-12 months) (n =2038), untreated severely subfeund (TTP: >12 months) (n = 1242), treated subfecund (n = 230) and treated severely subfecund (n = 1234) parents were compared to children born to more fertile parents (TTP: ≤5 months). We estimated mean monthly differences in mean age at achieving individual pubertal milestones (i.e. age at menarche, voice break, first ejaculation and Tanner stages 2, 3, 4 and 5 for breast or genital development and pubic hair growth) and a combined indicator of timing of puberty. Further, we compared mean age at achieving the individual pubertal milestones in children born by use of IVF or ICSI (n = 480) with children born by controlled ovarian stimulation or ovulation induction with or without intrauterine insemination (n = 902).

Main results and the role of chance

We found tendencies towards slightly later mean age at male pubertal timing and slightly earlier mean age at female pubertal timing among children born by untreated subfecund, treated subfecund, untreated severely subfecund and treated severely subfecund parents. There were no specific patterns with increasing TTP, use of MAR nor type of MAR treatment, and the magnitude of the mean differences for individual milestones and overall timing of puberty were small, i.e. 0.9 months (95% CI: -1.0; 2.8) for first ejaculation and -0.5 months (95% CI: -2.0; 1.0) months for age at menarche in boys and girls, respectively, born by treated severely subfecund parents when compared with children born by more fertile parents.

Limitations, reasons for caution

Non-differential misclassification of the self-reported information on parental TTP and pubertal development in the offspring may serve as an alternative explanation of the findings, possibly biasing the estimates towards the null. The information on pubertal development was collected from around 11 years of age and onwards.

Wider implications of the findings

This study adds to the growing body of literature suggesting only limited harmful effects of parental subfecundity and MAR on offspring's long-term growth and development.

Study funding/competing interest(s)

This work was supported by the Danish Council for Independent Research [DFF 4183-00152]; and the Faculty of Health at Aarhus University. The authors have no financial relationships or competing interests to disclose.

Article 25 of the United Nations' Universal Declaration of Human Rights enshrines the right to health and well-being for every individual. However, universal access to high-quality healthcare remains the purview of a handful of wealthy nations. This is no more apparent than in peri-operative care, where an estimated five billion individuals lack access to safe, affordable and timely surgical care. Delivery of surgery and anaesthesia in low-resource environments presents unique challenges that, when unaddressed, result in limited access to low-quality care. Current peri-operative research and clinical guidance often fail to acknowledge these system-level deficits and therefore have limited applicability in low-resource settings. In this manuscript, the authors priority-set the need for equitable access to high-quality peri-operative care and analyse the system-level contributors to excess peri-operative mortality rates, a key marker of quality of care. To provide examples of how research and investment may close the equity gap, a modified Delphi method was adopted to curate and appraise interventions which may, with subsequent research and evaluation, begin to address the barriers to high-quality peri-operative care in low- and middle-income countries.

We report a Dalitz plot analysis of charmless hadronic decays of charged B mesons to the final state KS0π+π0 using the full BABAR data set of 470.9±2.8 million BB events collected at the ϒ(4S) resonance. We measure the overall branching fraction and CP asymmetry to be B(B+→K0π+π0)=(31.8±1.8±2.1-0.0+6.0)×10-6 and ACP(B+→K0π+π0)=0.07±0.05±0.03-0.03+0.02, where the uncertainties are statistical, systematic, and due to the signal model, respectively. This is the first measurement of the branching fraction for B+→K0π+π0. We find first evidence of a CP asymmetry in B+→K∗(892)+π0 decays: ACP(B+→K∗(892)+π0)=-0.52±0.14±0.04-0.02+0.04. The significance of this asymmetry, including systematic and model uncertainties, is 3.4 standard deviations. We also measure the branching fractions and CP asymmetries for three other intermediate decay modes.

We measure the time-dependent CP asymmetry in the radiative-penguin decay B0→KS0π-π+γ, using a sample of 471×106 (4S)→BB-events recorded with the BABAR detector at the PEP-II e+e- storage ring at SLAC. Using events with mKππ<1.8 GeV/c2, we measure the branching fractions of B+→K+π-π+γ and B0→K0π-π+γ, the branching fractions of the kaonic resonances decaying to K+π-π+, as well as the overall branching fractions of the B+→ρ0K+γ, B+→K∗0π+γ and S-wave B+→(Kπ)0∗0π+γ components. For events from the ρ mass band, we measure the CP-violating parameters SKS0π+π-γ=0.14±0.25±0.03 and CKS0π+π-γ=-0.39±0.20-0.02+0.03, where the first uncertainties are statistical and the second are systematic. We extract from this measurement the time-dependent CP asymmetry related to the CP eigenstate ρ0KS0 and obtain SKS0ργ=-0.18±0.32-0.05+0.06, which provides information on the photon polarization in the underlying b→sγ transition.

We present measurements of Collins asymmetries in the inclusive process e+e-→h1h2X, h1h2=KK, Kπ, ππ, at the center-of-mass energy of 10.6 GeV, using a data sample of 468 fb-1 collected by the BABAR experiment at the PEP-II B factory at SLAC National Accelerator Center. Considering hadrons in opposite thrust hemispheres of hadronic events, we observe clear azimuthal asymmetries in the ratio of unlike sign to like sign, and unlike sign to all charged h1h2 pairs, which increase with hadron energies. The Kπ asymmetries are similar to those measured for the ππ pairs, whereas those measured for high-energy KK pairs are, in general, larger.

The e+e-→K+K- cross section and charged-kaon electromagnetic form factor are measured in the e+e- center-of-mass energy range (E) from 2.6 to 8.0 GeV using the initial-state radiation technique with an undetected photon. The study is performed using 469fb-1 of data collected with the BABAR detector at the PEP-II2 e+e- collider at center-of-mass energies near 10.6 GeV. The form factor is found to decrease with energy faster than 1/E2 and approaches the asymptotic QCD prediction. Production of the K+K- final state through the J/ψ and ψ(2S) intermediate states is observed. The results for the kaon form factor are used together with data from other experiments to perform a model-independent determination of the relative phases between electromagnetic (single-photon) and strong amplitudes in J/ψ and ψ(2S)→K+K- decays. The values of the branching fractions measured in the reaction e+e-→K+K- are shifted relative to their true values due to interference between resonant and nonresonant amplitudes. The values of these shifts are determined to be about ±5% for the J/ψ meson and ±15% for the ψ(2S) meson.

Based on a sample of 500 million e+e-→cc¯ events recorded by the BABAR detector at c.m. energies of close to 10.6 GeV, we report on a study of the decay D0→π-e+νe. We measure the ratio of branching fractions, RD=B(D0→π-e+νe)/B(D0→K-π+)=0.0713±0.0017stat±0.0024syst, and use the present world average for B(D0→K-π+) to obtain B(D0→π-e+νe)=(2.770±0.068stat±0.092syst±0.037ext)×10-3 where the third error accounts for the uncertainty on the branching fraction for the reference channel. The measured dependence of the differential branching fraction on q2, the four-momentum transfer squared between the D and the π meson, is compared to various theoretical predictions for the hadronic form factor, f+,Dπ(q2), and the normalization |Vcd|×f+,Dπ(q2=0)=0.1374±0.0038stat±0.0022syst±0.0009ext. is extracted from a fit to data. Using the most recent LQCD prediction of f+,Dπ(q2=0)=0.666±0.029, we obtain |Vcd|=0.206±0.007exp±0.009LQCD. Assuming, instead, |Vcd|=|Vus|=0.2252±0.0009, we obtain f+,Dπ(q2=0)=0.610±0.020exp±0.005ext. The q2 dependence of f+,Dπ(q2) is compared to a variety of multipole parametrizations. This information is applied to B0→π-e+νe decays and, combined with an earlier B0→π-e+νe measurement by BABAR, is used to derive estimates of |Vub|.

We study the processes e+e-→KS0KL0γ, KS0KL0π+π-γ, KS0KS0π+π-γ, and KS0KS0K+K-γ, where the photon is radiated from the initial state, providing cross section measurements for the hadronic states over a continuum of center-of-mass energies. The results are based on 469fb-1 of data collected with the BABAR detector at SLAC. We observe the φ(1020) resonance in the KS0KL0 final state and measure the product of its electronic width and branching fraction with about 3% uncertainty. We present a measurement of the e+e-→KS0KL0 cross section in the energy range from 1.06 to 2.2 GeV and observe the production of a resonance at 1.67 GeV. We present the first measurements of the e+e-→KS0KL0π+π-, KS0KS0π+π-, and KS0KS0K+K- cross sections and study the intermediate resonance structures. We obtain the first observations of J/ψ decay to the KS0KL0π+π-, KS0KS0π+π-, and KS0KS0K+K- final states. © 2014 American Physical Society.