Loss of cell cycle control is characteristic of tumorigenesis. The protein p21 is the founding member of cyclin-dependent kinase inhibitors and an important versatile cell cycle protein. p21 is transcriptionally controlled by p53 and p53-independent pathways. Its expression is increased in response to various intra- and extracellular stimuli to arrest the cell cycle ensuring genomic stability. Apart from its roles in cell cycle regulation including mitosis, p21 is involved in differentiation, cell migration, cytoskeletal dynamics, apoptosis, transcription, DNA repair, reprogramming of induced pluripotent stem cells, autophagy and the onset of senescence. p21 acts either as a tumor suppressor or as an oncogene depending largely on the cellular context, its subcellular localization and posttranslational modifications. In the present review, we briefly mention the general functions of p21 and summarize its roles in differentiation, migration and invasion in detail. Finally, regarding its dual role as tumor suppressor and oncogene, we highlight the potential, difficulties and risks of using p21 as a biomarker as well as a therapeutic target. CDKN1A, is the founding member of cyclin-dependent kinase (Cdk) inhibitors (CKI) [p21, encoded by the gene rs (CKI) ,4. Due trs (CKI) . It is wrs (CKI)  with a prs (CKI) . As a crrs (CKI) , p21 is rs (CKI) ,10, distrs (CKI)  as well rs (CKI) ,12. Revers (CKI) ,13. In prs (CKI) ,15,16. IThe independent discovery of p21 by different groups leads to its numerous names ,19,20,21In general, p21 is an important regulator of cell cycle checkpoints ensuring proper cell division. p21 inhibits cell proliferation directly through binding to Cdks  and prolIntriguingly, contradictory to its function as an inhibitor, low concentrations of p21 promote proliferation through the assembly and activation of cyclin D/Cdk4 or Cdk6 complexes in cancer cell lines . This isAdditionally, several studies revealed that p21 is involved in the major DNA repair pathways, which is attributed to its high PCNA binding capacity . HoweverThe “antagonistic duality” of p21  is partiIn essence, p21 does not work solely as a tumor suppressor preserving genomic stability, permitting cell cycle arrest or senescence and enabling DNA repair. Meanwhile, there is increasing awareness of its oncogenic potential, often attributed to its cytoplasmic localization , promotiOf note, the individual roles of p21 should not be viewed in isolation. Instead, its multifaceted functions are interconnected and reciprocally influenced by each other.From its cDNA isolation, p21 is associated with differentiation . Using sSeveral lines of evidence indicate that p21 plays either a positive or negative role in differentiation depending on the cell type and the stage of differentiation . OverexpMoreover, p21’s cytoplasmic localization plays a positive role for normal cell differentiation: the cytoplasmic residing of p21 was observed in mature human monocytes  and rat SOX2) [High attention has been paid to the link between p21 and differentiation/renewal of stem/progenitor cells. Interestingly, the reprogramming efficiency was highly increased upon depletion of p53 or p21 in MEFs ,66. The SOX2) . p21 is SOX2) , keratinSOX2)  and neurSOX2)  of mice.SOX2) . OverallSOX2) . In addiSOX2) . In contSOX2) ,96,97, pβ (TGF-β) [p21 is also involved in human cancer cell differentiation and development. In particular, epithelial–mesenchymal transition (EMT) and its reverse form mesenchymal–epithelial transition (MET) are crucial differential processes in cancer progression. While the activation of EMT permits cancer cells to acquire migratory, invasive and stem-like properties, MET is associated with the tumor-initiating ability required for metastatic colonization . Markedl (TGF-β) . p21 rep (TGF-β) . Consist (TGF-β)  as well  (TGF-β) . Silenci (TGF-β) .In further supporting p21’s role in cancer cell differentiation, the expression of p21 increases in various human malignant cell lines including lymphoma-derived cell line U937 ,105,106,Loss of differentiation control can lead to a variety of diseases including cancer . The entLRR1) acting as a critical regulator of cell motility promoting a non-motile, stationary cell state by preventing p21 from inhibiting the RhoA/ROCK/LIMK pathway [Cell migration is a tightly integrated process orchestrating embryonic morphogenesis and contributing to tissue homeostasis . Defects pathway . Knockin pathway . These m pathway . Moreove pathway ,128 or H pathway ,130,131. pathway .Oppositely, the complex of cytoplasmic p21 together with ectopic expressed cytosol-resided p53  suppresses cell invasion due to favoring apoptotic induction by targeting B-cell lymphoma 2 family proteins in non-small cell lung cancer cell line H1299 . It has β mediated breast cancer cell migration and invasion, whereas its gene silencing blocked the tumor invasion in a mammary fat pad xenograft mouse model and various triple negative breast cancer cell lines, without alterations in cell growth and proliferation [β-induced cell migration [p21 functioning as transcription factor/co-factor is essential for TGF-feration . In thisferation . Moreoveigration . In accoigration . Togetheigration . Suppresigration . p21 knoigration . The lonigration . Nuclearigration . Recentligration . After 1igration . The susigration .The role of p21 in migration/invasion is associated with the environmental and cellular context, which is not unexpected, considering the reciprocal impact between versatile factors and p21.p21 is often deregulated in human cancer. Depending on the cellular context, p21 promotes or inhibits tumorigenesis, extensively summarized by Abbas and Dutta ,4. Thougp21 is often decreased in human cancer through loss of functional p53 or hyperactive oncogenes like c-Myc: p53 mutations have been discovered in more than 50% of human malignancies , whereasIn line with p21’s “antagonistic duality” , its oveAlthough p21 knockout mice were initially described to remain tumor-free until the age of seven months , a subseCdkn1a;Puma;Noxa triple-knockout mice did not develop spontaneous tumors until the age of 500 days, suggesting the existence of additional pathways serving as mediators of p53-driven tumor suppression [Conversely, p21 depletion in a c-Myc background decreased the overall tumor onset , and it pression . In sum,Given p21’s “antagonistic duality”  in varioSimply interfering with p21 as anti-cancer therapy bears risks and undesired side effects. First, increasing p21 can cause senescence, a supposed permanent growth arrest , which wSecond, considering p21’s role in the cell cycle, stem cell differentiation and EMT of tumor cells, depleting p21 may result in either tumor suppressive or oncogenic effects depending on the cellular context. Cancer stem cells have been suggested to promote tumorigenesis as “seeds for metastasis” . p21 is LRR1 and the LRR1 gene is located at chromosome 14q21.3, which is frequently lost in metastatic cancer including breast cancer [Third, targeting cytoplasmic p21 is highly promising, as it contributes to tumor cell survival by inhibiting apoptosis, promoting cell migration and causing drug resistance ,16,157. t cancer ,203. AccCollectively, cytoplasmic localization of p21 could be a reliable biomarker and a promising intervention target. General targeting p21 will be associated with undesirable effects, regarding its multifaceted functions in stress-responsive senescence induction, apoptosis control, cell cycle regulation, genome integrity and stem cell maintenance.Given its differential expression and localization in human cancer, p21 could be targeted by three approaches : first, Currently, the best approach would be to target cytoplasmic p21, to inhibit its anti-apoptotic properties and to sensitize chemotherapy resistant cancer cells, as demonstrated in renal cell carcinoma  or breasBeing known over 25 years, p21 is still a challenging and fascinating protein. Rather than simply being a tumor suppressor, p21 also has oncogenic potential, demonstrated particularly by its sustained expression and its cytoplasmic localization, leading to chemoresistance and tumor heterogeneity, and reflecting its dual functionality depending on the cellular and environmental context. A great body of clinical, preclinical and cell-based studies provides insight into its molecular understanding, very often accompanied by inconsistency and divergence. While p21 conveys its multifaceted roles and impacts various fundamental cellular activities including cell differentiation and migration, its own regulation is dynamically affected by intra- and extracellular events. p21’s expression and localization influence the cellular response to external stimuli including chemotherapeutics. These agents, in turn, impact p21’s expression, localization, postmodification, stability and functions. Due to its functional “duality”  and its


As mobile devices and apps grow in popularity, they are increasingly being used by health care providers to aid clinical care. At our institution, we developed and implemented a point-of-care clinical photography app that also permitted the capture of video recordings; however, the clinical findings it was used to capture and the outcomes that resulted following video recording were unclear.The study aimed to assess the use of a mobile clinical video recording app at our institution and its impact on clinical care.A single reviewer retrospectively reviewed video recordings captured between April 2016 and July 2017, associated metadata, and patient records.We identified 362 video recordings that were eligible for inclusion. Most video recordings  were captured by attending physicians. Specialties recording a high number of video recordings included orthopedic surgery , neurology , and ophthalmology . Consent was clearly documented in the medical record in less than one-third  of the records. People other than the patient were incidentally captured in 29.6% (107/362) of video recordings. Although video recordings were infrequently referenced in notes corresponding to the clinical encounter , 7.7% (22/286) of patients were video recorded in subsequent clinical encounters, with 82% (18/22) of these corresponding to the same finding seen in the index video. Store-and-forward telemedicine was documented in clinical notes in only 2 cases . Videos appeared to be of acceptable quality for clinical purposes.Video recordings were captured in a variety of clinical settings. Documentation of consent was inconsistent, and other individuals were incidentally included in videos. Although clinical impact was not always clearly evident through retrospective review because of limited documentation, potential uses include documentation for future reference and store-and-forward telemedicine. Repeat video recordings of the same finding provide evidence of use to track the findings over time. Clinical video recordings have the potential to support clinical care; however, documentation of consent requires standardization. Mayo Clinic’s institutional archives reference the use of video cameras to record surgeries as early as the 1930s using equipment that would be considered bulky by today’s standards. Historical photographs show videographers perched from balconies above operating theaters to record surgeries . As the At present, video cameras remain in use to capture medical procedures for the purposes of quality improvement, training, and research ,2. A recAt present, cameras available in smartphones arguably capture photographs and video recordings with better quality than most consumer-grade digital cameras that were available less than a decade ago. In a time when at least 77% of Americans own smartphones and more than 86% of physicians report using an electronic health record (EHR), merging both technologies presents an attractive and convenient opportunity to enhance point-of-care documentation ,11. IndeWe previously described the implementation of a mobile app (PhotoExam) for point-of-care clinical photography at Mayo Clinic , includiThe PhotoExam app has predominantly been used for its photography function, which allows authorized users to securely photograph a clinical finding and tag it with metadata . However, more recent versions of the PhotoExam app include capability to capture and upload video recordings.As it was unclear how the video recording function was being used in clinical practice and we were unable to identify literature about the use of point-of-care mobile clinical video recording technology elsewhere, we aimed to assess the following attributes of video recordings captured using the PhotoExam app: (1) who was capturing video recordings , (2) what clinical findings were being captured on video recordings, and (3) was there a measurable impact of video recordings on patient care. Therefore, we retrospectively reviewed video recordings, their associated metadata, and patient records to assess the use and impact of the PhotoExam video recording feature.App Store and is compatible with recent versions of iOS. Its release and updates were announced in internal communications . Any health care staff with access to the EHR can use the app while their device is securely connected behind the institutional firewall. Use of the app was not mandated by the institution. Although we are not aware of specific, formal departmental initiatives promoting use, we cannot rule out the possibility that departmental quality improvement initiatives may have encouraged use within specific specialties. Our anecdotal experience has been that clinical champions within a department often encouraged colleagues to use the app. The features and functionality of the video recording function are identical to those previously described for the photography function [The PhotoExam app is available to health care providers at all Mayo Clinic sites via an internal function  except tThe users did not receive any formal training on practical aspects such as use case scenarios or how to capture clinically relevant video recordings with high fidelity. However, an internally accessible website provided technical support and instructions on the app’s use. We are unaware of formal integration of the app into medical training programs; however, users included residents and fellows in training.The study procedures were reviewed and approved by the Mayo Clinic’s institutional review board.We queried the clinical asset management database to identify all video recordings taken using the PhotoExam app between April 15, 2016, (when the video recording feature first became available) and July 17, 2017. We excluded records corresponding to patients who refused the use of their medical records for research purposes, known test patients  and incidental video recordings .Employee work role and department were identified by cross-referencing a human resources database. These data were missing in the data source for a small number of users who were no longer employed by Mayo Clinic at the time of the query. Data available by review of the video recording and the patient medical records were extracted by 1 reviewer (JCC). Data were extracted into a data extraction form in REDCap  and expoLacking a standardized tool to assess the quality of provider-captured clinical video recordings, we adapted the quality assessment rubric used previously for assessing photographs taken using PhotoExam . By consDoes image quality or blurriness limit ability to see the area of focus?Does the video recording objectively portray size using a ruler?Does the video recording zoom in or out or move around to optimally characterize the finding as needed?Is there sufficient lighting and color differentiation to see the area of focus?Is the audio clear and audible (if present)?Is the video recording image stable?Is the video recording right side up?yes on questions 2, 3, 4, 5, 6, and 7, and a favorable score was awarded for an answer of no on question 1. A quality score was calculated as a percentage of applicable favorable scores awarded on rubric items. For video recordings that included sound, the total score was calculated as a percentage of items out of 7. For video recordings that did not include sound, the total score was calculated as a percentage of items out of 6 because item 5 did not apply.A favorable score was awarded for an answer of other. Throughout the paper, sample sizes for features with missing data or for subsets of interest are indicated in italics in parentheses. Results are reported at the video recording level—rather than patient level—unless otherwise specified. Statistical analyses were performed using SAS version 9.4 (SAS Institute). All tests were 2 sided, and P values less than .05 were considered statistically significant.Continuous features were summarized with means and standard deviations when approximately normally distributed and with medians and interquartile ranges otherwise. Categorical features were summarized with frequency counts and percentages. For differences in quality score, referral generation, and consent documentation between specialties, analysis of variance and chi-square tests were performed across the most common user specialties  with all other specialties grouped together as test patient record that had not been identified in the initial screening process, and 16 video recordings appeared to be incidentally recorded. These video recordings were all excluded, yielding 362 video recordings of 286 patients that were included in the study , and patients were largely white , followed by nurses  and residents/fellows . When assessed according to clinical department, approximately one-third  of video recordings were taken within orthopedic surgery, 21.9% (77/351) were taken within neurology, and 15.7% (55/351) of video recordings were taken within ophthalmology..To assess the extent of utilization of the app, we assessed the number of video recordings or photographs taken of the patient during each clinical encounter. To assess the provider’s experience level, we measured the cumulative number of video recordings and photographs the recording provider had previously captured using the app as of the time of each video recording. In most cases, only 1 video recording was recorded during the encounter and no photographs were captured . FurtherPatients included in 22 video recordings  were video recorded during subsequent clinical encounters, with 82% (18/22) of video recordings of these patients demonstrating the same finding seen in the index video.Similarly, 19.2% (55/286) of patients’ video recordings were associated with additional photographs taken using the PhotoExam app. In 71% (39/55) of these cases, the photographed finding was the same as the video-recorded finding.Independent of the recording provider’s identified specialty, clinical findings were classified according to finding specialty categories. In 107  video recordings, we noted that people other than the patient were incidentally captured. In 80  of these, medical personnel were included, and in 31  video recordings, other people who had accompanied the patient to the visit  were included. As both medical personnel and other people who had accompanied a patient to a visit could have been captured in the same video recording, these percentages add up to greater than 100%.As the PhotoExam app allows the user to include or omit the recording of sound, we were interested in the inclusion and content of the recorded audio. Audio was only recorded in 118  video recordings. In 36.4% (43/118) of cases, only background noise was captured, suggesting that audio did not need to be recorded in those cases. In 55.1% (65/118) of cases, the audio included provider instructions , and in 11.0% (13/118) of cases, providers recorded commentary  about the observed findings. In 28.0% (33/118) of cases, sounds made by the patient, which may be relevant to an observer, were captured.Upon manual review of these 118 video recordings that included audio, the audio recorded findings were deemed to be the primary finding in 2.5% (3/118) of the video recordings, audio recorded and video recorded findings were considered equally important in 27.1% (32/118) of cases, and, in the remaining 70.3% (83/118), the video recorded finding was deemed the primary finding.other specialties, with quality scores of ophthalmology, neurology, and orthopedic surgery falling within this range (P=.59).Our quality assessment revealed that most video recordings were acceptably in focus with adequate lighting, stability, and sound. However, video recordings frequently did not adequately demonstrate scale  or perspective . The mean quality score across video recordings was 67.8 (SD 7.7)%. There was no significant difference in quality score when compared across specialties. Average quality scores ranged between 65.8% in emergency medicine and 68.5% in P<.001). Exploratory comparisons between individual specialties and the others revealed driving factors to be high rates in orthopedic surgery  compared with low rates in emergency medicine  and other  specialties .In 115  video recordings, patient consent was clearly documented in the medical record: for 113 of these video recordings (98.2%), a signed media consent form was scanned into the medical record, and for 2 video recordings (1.7%), the provider documented in the clinical note that verbal consent was obtained. There was a significant difference between specialties in terms of the percentage of video recordings that were associated with explicitly documented consent within clinical notes or a signed media consent form  video recordings were referenced in the clinical notes corresponding to the visit, and in only 2 cases  the use of telemedicine with remote, asynchronous review of the video recording by another provider was explicitly documented in the clinical notes.P<.001), with the main driver being a high rate of referrals made from the emergency department, where half of the video recordings were associated with a referral compared with 7% or fewer encounters for all other specialties.In 30 cases , an outcome of the visit was generation of a referral to a specialist. In the majority of these cases , the referral occurred on the same day. Of the 20 same-day referrals, 14 (70%) were specialist referrals made for patients seen in the emergency department. Overall, 16 total referrals were made in the emergency department, meaning that only 2 patients for whom a referral was generated in the emergency department were not seen by the specialist on the same day the referral was made. Neurology and plastic surgery accounted for the majority of the specialists consulted, contributing 10 and 6 referrals, respectively. There was a significant difference between departments in the proportion of video recordings associated with a referral  utilized the app to capture the work of the breathing of an infant with bronchiolitis who required hospital admission. Another coauthor (KDW) who was covering the pediatric ward was able to view the video from elsewhere in the hospital, and this was noted to facilitate the appropriate disposition of the patient to the intensive care unit.motor function and balance in a variety of ways. Common use cases included capturing of abnormal gait , tremors, and dystonia. Face, letter, and number recognition exercises were recorded and used to document mental status. Ophthalmologic video recordings captured slit lamp examinations, which were generally conducted without the use of a magnifying objective.Overall, 19 video recordings demonstrated Innovative uses included capturing radiographic videos , dressing of a wound and application of vacuum-assisted closure device , recording brief procedures  and capturing patient-provided video recordings .To our knowledge, this is the first report in the literature to summarize the use of a point-of-care mobile app to capture and upload clinical video recordings to the EHR in a manner that is secure and HIPAA compliant.In our initial report on the use of the photography feature of the PhotoExam app, attending physicians captured more photographs than other user groups , with nurses taking a similar number of photographs . In this study, attending physicians and nurses were still the leading users, though there was a greater discrepancy between the percentage of video recordings captured by the top user groups when compared with photographs, with attending physicians and nurses capturing 54.1% (190/351) and 19.7% (69/351) of video recordings, respectively. With respect to specialty, our initial report on PhotoExam revealed that 54.1%  of photographs were captured within dermatology and 25.6%  were captured within surgery. In contrast, leading user departments in this study were orthopedic surgery , neurology , and ophthalmology . This is not surprising as dermatology and surgery may be able to rely on static clinical findings, whereas orthopedic surgery, neurology, and ophthalmology commonly refer to active physical examination findings.Analysis of usage patterns indicated steady growth in use over time, though the number of photographs taken using the app dwarf the number of video recordings. For example, in the first 8 months after the launch of the PhotoExam app, 22,784 photographs were captured compared with 148 video recordings in the 8 months following the addition of video recording functionality to the app . There aMost video recordings were recorded at the Mayo Clinic Rochester campus. This likely—at least partly—reflects differences in patient visit volumes between sites. The majority of video recordings were taken by attending physicians. However, nurses and residents/fellows also captured a significant number of video recordings. In comparison, in our previous study on the use of the app to capture photographs, attending physicians captured more photographs than other user groups  but nurses took a similar number of photographs  . On the In addition to permitting moving images to be captured, video recordings also permit sound to be recorded. Common inclusions on audio tracks included provider commands  and a provider’s verbal description (to indicate what is being captured). Furthermore, sounds made by patients, which could be relevant to the clinical finding, were also captured.In general, video recordings were of high quality, though many did not extensively demonstrate perspective by rotating about the clinical finding, and many did not explicitly demonstrate size/scale using an objective measuring device . In retrospect, perspective may be less important for some findings  than for others  and therefore may be less relevant to consider when assessing these video recordings for quality. In addition, our rubric may have been excessively stringent by requiring the use of a ruler to be deemed as adequately demonstrating size/scale. Our previous use of this rubric for assessment of photography quality  did not Patient consent was not always clearly documented in the EHR. However, we are confident that patient consent was obtained for all video recordings because the app includes a hard stop  that requires the user to attest that consent was obtained from the patient before being permitted to proceed with photography. One reason verbal consent may not have been clearly documented in clinical notes could be that providers may have thought that attesting that consent was obtained within the app was sufficient for documentation purposes. One possible improvement to the app would be to have the user select the method of consent  and indicate the person providing consent , which would then be documented with the video recordings. During the early stages of the app’s development, the idea of having patients sign the screen of the device to provide written consent was considered. However, this option was not pursued because providers’ personal mobile devices were often used and would ideally need be sanitized before having patients handle them. Furthermore, logistical issues relating to internal form processing and practical considerations of handing a patient an unlocked mobile device that contains protected health information and other private, personal information limited our ability to pursue this mechanism for consent documentation.2-party consent states, consent is required of each staff member, family member, or friend who is a party to the recorded conversation. However, consent can be expressed or implied based on the circumstances. As in the case of the parent holding a child, if the individual is aware of the video recording and continues to participate, consent may be implied.In many cases, people other than the patient were incidentally captured in video recordings. Most of the individuals incidentally captured on the video recordings appeared to be staff members, but others appeared to be family or friends who accompanied the patient. It is unclear whether these individuals also separately provided consent to be included in the video recordings or whether their consent was implied by facilitating video recording . From a legal standpoint, patients have a fundamental right to privacy that includes the right to consent to be photographed or video recorded. Staff, family, and friends do not have the same privacy rights. Courts have held that when individuals are in public areas, such as common areas within a hospital, they do not have reasonable expectations of privacy and can be photographed and, in most states, video recorded without the need for their prior consent. In a minority of states, a recording of a conversation requires the consent of every person in the conversation. If the video recording occurs in one of these We observed evidence that video recordings favorably affected clinical care. For example, we observed that video recorded findings were either video recorded or photographed at subsequent visits, suggesting that clinical findings were being tracked over time using the app and presumably referenced at those visits for comparison. In 8% of cases, a referral to a specialist was generated, and in two-thirds of these cases, referrals occurred the same day. Furthermore, video recordings captured in the emergency department were more likely to be associated with a referral than those captured within other specialties. Although it is tempting to speculate that the existence of a video recording within the EHR facilitated or expedited referrals, we do not have additional evidence to support this hypothesis. The authors’ anecdotal experience has been that consulting specialists find video recordings helpful because they allow specialists to gather important information and provide tentative management advice before seeing the patient in-person. Review of video recordings may also help specialists prioritize consultations or expedite care when appropriate .We were disappointed that providers only infrequently mentioned video recordings within clinical notes. In fact, when video recordings were mentioned in clinical notes, they were only mentioned in notes corresponding to the clinical encounter where the video recording was recorded and were not mentioned in subsequent follow-up visits. We had anticipated that other providers who see the patient in follow-up might reference previously taken video recordings. As noted above, we speculate that providers who captured repeat video recordings or photographs at follow-up visits viewed those video recordings, but we do not have evidence of this. It is unclear whether the absence of further references in follow-up and referred consultation notes reflects an incomplete search of the patients’ medical records, a lack of viewership by subsequent physicians, a simple omission on the part of the provider in documentation, or a lack of impact of the video recording on future medical care. Video recording access log audits would help demonstrate how often other providers view the video recordings.Strengths include that we captured data from a variety of sources, including photograph metadata, human resources records, manual review of video recordings, and review of clinical documentation. We also reviewed longitudinal data to identify when additional photographs or video recordings of the captured findings were obtained.The major limitation was the use of a single reviewer to abstract data and review video recordings. Although we included patients seen at multiple sites within various settings, another limitation that limits the generalizability of our findings is that our patient population is not representative. Furthermore, we were unable to clearly associate video recordings with objective clinical outcomes. We systematically assessed the technical quality of video recordings; however, in this descriptive study, we did not include an assessment of suitability for clinical use. Conducting such an assessment in the course of our review presents several challenges. For one, the reviewer may not be familiar with the clinical requirements of a given subspecialty and may therefore not be appropriate to assess the suitability for clinical purposes. Second, the clinical utility may not be apparent or evident to those who are not directly involved in the patient’s care during a retrospective review . In part, to address this aspect of the app’s use and assess the clinical impact of the app, we separately conducted Web-based user surveys (unpublished) that included questions about use cases and outcomes of photography. To keep the survey brief and maximize the response rate, the questions asked about the app in general and did not ask the same questions separately about the photography and videography features. Most users utilized the app exclusively to capture photographs—rather than video recordings—and, therefore, responses in general were in reference to photography. Therefore, the clinical utility of the video recording feature remains an area needing study.Through the authors’ use of the app in clinical practice, a number of legal questions have arisen. Although it is out of the scope of this study to review them all, several of these questions are worth raising. For example, in video recordings where people other than the patient are included, have consent laws been violated? In some cases, consent for video recording may be implied—for example, if a parent holds a child in their lap and poses them to the video camera for photography, they are providing implied consent. However, if another patient is captured on a video recording while walking by, they have not provided implied consent. Even in cases where others may be incidentally included in video recordings, the HIPAA privacy rule permits certain incidental disclosures as long as reasonable safeguards are put in place to limit these disclosures. For example, policies, procedures, and training may be reasonable safeguards to limit incidental disclosures. In cases where others are incidentally included in recordings, other privacy rights beyond HIPAA may limit reuse of the video recording without the express consent of all parties included in the video recording.two-party consent laws that require consent of parties involved to be used as evidence in court. Another legal consideration if the video recording is to be used for legal proceedings is maintenance of the chain of custody. The use of electronic log files that document the creation and any modifications to the video recording can help maintain the chain of custody.If a recording is to be used in court proceedings, state laws may dictate consent requirements. For example, some states have In conclusion, the video recording feature of the PhotoExam app has proven to be a versatile tool that has uses within many different specialties at Mayo Clinic. Clinical video recordings offer the potential to augment clinical documentation, support assessments at follow-up visits, and facilitate telemedicine. In particular, the ability to closely track patient examination findings over time offers the potential to more accurately document chronic and progressive conditions. This technology may be used to capture objective assessments of the efficacy of treatments and medical interventions over time, and it can facilitate collaboration among multiple members of a multidisciplinary patient care team.


Studies examining organizational factors that may influence constipation management in long-term care (LTC) hospitals are lacking. This study aimed to clarify the practice of constipation management in LTC hospitals and to explore its factors, including ward manager’s perception, organizational climate, and constipation assessment.In this cross-sectional questionnaire survey of ward managers and staff nurses working in LTC wards, we determined daily assessment and practices regarding constipation management. We also conducted multivariate analyses to examine factors related to constipation management.There was a 20% response rate to the questionnaire. Nearly all LTC wards routinely assessed bowel movement frequency; other assessments were infrequent. Laxatives were used, but the use of dietary fiber and probiotic products was implemented in only 20–30% of wards. The implementation of non-pharmacological management and adequate use of stimulant laxatives were positively associated with the ward manager’s belief and knowledge, organizational climate, the existence of nursing records for constipation assessment, planned nursing care for constipation, and organized conferences and in-hospital study sessions on constipation management.Areas to improve constipation management in LTC hospitals include altering the ward manager’s perception, improving hospital’s organizational climate, and introducing standardized assessment/care planning systems. Constipation management is an essential component of long-term care (LTC) for older adults. Constipation can cause discomfort and abdominal pain , as wellNurses in LTC hospitals must provide care for older adults with severe physical and cognitive problems . The patNursing practice guidelines recommend non-pharmacological management for constipation in addition to appropriate use of laxatives . Non-phaEffective constipation management requires bowel movement assessment , includiWard managers’ perceptions and the organizational climate in LTC hospitals can contribute to effective constipation management. It has been reported that ward managers who acknowledge the importance of evidence-based nursing practice support their staff in performing evidence-based practices , 17. AddHere, we aimed to assess the current constipation management practices in LTC hospitals and to explore the factors related to constipation management, specifically individualized and daily constipation assessment in LTC hospitals, the ward managers’ perception, and the organizational climate.Constipation was defined as the condition in which a person has difficulty in comfortably passing a sufficient amount of stool .We conducted a cross-sectional questionnaire survey of ward managers and staff nurses working in LTC wards in Japan from August to September 2018. We randomly selected 1554 hospitals from 3844 hospitals with LTC wards from a hospital database representing all of Japan in 2015 .In this study, the questions posed to ward managers concerned the general characteristics of hospitals, wards, and inpatients; organizational factors; and ward manager demographic characteristics. The questions asked to staff nurses concerned their demographic characteristics, how constipation management was assessed, and the actual practice of constipation management.Hospital characteristics included hospital ownership and total number of beds. Ward characteristics included the total number of beds in the ward, average length of patient stay, bed occupancy rate, number of hospitalized patients, number of full-time registered nurses, licensed practical nurses, care workers, and type of reimbursement (types 1 or 2). To be designated as type 1 wards, more than 80% of admitted patients should have high medical acuity levels, whereas in type 2 wards, only more than 50% need to have high acuity levels . We inveWe inquired about the presence or absence of a certified nurse in wound, ostomy, and continence nursing; education availability for staff nurses ; case conferences; the existence of committees; and nursing care plans for constipated patients.The organizational climate was reported by staff nurses using a scale , rated oThe demographics of ward managers included age, sex, and qualification. Work-related variables were measured by years working in current workplace, types of workplace experience, experience in receiving education regarding constipation management , and knowledge on stimulant laxative use. To examine the ward manager’s knowledge on laxative use, we asked whether the stimulant laxatives should be used every day, rated on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree).We further examined the ward manager’s beliefs and preferences regarding use of laxatives. Regarding beliefs, we asked: “I believe we cannot manage constipation without laxatives.” For preference, we asked: “I want to manage constipation without relying on laxatives.” The answers were rated on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). To achieve face validity, we asked the nurses in LTC hospitals and the gastroenterologists if all questions were clearly worded and would not be misinterpreted.The characteristics of staff nurses, including age, sex, qualifications, and years working in their current workplace, were recorded.Items regarding constipation assessment at the initial intake and on a daily basis were developed based on the nursing practice guidelines . The iniItems concerning constipation management were developed based on recommendations from the clinical/nursing practice guidelines for constipation , 23, 26.We asked the nursing staff to describe the daily constipation management practice in LTC wards based on the abovementioned pharmacological and non-pharmacological managements. In addition, we asked the nursing staff to select three patients with severe constipation and to describe the daily constipation management practice for each patient.The following outcome variables were used: the total number of non-pharmacological management practices, whether dietary fiber and probiotic products are used in the ward, and non-use of stimulant laxatives on consecutive days. The total number of non-pharmacological management practices reflects effective constipation management with diverse options, because multiple  and indiData analyses were conducted by utilizing data for each ward as a unit of analyses; some data on individual patients were summed together to represent ward characteristics. The variables such as knowledge of laxative use and belief were reversed to high knowledge and belief for constipation management with a high score. First, we generated descriptive statistics. Second, we conducted bivariate analyses to examine associations between constipation management and ward manager’s perceptions, organizational climate, and other variables.Finally, we conducted multivariate analyses. We used the multiple linear regression analysis for the total number of non-pharmacological management practices and multiple logistic regression analysis for dietary fiber products, probiotic products, and non-use of stimulant laxatives on consecutive days.P < .20. To control for ward patient characteristics , the number of hospitalized patients per LTC ward, those with a gastric feeding tube, and those receiving total parenteral nutrition were also applied using the force-entry method as independent variables. The significance level was P < .05 (two-tailed). All analyses were conducted using SPSS Statistics for Windows, version 25.0. .The ward manager’s perception and organizational climate of the learning atmosphere were entered in the model using the force-entry method; other variables were entered using the forward selection for variables with Among the 1180 hospitals, 283 returned questionnaires. Among these, 36 hospitals did not return the completed questionnaires for both ward managers and nursing staff; therefore, we only analyzed data from 247 hospitals .Bed occupancy rates in this study were 88.7% ± 13.8%, comparable with the results of our previous study  on LTC wAt the initial intake, on the day of admission, in more than half of the wards (69.9%), nurses had fields for recording a medical history of laxative use, and in 63.9% of the wards, nurses recorded laxative use as a part of the medical history Table . For daiIn almost all wards, nurses used magnesium oxide (97.5%), sodium picosulfate (95.5%), and senna 89.3%) (Table % (Table P = .008), the organizational climate of the learning atmosphere , and the belief of ward managers regarding use of laxatives  , existing record fields for assessing bowel movement time , and participation of the ward managers in in-hospital study sessions for constipation management .Use of dietary fiber products was positively associated with case conferences for discussing constipation management (odds ratio (OR) = 2.26; P = .001), existing record fields for assessing stool consistency using BSFS , and beliefs of ward managers regarding use of laxatives . Non-use of stimulant laxatives on consecutive days was positively associated with the existing record fields of stool consistency using BSFS  and ward manager’s knowledge of adequate use of stimulant laxative , but it was negatively associated with ward manager’s age .Use of probiotic products was positively associated with the organizational climate of learning atmosphere  were not as extensively examined. Given that nurses determined the presence of constipation based on bowel movement frequency in many cases , it is hIn almost all LTC wards, nurses used laxatives daily, which was consistent with previous studies , 33. ConLTC ward nurses did not implement non-pharmacological management as frequently as the use of laxatives. They reported increased fluid intake and regular encouragement to use the bathroom. Meanwhile, only 20–30% of ward nurses implemented the intake of dietary fiber and probiotic products, a relatively new but costly approach, which has been reported in a previous study . Given tCertain characteristics of LTC ward managers, including their perception of constipation management and their knowledge of stimulant laxative use, were associated with practicing constipation management. Ward manager support has been shown to enhance nurses’ evidence-based practice . TherefoThe existence of nursing record fields for constipation assessment, including the standardized assessment tool, and a nursing care plan for constipation were also associated with the practice of constipation management. The result is consistent with that of a previous study reporting that care planning for laxative use was related to its actual use . Thus, mThe conference and organizational climate were associated with the use of non-pharmacological management and implementation of probiotic and dietary fiber products, rather than laxative use. The results suggest that while the use of medication could be changed only by intervention from the ward managers and the recording system, non-pharmacological constipation management, which is time-consuming and costly, would need an additional approach to promote discussion and care in the organization.Based on the study results, we recommend two major strategies targeted at ward managers and hospital organization to improve constipation management in LTC hospitals. For LTC ward managers, interventions to facilitate and support successful constipation management  might beThis study has several limitations. First, the cross-sectional design prevented us from concluding a causal relationship among variables. Second, we only asked one staff member about the organizational climate; therefore, it may not have been adequately assessed. Third, the low response rate in this study may lead to sampling bias; nonetheless, we attempted to increase the response rate by limiting the number of participants in each hospital. As the responders tended to be interested in constipation care compared with the non-responders, the practice of non-pharmacological management may be overestimated. Finally, we could not determine the constipation management for each individual patient. Patients’ physical conditions and causes of constipation vary. In future studies, we should clarify the constipation management for each patient to determine effective strategies according to their individual condition.Our data revealed that the assessment and practice of constipation management were not conducted sufficiently. Constipation management implementation was associated with both ward manager and organizational factors, including ward manager’s perception and knowledge of laxative use, organizational climate, care planning, assessment, and conferences. Interventions by ward managers and organization would promote more effective constipation management in LTC hospitals.


The authors beautifully depict how long multifocal  penile and bulbar can be approached using a ventral onlay buccal graft technique in a very successful manner. The authors highlight that although a number of surgical options for caring for such patients exists, the present approach is very well suited for managing such complex urethral reconstructive cases. Our selection for the 2nd prize is awarded to the video by Wilson Lin et al. from Yeshiva University Albert Einstein College of Medicine in New York, USA entitled “Addressing the challenges of reoperative robotic-assisted sacrocolpopexy” (available at. http://www.intbrazjurol.com.br/pdf/vol44n06/Lin_1263_1264.pdf). The authors highlight several important surgical concepts in this video including that minimally invasive robotic surgery remains a feasible surgical option in patients having undergone multiple abdominal and pelvic surgeries in the setting of pelvic organ prolapse. Furthermore, there are some very useful technical points and considerations that are disseminated in this video and would encourage surgeons tackling such cases to review and possible adopt some of these surgical refinements into their armamentarium. The 3rd prize for best video of the year goes to the video entitled “Step by step male to female transsexual surgery” (available at. http://www.intbrazjurol.com.br/pdf/vol44n02/Silva_407_408.pdf) by Rodrigo Uliano Moser da Silva et al. from Hospital de Clinicas de Porte Alegre from Brazil. The very skilled surgeons within this group have performed 174 such procedures as is highlighted and artfully depicted in the respective sequential technical steps that are encompassed within such complex surgical procedures. These are surgical procedures that unquestionably should be performed at a few select centers across the world and those programs entertaining the development or refinement of their transsexual surgical program should consider benchmarking this video as the reference on how this surgery can be accomplished in an optimal manner in terms of surgical outcomes and patient satisfaction.One of my distinct honors as the editor of the video section is to reflect on the prior year and to highlight some of our major accomplishments and contributions, with once again our submitting authors highlighting the incredible surgical talents and innovation being adopted across the world. In this regard, I am pleased to once again share with you the selection of the three best videos of the year, with the criteria for selection being the accepted videos that most vividly depict the creative approaches to surgery within our field, with the ultimate goal of optimizing patient related outcomes. In this regard, I am pleased to announce the 1st prize selection being the video by Luciano Favorito et al. from the Hospital Federal de Lagoa in Rio de Janeiro, Brazil entitled “Double inlay plus ventral onlay buccal mucosa graft for simultaneous penile and bulbar urethral stricture” (available at. Lastly, I would like to announce a new selection as part of this annual editorial which is to select the reviewer of the year for our section. Before doing so, I would like to acknowledge and recognize the meaningful contributions of all our reviewers who have meticulously reviewed all video submissions and resubmissions in a timely manner making thoughtful recommendations and selecting only those deemed of greatest clinical merit for inclusion within our journal. In this regard, I am pleased to announce that Dr. Trushar Patel, assistant professor of urology and program director, department of urology, University of South Florida as our selection for reviewer of the year. Trushar is not only an exceptionally skilled robotic surgeon conducting complex oncologic and reconstructive cases but has done so while being a very dedicated reviewer for the video section over the past several years and always providing great insight and practical viewpoints in his video reviews. Very much appreciate all of his work and assistance over the prior years and congratulate him on this recognition.Finally, I would like to thank all of our readers and contributors for their limitless efforts to continually improve surgical techniques and approaches. May this be a very happy and healthy holiday period for all of you and your families, with our very best wishes in 2019!


AbstractAmblycheilakatzi Duran & Roman, sp. nov. is described from calcareous canyons and steep hillsides in the Trans-Pecos region of western Texas. It is distinguished from all other Amblycheila based on multiple morphological characters, biogeography, and ecology. A revised key to the genus Amblycheila is provided.A new rock-dwelling (petrophilous) tiger beetle,  Amblycheila Say, 1829 includes seven currently recognized species , Texas A&M University Insect Collection (TAMUIC), American Museum of Natural History Insect Collection (AMNH), Carnegie Museum of Natural History (CMNH), Florida State Collection of Arthropods (FSCA), Collection of David W. Brzoska (DWBC), Collection of Daniel P. Duran (DPDC), Collection of Stephen J. Roman (SJRC), Collection of David E. Katz (DEKC), Collection of Daniel Sundberg (DSC). Specimens of the new species were compared to material of all congeners, including A.hoversoni Gage, 1990, A.picolominii Reiche, 1840, A.nyx Sumlin, 1991, A.halffteri Mateu, 1974, A.cylindriformis , A.baroni Rivers, 1890 and A.schwarzi Horn, 1904.Type material is deposited in the following institutional and private collections (acronyms used in the text are in parentheses): Body measurements are defined as follows. The total body length excludes the labrum and is measured as the distance from the anterior margin of the clypeus to the elytral apex, including the sutural spine, when present. The width of the pronotum is measured to include the lateral margins of the proepisterna. Pronotal width was measured at the widest point of the apex, as well at the narrowest point near the base.Taxon classificationAnimaliaColeopteraCarabidaeRoman & Duransp. nov.43136755-FA25-5D43-87FC-0163974AEAFFhttp://zoobank.org/F2A07537-21DD-4371-A52F-2BAB80E8EF84Holotype: 1 ♂, USA: Texas / Val Verde Co / 5mi E Langtry / 15-VI-2017 / leg. D. Katz (USNM). Paratypes: 2 ♂♂, 2 ♀♀, same label data as holotype. 1♀, USA: Texas, 5mi W Langtry / 12-VII-2010 D. Katz (DEKC). 1 ♂, USA: Texas / Val Verde Co / Langtry / 18-VI-2013 / leg. D. Sundberg (DSC). 1 ♂, USA: Texas, / Val Verde Co / Langtry / 14-VI-2014 / leg. D. Sundberg (DSC). 1 ♂, USA: Texas, / Val Verde Co / Langtry / 28-XI-2014 / leg. D. Sundberg (DSC). 1 ♂, USA: Texas, / Val Verde Co / Langtry / 06-VII-2013 / leg. D. Sundberg (DSC). 1 ♂, USA: Texas, / Val Verde Co / Langtry / **-VII-2014 / leg. D. Sundberg (DSC). 1 ♂, USA: Texas, / Val Verde Co / 3.2mi W. Langtry / 21-VI-2014 / leg. D. Duran (DPDC). 5 ♂♂, 3 ♀♀, USA: Texas, / Val Verde Co / 4mi W Langtry / 18-VI-2015 / leg. S. Roman (SJRC). 1♀, USA: Texas, / Terrell Co / 13mi W Langtry / 18-VI-2015 / leg. S. Roman (SJRC). 3 ♂♂, 4 ♀♀, USA: Texas, / Val Verde Co / 3.5mi W Langtry / 01-VI-2017 / leg. S. Roman (SJRC). 2 ♂♂, USA: Texas, / Val Verde Co / 3.5mi W Langtry / 01-VI-2017 / leg. S. Roman (SJRC). 2 ♂♂, 2 ♀♀, USA: Texas, / Val Verde Co / 3.5mi W Langtry / 01-VII-2019 / leg. S. Roman (SJRC). 1 ♂, 2 ♀♀, USA: Texas, / Val Verde Co / 3.5mi W Langtry / 01-VII-2019 / leg. D. Katz (DKC). 1 ♂, USA: Texas, / Val Verde Co / 3.5mi W Langtry / 01-VII-2019 / leg. D. Katz (DKC). 4♂, 5 ♀♀, USA: Texas, / Val Verde Co / 3.5mi NW Langtry / 23-V-2016 / leg. D. Brzoska (DWBC). 1 ♂, USA: Texas, / Val Verde Co / 12.5mi NW Langtry / 23-V-2016 / leg. Brzoska (DWBC). 1 ♂ USA: Texas / Brewster Co / Heath Canyon / 22/IX/2019 / leg. J. Chong/S. Roman (SJRC). 6 ♂♂, 5 ♀♀, ex ovum, USA: Texas, / Terrell Co / 13mi W Langtry /SJRC). 24 ♂♂, 24 ♀♀, ex ovum, USA: Texas, / Val Verde Co / 13mi W Langtry / 18-VI-15 / leg. S. Roman (SJRC): 1 ♀ (USNM), 1 ♂, 1 ♀ (TAMUIC), 1 ♂, 1 ♀ (AMNH), 1 ♂, 1 ♀ (CMNH), 1 ♂, 1 ♀ (FSCA).18-VI-15 / leg. S. Roman . No other geographically proximate congeners can be confused with this species. Amblycheilaschwarzi is most similar in body shape and size, but its dorsal elytral texture is not smooth or polished, it possesses a greater number of shallow setigerous punctures that are arranged more regularly into rows between the dorsal carinae, and the two species are separated by 1300 km, with congeners occurring in the intervening areas.This species can be distinguished from all other Amblycheila. Total body length 23.35–27.75 mm, mean ♀ 26.0 mm, mean ♂ 26.0 mm. Head , black, slightly polished, nearly smooth, with fine shallow rugosity, especially near margins; trapezoidal in shape with nearly straight sides, widest near apex, 5.80–7.60 mm (mean = 6.95); base narrow, 4.00–5.30 (mean = 4.70), setae sparse (1–7 per side) and present along lateral third of dorsal surface; disc with thin weakly impressed median line and deeply impressed transverse line; notopleural sutures clearly defined, not visible from dorsal view; proepisternum black, dull, glabrous or with few sparse long setae mostly concentrated near the coxae; meso- and metasternum glabrous or with a few setigerous punctures, especially near coxae. Elytra amygdaloid, 13.60–16.40 mm length (mean = 15.15), shape similar in both sexes; sutural spine absent, micro-serrations absent; elytral dorsal surface smooth and slightly polished, with sparse and irregularly placed setigerous punctae present between dorsal carinae; additional small shallow setigerous punctures are present in lateral areas, especially between dorsal carinae and epipleura.Legs: Pro-, meso- and metacoxae dark reddish brown to black, with sparse setae; trochanters dark reddish brown to black, pro- and mesotrochanter with a single long seta, sometimes with additional shorter setae; metatrochanter glabrous, apex blunt, lacking a produced apical tip; femora black, surface with multiple rows of erect brown setae; tibiae dark reddish brown to black, surface with erect brown setae similar to femora, with additional dense brown setae present at the apices near the tibial spines; tarsi dark reddish brown to black, bearing fine erect setae on lateral and ventral areas, tarsal claw long, simple.Abdomen: Ventrites black, erect setae present and mostly restricted to a distinct row running parallel to the suture between ventrites, abdominal setae on ventrites 1–4 sparser in female that male; terminal abdominal ventrite with scattered setae near apical half in males, no setae present in females except for a dense fringe of setae emerging from the tip of the apex.Amblycheila is named after David Katz, the discoverer of this remarkable petrophilous insect. We propose the common name of Trans-Pecos Giant Tiger Beetle.This new Amblycheilakatzi is currently known only from western Texas in the Trans-Pecos region of the Chihuahuan Desert. All known occurrences are from steep-sided canyons in Val Verde and Terrell Counties, where natural or man-made forces have exposed bedrock, primarily Cretaceous limestone (Latrodectus spiders were abundant. The second author discovered 2nd and 3rd instar larvae in fine calcareous clays within grooves and crevices in vertical limestone walls (Fig. imestone  (Fig. 3Aimestone . Adult blls Fig. .Amblycheilakatzi can be at low densities, and is present in habitat that would not generally be checked by tiger beetle collectors. No other North American tiger beetle is apparently associated with vertical rock walls, and this unusual behavioral characteristic may further contribute to the lack of known specimens.This species is likely more widespread than presently known. Amblycheila species are known from Mexico, but this is likely due to collecting bias.Given the fact that all four localities are very close to the US/Mexican border, it is a near certainty that this species occurs in northern Mexico as well. Only two of the eight Amblycheila, we reviewed the literature for potentially informative characters that could diagnose species (A.hoversoni indicates that it can be distinguished from all other Amblycheila based on the presence of a single row of punctae between the dorsal and lateral carinae. We examined long series of A.hoversoni, and this character was not always consistent, therefore we did not include it in our key.When constructing a dichotomous key to the genus


Finally, the powders were successfully regenerated by simple ethanol washing, showing almost complete absorption recovery.Tannin- and lignin-furanic foams are natural porous materials that have attracted high interest in the scientific and industrial communities for their high thermal and fire-resistant properties. However, no interesting solutions have been proposed for the management of their end-life as yet. In this study, the phenolic-furanic powders derived from the foams were analyzed for their capacity to remove different pollutants like neutral, cationic, and anionic organic molecules from wastewater. It was observed that the macromolecules produced from initially bigger fractions were more suitable to remove methylene blue and sodium dodecyl sulfate (SDS) while contained absorptions were observed for riboflavin. Acidified tannin powders were also prepared to understand the role of the flavonoid in the absorption mechanism. The latter showed outstanding absorption capacity against all of the tested pollutants, highlighting the key-role of the flavonoid fraction and suggesting the limited contribution of the furanic part. All adsorbents were investigated through FT-IR and solid state  Water plays a major role in many industrial activities such as the textile dyeing and washing, chemical manufacturing, and heavy-metal mining ,2,3,4,5.There are several strategies to approach wastewater treatment that range from well-known processes like filtration, flocculation, and decantation to specially designed adsorbents or by-products of the agricultural industry ,7,8,9.A recent study presented interesting organic hydrogels and inorganic nanocomposites for the removal of methylene blue dyes with very high adsorptions ,11,12. ANatural polyphenols such as lignin and tannins are characterized by high numbers of aromatic and hydroxyl groups  and theiFirst generation tannin-furanic foams have already been studied for their capacity to absorb pollutants ,21,22,23More recently, formaldehyde-free furanic foams made of tannin and lignin have been prepared ,27. ThesThe objective of this study was to observe the absorption properties of the polyphenolic-furanic powders derived from the foams against three different classes of pollutants  in order to find an interesting end-life application for these materials. Mimosa (Acacia mearnsii) tannin powder “Weibull AQ” was supplied by Tanac SA . Black liquor was supplied by Lenzing AG . For the production of the foams, furfuryl alcohol was supplied by Trans Furans Chemicals . Diethylether and sulfuric acid 98% were purchased from Merck . The other chemicals used were technical grade acetone, formaldehyde (37%), chloroform, methylene blue, sodium dodecyl sulfate and riboflavin, all purchased from VWR  and Roth .The preparation of the foams was undertaken by homogenizing the tannin (or tannin-black liquor (BL) mixture) with water, furfuryl alcohol (FOH), formaldehyde (37% water solution), and diethylether (DEE). Afterward, sulfuric acid (4 M) was added and the suspension was further stirred to obtain a homogeneous blend that was poured into a wooden mold. The mold was then covered and placed in a laboratory hot press for 5 min at different temperatures for expansion. The foams were successively pulverized using a mortar and pestle and washed with distilled water. Afterward, the powders were dried in a convection oven at 103 °C and finally washed with ethanol to remove all unreacted chemicals. After drying, the powders were sieved and those of a particle size up to 250 µm were used for the adsorption experiments.Acidified tannin gel was prepared following the procedure described by ,35,36 wiThree different water contaminants were tested: (i) riboflavin, (ii) sodium dodecyl sulfate, and (iii) methylene blue (structures shown in R2 = 0.9999).The remaining concentration of riboflavin and methylene blue were determined using a Shimadzu UVmini 1240 UV/vis spectrophotometer . After adsorption, the solutions were centrifuged at 3000 rpm for 3 min and the absorption of the supernatant was measured at 450 nm for riboflavin and 656 nm for methylene blue. A multipoint calibration curve for both compounds was created . The results are expressed as mg pollutant absorbance per g adsorbent.C0 and C1 are the initial and the equilibrium concentration of pollutant (ppm), respectively, and V (mL) and W (mg) are the volume of the solution and the mass of the adsorbent, respectively.Furthermore, the adsorption capacity −1 with a resolution of 4 cm−1. The spectra were then investigated in the spectral region between 1800 and 600 cm−1, averaged, normalized, and baseline corrected with the software KnowItAll .The polyphenolic powders  were scanned with an FT-IR Frontier  spectrometer coupled with an ATR miracle unit. The spectra were registered in triplicate with 32 scans in the spectral region between 4000 and 600 cm13C at 125.78 MHz and the MAS rotor spinning was set to 14 kHz. Cross polarization (CP) was achieved by a ramped contact pulse with a contact time of 2 ms. During acquisition, 1H was high power decoupled using SPINAL with 64 phase permutations. The chemical shifts for 13C are reported in ppm and are referenced external to adamantane by setting the low field signal to 38.48 ppm.Spectra of the standard tannin foam, the acidified tannin gel, and the original tannin powder were obtained on a Bruker Avance NEO 500 wide bore system  at the NMR Center of the Faculty of Chemistry, University of Vienna. A 4 mm triple resonance magic angle spinning (MAS) probe was used with a resonance frequency for The data elaboration was done with the software Top-spin 4.0.6 (Bruker) and OriginPro (OriginLab) while the calculations of the theoretical chemical shifts were done with the software NMR-Predict developed by the University of Lausanne (L. Patiny) and the University of del Valle (J. Wist) ,41,42.As methylene blue is particularly well soluble in ethanol and chloroform, a cheap and easy method to regenerate the adsorbents after adsorption was developed. A total of 150 mg of foam powders were washed with 150 mL of ethanol at different temperatures  in a magnetically stirred beaker for 10 min. Afterward, the mixture was filtrated and the foam could be recovered. Furthermore, it is possible to separate the methylene blue from the ethanol at reduced pressure to repurpose the solvent.The regenerated foams were further tested for their adsorption capacity and the results were compared with the first adsorption cycle.ANOVA and Tukey’s post hoc test were performed at a significance level of α = 0.05 using the IBM SPSS 25 statistics processor to determine significant differences between the adsorbents.It was evident that the nature of the pollutant had a major influence in the remediation capacity of the powders: charged pollutants like the anionic surfactant SDS and even more of the cationic dye methylene blue were significantly adsorbed, while the neutral riboflavin was much less adsorbed. This observation confirms the finding of previous research when heavy-metal cations were absorbed . It was A positive effect of the lignin was observed when compared to the results for adsorption by tannin based polymers in the literature. Similar materials adsorbed roughly 45 mg methylene blue per gram adsorbent and 22 mg SDS per gram of the tannin polymer . The resThe adsorption mechanism of SDS on flavonoids was studied by Liu and Guo where they stated that the more negatively charged B and C ring interacted with the SDS . This fiAcidified tannin gels were produced and their pollutant absorption capacity were investigated to understand the contribution of tannin in the absorption process. The results of pollutant absorption capacity measured with the same parameters are reported in These high adsorptions suggest that the major contribution to the absorption process is given by the tannin part, while the furanic moieties of the polymers limit the establishment of secondary forces with the pollutants. These unexpected results further addressed the interest in the chemistry of the adsorbents, therefore a detailed chemical characterization of the powders was carried out.In −1 and the signal at 795 cm−1, which were attributed to furanic C–H bending (out-of-plane) [−1, which suggests increased aromatic contribution as well as a general increase in the region between 1350 and 1100 cm−1, which is dominated by Carom–O vibrations [−1, which was higher for the tannin gel than for the foam, and the tannin powder could be attributed to the interflavonoid vibrations [The spectra of the tannin gel presented a similar profile to the standard foam except for a decrease in the signals typically due to the furanic moieties like the carbonyl group at 1703 cmf-plane) . The tanbrations . The banbrations .13C-NMR analysis of the adsorbing powders and of the tannin powder was performed and is reported in The solid state Comparing the spectra of the foam with that of the gel, we observed that the bands attributed to the furanic part decreased in the tannin gel, in particular, the carbonyl signal due to γ-diketons resulting from the furanic ring opening at 210–190  disappeaThe two spectroscopic investigations highlighted that tannin gel has a similar chemistry to the tannin foam without furanic contribution and differs from the tannin powder because: (i) the carbohydrate fraction is removed, and (ii) the molecular mass is increased through the establishment of further interflavonoid bonds. The gel is then constituted by higher molecular mass flavonoids, no furanics, and no sugars, which explains its outstanding absorption activity.These adsorbing materials have shown an interesting absorption capacity, especially for charged pollutants, therefore their regeneration was considered by washing them with ethanol. It can be stated that almost all of the absorbing sites were already free after washing with ethanol at room temperature. This means that the foams can be almost completely regenerated with a contained removal decrease, suggesting that these materials are suitable for several removal cycles.The present study had the objective to understand the possibility of using tannin and tannin-lignin furanic powder as a pollutant adsorbent in wastewater treatments. We discovered that these materials have high affinities for cationic dyes and anionic surfactants, while low absorption was observed for the neutral molecules (riboflavin). The flavonoid backbone of the macromolecule is the moiety that positively contributes to the absorption because acidified tannin gels present much higher absorptions. On the other hand, the furanic part limits the pollutant adsorption because the number of reactive sites on the flavonoids is reduced by the presence of furanic moieties. Furthermore, the higher dimension of the starting building blocks  and the higher crosslinking degree  contribute to increasing the absorption capacity due to the minor chance for the furanic part to hinder the absorption activity of the flavonoids. This finding was also confirmed through spectroscopic analysis of the acidified tannin gels, which highlighted the increase of interflavonoid linkages in the tannin. Notwithstanding the limiting contribution of the furanic part, we can determine that the tannin foams can be used as a pollutant absorbent at the end of their life, especially because the absorbing capacity can be almost completely recovered after simple ethanol bathing.


The ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: (1) Increase time nurses spend in direct patient care. (2) Improve safety and reliability of care. (3) Improve experience for staff and patients. (4) Make changes to physical environments to improve efficiency.To explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale QI intervention.Multiple methods within six hospitals including 88 interviews , 10 ward manager questionnaires and structured observations on 12 randomly selected wards.Resource constraints and a managerial desire for standardisation meant that, over time, there was a shift away from the original vision of empowering ward staff to take ownership of Productive Ward towards a range of implementation ‘short cuts’. Nonetheless, material legacies  have remained in place for up to a decade after initial implementation as have some specific practices . Variations in timing of adoption, local implementation strategies and contextual changes influenced assimilation into routine practice and subsequent legacies. Productive Ward has informed wider organisational QI strategies that remain in place today and developed lasting QI capabilities among those meaningfully involved in its implementation.As an ongoing QI approach Productive Ward has not been sustained but has informed contemporary organisational QI practices and strategies. Judgements about the long-term sustainability of QI interventions should consider the evolutionary and adaptive nature of change processes. There is a need for greater insight into the assimilation of quality improvement (QI) interventions into day-to-day healthcare practice and their sustained impact.The ‘Productive Ward: Releasing Time to Care’ programme is a QI intervention which aims to give ward staff the tools, skills and time needed to implement local improvements in order to: (1) Increase time nurses spend in direct patient care. (2) Improve safety and reliability of care. (3) Improve experience for staff and patients. (4) Make changes to physical environments to improve efficiency. The rationale for Productive Ward was strongly marketed as empowering front-line staff, especially nurses, to ‘take back control’ of their wards and—through efficiency savings—‘release time to care’.The NHS Institute for Innovation and Improvement in England developed Productive Ward in 2005/2006 for application in hospitals and wards, and was first implemented in 2007.As a large-scale QI intervention Productive Ward has three distinctive features. First, it underwent a systematic and extensive design and development process prior to widespread adoption.Our overall research aim is to explore the impacts and wider legacies of the Productive Ward since its introduction over a decade ago. Responding to a call for more ‘theoretically informative improvement research’We conducted a multiple methods study in six case studies comprising purposively sampled acute hospitals. We used multiple sources of information to arrive at ‘best guess’ dates for all adopting English acute hospitals to sample hospitals estimated to have adopted Productive Ward in different years, with the aim of attaining maximum variation. We also sampled for diversity with respect to region, type and size (number of wards) of hospital. Data collection during the period March 2017 to February 2018 comprised a total of: 88 semistructured interviews ; structured observations to note material legacies and observable processes on 12 randomly selected wards  using a template based on the goals of Productive Ward; and 10 ward manager questionnaires on processes not observable without intrusion, also based on Productive Ward goals. Eligible wards were those that had implemented the three Productive Ward foundation modules and at least one process module. To analyse the interview data we used the Framework method.We retrospectively analysed the adoption, implementation, assimilation and legacies of Productive Ward in each of our case studies. In doing so we purposefully distinguished between implementation  and assimilation . We categorised the strategies used to implement Productive Ward in each hospital using a published framework which provided a comprehensive categorised list of published implementation strategiesDescriptive case studies were written based on the overall framework. Documentary, observational and ward manager questionnaire data were included at this stage. During analysis, within cases we looked for concordances and differences between interviewees’ accounts and between data sets and treated these as data. For example, interviews with lower grades of staff were sometimes at odds with programme leaders’ accounts of their involvement; or observations of wards sometimes belied interview accounts of legacy. We conducted a cross-case analysis of our six case studies, linking legacies to the processes of adoption, implementation and assimilation.Below we work backwards by first setting out the legacies of the Productive Ward as we observed them in the six hospitals at the time of our fieldwork (up to 10 years postadoption). We then explain the variation in these legacies by considering the ways in which the Productive Ward was assimilated into routine practice, and how different implementation strategies and timing of adoption may have shaped these long-term organisational processes.In each of the six hospitals we observed material legacies of the Productive Ward which remained up to 10 years after initial implementation. Notwithstanding the differing forms of assimilation of the programme in the six hospitals—and how these evolved over time (see below)—we noted that displays of ward metrics data, use of ‘safety crosses’ (to show daily patient harm incidents per month) and storage systems were commonplace on the 12 wards we studied. While maintaining these outward signs of Productive Ward, in day-to-day practice legacies had sometimes become disconnected from their original purpose. For instance, safety crosses were not always clear, up to date or on public display and ‘Knowing How We are Doing’ boards could include data that were difficult to interpret, often out of date and seemingly rarely discussed by ward teams.Our structured observations found that 7 of 18 potential process legacies arising from the modules were still present on all 12 wards . In contrast, three of these potential legacies were not evident on any of the 12 wards; none displayed a ‘ward vision’, written standard operating procedures or an up-to-date ‘Visit Pyramid’ (a graphic display indicating predetermined visits by executive and senior staff which are focused on Productive Ward progress). Ward manager responses to our questionnaires suggested several other standardised processes were commonly still in place . The extent to which these processes solely originated with—and have been maintained by—Productive Ward was sometimes unclear. The Productive Ward resources  are now rarely used. Nonetheless, staff who had been meaningfully involved in the initial implementation of Productive Ward  identified wider legacies, such as using Plan-Do-Study-Act improvement cycles, having a ‘lean’ mindset regarding cutting out waste and improving flow, and giving ward staff a greater voice in QI.Over time the impact of Productive Ward was not confined to individuals or wards; it also shaped QI capabilities within hospitals. By the end of our study whole hospital QI programmes which were at least partially based on Productive Ward were still operational in Hospitals A and C. Hospital A operated a shared governance system to capture staff suggestions for QI while Hospital C was still implementing and developing it’s ‘Trust Quality Bundle’ which had been adapted from Productive Ward. Hospital F’s experience with Productive Ward led them to create both a new Head of Nursing for QI role and a central QI team who delivered training. Former leads of Productive Ward were still offering Productive Ward support to wards in Hospital B, and training in Lean and QI to all staff in Hospitals D and F.et al’set al would refer to as ‘loose-coupling’In two of the six hospitals (A and B) we would define what had occurred during the initial implementation period as ‘transformation’; the use of the Productive Ward was as intended . By the et al’s frameworkMore nuanced were the stories of the remaining two hospitals. Hospitals C and D adapted Productive Ward significantly while retaining some of the tools; Hospital C also retained the ‘look’ of Productive Ward with its trademark graphic of a house built of (modular) ‘bricks’. Hospital C had radically customised Productive Ward following the implementation period and assimilated the programme in this adapted form with other relevant QI programmes to avoid duplication; modules were modified and new modules added over time to meet new priorities and this continued to operate at the time of our fieldwork . In Hospital D, which merged its nascent Productive Ward programme with ‘Lean-based’ training it had already commissioned, we found organisational-level legacies of Productive Ward  but little involvement of lower staff bands in Productive Ward-related activities. We found locating Hospitals C and D within Kislov Implementation of the Productive Ward was supported by detailed guides for ward, project and executive leaders. We found a consistent failure to extend strategic engagement beyond nursing in their steering groups see . The—typThere were three key areas in which the hospitals differed. First, hospital A was the only hospital to follow guidance on how it selected early ‘showcase wards’ by inviting and assessing applications based on a ‘sustainability guide’; the five remaining hospitals either relied on nomination by senior nurses or selected wards because they had stable staffing, a keen ward manager or were deemed ‘high risk’. Second, the earliest adopting hospitals, which had either helped develop the materials/toolkit or had extensive training from the original designers of Productive Ward  see  had bettThere was considerable variation between wards in the same hospital in terms of implementation. Attitudes of ward managers, and the degree to which they involved staff in any meaningful way, was one issue. Another was that implementation efforts become laboured and Productive Ward teams overstretched as they either began to run out of time to implement all the mandatory modules in their targeted number of wards before their funding ceased or progressed to the more challenging wards and/or time-consuming modules.et al’s categorisation revealed that some elements of local approaches to implementation were common, . The two hospitals that stood out in terms of evaluative strategies were those where the Productive Ward team were integrated within an existing QI  or change management  team. These hospitals were also notable in forming strategic relationships with central services to aid implementation. Hospital D attempted to build in sustainability from the start of their implementation strategy, using a local system of monthly spot checks, audit sheets, required actions and reporting; in Hospital F ward-level monthly reports included identification of risks to sustainability. Despite this, significant events in each of the two hospitals  meant that in both cases Productive Ward—as an active programme—effectively ceased shortly after the implementation period.The fourth difference in implementation approach was the involvement of patients. While patients were represented on the Productive Ward steering group in Hospitals A, C and F, there was minimal involvement of inpatients on wards in all hospitals. Hospital A, which had a relatively strong history of patient involvement, stood out in how it harnessed patient/public input.In seeking to address calls to examine both the ‘extent, nature (and) impact of adaptations to … programmes once implemented’For the most part, Productive Ward was designed to address the needs of nurses working on wards. The components we typically observed as having been sustained (Well Organised Ward and Patient Status At a Glance boards) were those used—and found useful—by a majority of nursing staff. Productive Ward did also develop QI capacity among those staff meaningfully involved in its implementation. We also found evidence of how the programme helped shape contemporary hospital-wide QI strategies. However, we found several examples of ‘improvements’ being present on wards but only applied in a superficial and ritualistic way . For example, while Productive Ward was undoubtedly part of an emerging movement to make metrics visible and public—through Knowing How We are Doing boards and Safety Crosses—to avoid stasis hospitals need to regularly retrain staff in their use and take advantage of technological developments if intended wider benefits were to be realised on an ongoing basis.et alet al; as Kislov et al later noted rather than ‘distinct independent categories’ the four types can indeed ‘represent stages of the same process’.et al who identified ‘collective change agency’ as one way of closing a compatibility gap between a QI intervention and adopting hospital.When considering our empirical findings in the light of earlier accountset al have previously raised a possible contradiction between a rhetoric of empowerment (as in the Productive Ward) and command-and-control procedures for auditing performance data.et al highlighted empirically how ‘top down’ distortions through ‘performance management systems set up by the remote centre’ limited the intended impact of managed clinical networks for cancer.et al’s call for better understanding of how local leaders can balance sensible adaptation of QI interventions with the risk of distortion of core elements of a programme such as Productive Ward.Second, Lozeau et al have previously suggested that ‘loose-coupling’ between a QI intervention and an adopting hospital can occur when implementation stalls because of simultaneous improvement initiatives overburdening staff.Third, Jones There are several limitations to our study. First, given the retrospective nature of the fieldwork it was sometimes challenging to trace possible legacies of Productive Ward since one or more other QI interventions had often been implemented concurrently or subsequently. Furthermore, wards and hospitals varied with respect to the number of staff available who had been in post during implementation of the programme. Second, assimilation was a challenging concept to explore retrospectively over such a lengthy time period. Lastly, much of our data come from two randomly selected wards in our case study hospitals. Ward practices, perhaps especially QI work, are strongly influenced by ward managers. A different picture of QI work may have emerged at the time of our data collection had we studied other wards.We found that Productive Ward has had a lasting impact on specific ward practices; some material and processual changes have remained in place for up to a decade after initial implementation. In this widest sense five of our six case studies could be described as having seen some form of sustained impact from the Productive Ward over the last decade. However, as an ongoing QI approach—continually used to identify and improve problem areas—Productive Ward has been less successful. The resources available at the point of adoption and the—closely related—issue of how the Productive Ward was then implemented locally, shaped the evolving forms of assimilation into routine practice over time; these and wider contextual changes largely determined the legacies of the programme.