The perioperative utility of 3D printed models in complex surgical care: feedback from 106 cases

INTRODUCTION

3D models are an emerging tool for surgical planning, providing an augmented method for the visualisation of a patient's anatomy. As their use increases, more data about the utility of these models is critical to inform budget allocation. This study provides the most comprehensive analysis to date for the use of 3D models in perioperative management.

METHODS

3D models for complex surgical cases in NHS hospitals were delivered alongside a surgeon feedback survey. The survey on the model's utility had been designed alongside the university data analytical team and focused on five areas: surgical planning and diagnosis, economic impact, impact on intraoperative and preoperative time, effect on communication and direct impact on the patient.

RESULTS

There were 106 models used by 63 surgeons for complex surgical cases between May 2020 and March 2021, across multiple surgical specialties. The models were reported to have benefits in all perioperative areas, with 92.5% of responses agreeing that the 3D model was a better method for diagnosis and planning than traditional 2D techniques. Benefits were reported on preoperative planning (92.4%), economic savings due to equipment selection (54.4%), reduction in surgical time (41.5%) and surgeon-to-surgeon communication (92.6%).

CONCLUSION

3D models were shown to have a wide range of benefits in a surgical setting. The reduction in surgical time could have the potential to help alleviate surgical backlogs. With more widespread use and optimisation of costs the use of 3D models could become the standard for unusual and complex surgical cases.

Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy

BACKGROUND

Although studies have suggested standard therapy for clinical T2N0 esophageal cancer should be primary surgery, we hypothesize there is a subgroup for whom induction therapy may result in improved overall survival.

METHODS

Patients with cT2N0 esophageal cancer receiving induction therapy or upfront esophagectomy (UE) were identified in the National Cancer Data Base. The UE patients were dichotomized as (1) pathologically upstaged, or (2) same-staged or downstaged. Logistic regression models identified variables associated with upstaging, and Kaplan-Meier analysis compared median overall survival.

RESULTS

From 2006 to 2012, 932 cT2N0 patients (52.2%) received UE, and 853 (47.8%) received induction therapy first. In all, 326 of 713 UE patients (45.7%) were upstaged: 87 of 326 (26.7%) had T upstaging; 98 of 326 (30.1%) had N upstaging; and 141 of 326 (43.3%) had both. Patients upstaged after UE had a higher tumor grade (35.1% versus 57.1% grade 3), and a higher rate of lymphovascular invasion (57.1% versus 17.7%; both p < 0.001). Variables associated with upstaging included lymphovascular invasion (odds ratio 6.0, 95% confidence interval: 2.9 to 12.5, p < 0.001) and tumor grade 3 (odds ratio 9.4, 95% confidence interval: 1.8 to 48.4, p = 0.007). Of upstaged UE patients, only 144 (44.2%) received adjuvant therapy. The median overall survival for cT2N0 patients upstaged after UE was 27.5 ± 2.5 months versus 43.9 ± 2.9 months for induction therapy patients (any resultant pathologic stage, p < 0.001).

CONCLUSIONS

Half of all cT2N0 patients were pathologically upstaged after UE, with worse survival compared with patients receiving induction therapy. Refining an upstaging model would help select patients for induction therapy and increase the rate of chemotherapy in patients at risk for systemic disease.

A Phase I Trial of BKM120 (Buparlisib) in Combination with Fulvestrant in Postmenopausal Women with Estrogen Receptor-Positive Metastatic Breast Cancer

PURPOSE

This trial was conducted to determine the maximum tolerated dose (MTD) and preliminary efficacy of buparlisib, an oral pan-class I PI3K inhibitor, plus fulvestrant in postmenopausal women with metastatic estrogen receptor positive (ER(+)) breast cancer.

EXPERIMENTAL DESIGN

Phase IA employed a 3+3 design to determine the MTD of buparlisib daily plus fulvestrant. Subsequent cohorts (phase IB and cohort C) evaluated intermittent (5/7-day) and continuous dosing of buparlisib (100 mg daily). No more than 3 prior systemic treatments in the metastatic setting were allowed in these subsequent cohorts.

RESULTS

Thirty-one patients were enrolled. MTD was defined as buparlisib 100 mg daily plus fulvestrant. Common adverse events (AE) included fatigue (38.7%), transaminases elevation (35.5%), rash (29%), and diarrhea (19.4%). C-peptide was significantly increased during treatment, consistent with on-target effect of buparlisib. Compared with intermittent dosing, daily buparlisib was associated with more frequent early onset AEs and higher buparlisib plasma concentrations. Among the 29 evaluable patients, the clinical benefit rate was 58.6% (95% CI, 40.7%-74.5%). Response was not associated with PIK3CA mutation or treatment cohort; however, loss of PTEN, progesterone receptor (PgR) expression, or mutation in TP53 was most common in resistant cases, and mutations inAKT1 and ESR1 did not exclude treatment response.

CONCLUSIONS

Buparlisib plus fulvestrant is clinically active with manageable AEs in patients with metastatic ER(+)breast cancer. Weekend breaks in buparlisib dosing reduced toxicity. Patients with PgR negative and TP53 mutation did poorly, suggesting buparlisib plus fulvestrant may not be adequately effective against tumors with these poor prognostic molecular features.

Abstract PD5-6: A phase I study of BKM120 and fulvestrant in postmenopausal women with estrogen receptor positive metastatic breast cancer

Background

BKM120, an oral pan-Phosphatidylinositol-3-kinase (PI3K) inhibitor, plus fulvestrant (F) induced synergistic anti-tumor effect in preclinical studies of estrogen receptor positive (ER+) breast cancer. We therefore conducted a phase I trial of BKM120 and F in postmenopausal women with ER+ metastatic breast cancer (MBC) to determine the maximum tolerated dose (MTD), tolerability and preliminary efficacy.

Methods

A 3+3 phase I design was chosen for phase IA with BKM120 administered orally to define MTD [Table 1]. Cycle (C) length was 28 days. F 500mg was administered intramuscularly on C1 day (D)1 and D15 then on D1 of each subsequent cycles. Two expansion cohorts, phase IB (intermittent dosing: 5 days on and 2 days off) and Cohort C (continuous dosing: daily) of BKM120 at MTD, was initiated to further assess the tolerability and efficacy. Patients (pts) with ER+ MBC with measurable disease were eligible. No more than 3 lines of systemic therapy in the metastatic setting were allowed in phase 1B or Cohort C. Tumor measurement occurred every 3 cycles. Adverse events (AEs) were assessed by CTCAE 4.0 and response by RECIST 1.1.

Results

Thirty one pts, with median age of 58 (range: 34-71) years, prior exposure to a median of 1 (range: 0-9) endocrine and 0 (range: 0-2) chemo regimens, were enrolled. Majority of pts (83%) had visceral metastasis. Thirty, 25, and 22 pts were evaluable for AE, response and clinical benefit (CB), respectively. Most C1 AEs were grade (G)1 or 2, except 1 G3 diarrhea. No DLT occurred in C1. However, G2/3 AEs required BKM120 interruption and/or reduction in C2 or beyond occurred in 16 (53%) pts, including 9 ALT/AST elevation (G2 10%, G3 17%, G4 3%), 7 rash (G3 23%), and 1 pt each with G2 confusion, G3 hyperglycemia, G2 pneumonitis, and G3 tremor. As of June 3, 2014, 1 pt withdrew consent, 19 pts discontinued therapy due to progressive disease (PD) (n=15) or AE (n=4), 11 pts continue to receive BKM120/F. Fourteen (63.6%, 95% CI: 43.0 - 80.3%) of the 22 evaluable pts derived CB, including 7 partial response (PR) and 7 prolonged stable disease (SD) &gt; 6 months. Archival tumor and circulating tumor DNA are being analyzed for presentation. Data will be updated.

Table 1 Study enrollment and resultsCohortNBKM120N pt BKM120 interrupted/reduced (AE)*PDPR (Cycle completed)SD (Cycle completed)NE1A DL1380 mg daily2 (confusion, ALT)101 (22)1 (a)1A DL26100 mg daily3 (ALT, rash)22 (13,3 (a))2 (9, 7)01A DL2b2100 mg intermittent0002 (6, 6)01B10100 mg intermittent6 (AST, ALT, rash Hyperglycemia)02 (15+, 12)5 (16+, 9+, 9, 6, 6)3 (a, a, b)C10100 mg daily5 (rash, ALT, diarrhea, tremor)23 (9+, 8+, 4+)3 (3+, 3+, 3+)#2 (1+, 2+)Total (N)31 1657136*All occurred in C2+ except the diarrhea, CBR: 63%, NE: Not evaluable, a: off due to AE, b: withdrew consent, # NE for CBR

Conclusion

BKM120 100mg, administered daily or intermittently, plus F was tolerable without DLT during C1. Grade 2/3 AST/ALT and rash were common in both dosing schedules in subsequent cycles resulting in BKM120 interruption/reduction. Promising activity observed in this trial warrants further development of this combination in ER+ BC. Phase III studies are ongoing in pts with ER+ MBC progressed on aromoatase inhibitor.

Citation Format: Cynthia X Ma, Jingqin Luo, Michael Naughton, Foluso Ademuyiwa, Rama Suresh, Timothy Pluard, Gayathri Nagaraj, Kaitlin Arnold, Craig Lockhart, Matthew J Ellis. A phase I study of BKM120 and fulvestrant in postmenopausal women with estrogen receptor positive metastatic breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr PD5-6.

Aerobic training-induced improvements in arterial stiffness are not sustained in older adults with multiple cardiovascular risk factors

There is a well-established relationship between increased arterial stiffness and cardiovascular mortality. We examined whether a long-term aerobic exercise intervention (6 months) would increase arterial compliance in older adults with hypertension complicated by Type 2 diabetes (T2DM) and hyperlipidemia. A total of 52 older adults (mean age 69.3±0.6 years, 30 males and 22 females) with diet/oral hypoglycemic-controlled T2DM, hypertension and hypercholesterolemia were recruited. Subjects were randomly assigned to one of two groups: an aerobic group (6 months vigorous aerobic exercise, AT group) and a non-aerobic group (6 months of no aerobic exercise, NA group). Arterial stiffness was measured as pulse-wave velocity (PWV) using the Complior device. Aerobic training decreased arterial stiffness as measured by both radial (P=0.001, 2-way analysis of variance with repeated measures) and femoral (P=0.002) PWV. This was due to a decrease in arterial stiffness in the AT group after 3 months of training, which was not maintained after 6-month training for either radial (P=0.707) or femoral (P=0.680) PWV. Our findings indicate that in older adults with multiple cardiovascular risk factors, short-term improvements in arterial stiffness became attenuated over the long term.

Statistical methods for assays with limits of detection: Serum bile acid as a differentiator between patients with normal colons, adenomas, and colorectal cancer

In analytic chemistry a detection limit (DL) is the lowest measurable amount of an analyte that can be distinguished from a blank; many biomedical measurement technologies exhibit this property. From a statistical perspective, these data present inferential challenges because instead of precise measures, one only has information that the value is somewhere between 0 and the DL (below detection limit, BDL). Substitution of BDL values, with 0 or the DL can lead to biased parameter estimates and a loss of statistical power. Statistical methods that make adjustments when dealing with these types of data, often called left-censored data, are available in many commercial statistical packages. Despite this availability, the use of these methods is still not widespread in biomedical literature. We have reviewed the statistical approaches of dealing with BDL values, and used simulations to examine the performance of the commonly used substitution methods and the most widely available statistical methods. We have illustrated these methods using a study undertaken at the Vanderbilt-Ingram Cancer Center, to examine the serum bile acid levels in patients with colorectal cancer and adenoma. We have found that the modern methods for BDL values identify disease-related differences that are often missed, with statistically naive approaches.

Mammaglobin-A DNA vaccine increases the IFN-γ CD4+ICOS+ T- cells frequency in human breast cancer patients (165.26)

Mammaglobin-A (Mam-A), a 10kD secretory protein, is over expressed in 80% of primary and metastatic human breast cancers. Previous studies in our laboratory using a HLA-A2/Human CD8 transgenic murine model have demonstrated that Mam-A DNA Vaccine elicit specific CD8+ cytotoxic T-cell (CTL) responses to Mam-A and induces tumour regression in SCID mice. In our current study we report the activation of T-helper cells with specific expression of ICOS (inducible costimulator), a T-cell specific activation marker, following Mam-A vaccination. Stage IV breast cancer patients were chosen for the study and vaccinated by Mam-A DNA vaccine on 0, 28 and 56 days. Six months following Mam-A vaccination (n=5), flow cytometry analysis demonstrated a increase in CD4+ICOS+ T-cell frequency from 5±2% to 23± 4% with a concomitant drop in the CD4+Foxp3+T-cell (Treg) frequency from 19±6% to 10±5%. However, the frequency of CD4+CD25+ICOS+ did not change following vaccination (23±5%). ELISpot analysis demonstrated that following vaccination, CD4+ICOS+ sorted T-cells demonstrated a cytokine phenotype switch from IL-10 to IFN-γ. We conclude that following Mam-A DNA vaccination, there is a specific activation T-cells with increase in the pro-inflammatory IFN-γ CD4+ICOS+T-cells along with decrease in Treg frequency. We propose that this switch in T-cell frequency following vaccination may be important in tumor regression in breast cancer patients.

Risk factors for seropositivity to bovine coronavirus and bovine respiratory syncytial virus in dairy herds

A cross-sectional study was conducted to evaluate the association between herd-level characteristics, management routines and farm-level antibody status of bovine coronavirus (BCV) and bovine respiratory syncytial virus (BRSV) in 257 Swedish dairy herds. The possible spatial clustering of positive herds compared with negative herds was also investigated. For each herd, a pooled milk sample from five primiparous cows was analysed for the presence of antibodies to BCV and BRSV. Herd-level information was obtained by a questionnaire. Logistic regression was used to evaluate the association between predictors and antibody status to BCV and BRSV. Large herd size, being located in southern Sweden, and not providing boots for visitors were found to be associated with being antibody-positive to BCV and BRSV. A short distance to the nearest cattle herd was an additional risk factor for BCV. One of the studied areas was suitable for spatial analysis. Positive herds were not spatially autocorrelated when compared with negative herds as estimated by the K-function regarding both BCV and BRSV. This indicates that local factors such as daily visiting milk trucks and wild animals were unlikely to be important sources of infection in this area. Moran's I statistics and semi-variogram showed no evidence of spatial autocorrelation in the residuals, indicating that remaining unidentified factors are not spatially dependent in the areas under study.

Sigmoid-colonic motility in health and irritable bowel syndrome: a role for 5-hydroxytryptamine

Abstract Evidence suggests that sigmoid-colonic motility is increased in patients with irritable bowel syndrome (IBS). 5-Hydroxytryptamine (5-HT) plays a role in the control of motility, but its involvement in the dysmotility seen in IBS remains unclear. To investigate the relationship between platelet depleted plasma 5-HT (PDP 5-HT) concentration and sigmoid-colonic motility in patients with IBS and healthy volunteers. Pre- and postprandial PDP 5-HT concentrations were assessed while recording sigmoid-colonic motility in 35 IBS patients (aged 19-53 years, eight male) and 16 healthy volunteers (aged 18-39 years, six male). Motility was recorded using a five-channel solid-state catheter introduced to a depth of 35 cm into an unprepared bowel. 5-Hydroxytryptamine concentration was measured by reverse-phase HPLC with fluorimetric detection. Irritable bowel syndrome patients had elevated concentrations of PDP 5-HT under fasting (P < 0.004) and fed (P = 0.079) conditions compared with controls. Likewise, they exhibited increased sigmoid-colonic motility under fasting (activity index: P < 0.02) and fed (P < 0.05) conditions compared with controls. Platelet depleted plasma 5-HT concentration positively correlated with colonic activity index under both fasting (r = 0.402; P = 0.003) and fed (r = 0.439; P = 0.001) conditions. These data show a possible relationship between endogenous concentrations of 5-HT and sigmoid-colonic motility recorded in both IBS and healthy subjects.

Vascular endothelial growth factor-trap overcomes defects in dendritic cell differentiation but does not improve antigen-specific immune responses

PURPOSE

Induction of antitumor immune responses requires adequate function of dendritic cells. Dendritic cell defects in cancer patients have been implicated in tumor escape and the limited efficacy of cancer vaccines. Previous studies have shown that vascular endothelial growth factor (VEGF) plays a major role in abnormal dendritic cell differentiation and function in cancer. It has been proposed that inhibition of VEGF may result in improved immune responses. The goal of this study was to test this hypothesis.

EXPERIMENTAL DESIGN

Fifteen patients with refractory solid tumors were enrolled into a phase I clinical trial of VEGF-Trap. Phenotype and function of different subsets of mononuclear cells were measured before and at different time points after the start of treatment.

RESULTS

VEGF-Trap treatment did not affect the total population of dendritic cells, their myeloid or plasmacytoid subsets, myeloid-derived suppressor cells (MDSC), or regulatory T cells. It significantly increased the proportion of mature dendritic cells. However, that improvement was not associated with an overall increase in immune responses to various antigens and mitogens. A subset analysis revealed significant improvement in immune responses in patients who had no increase in the proportion of MDSC. An improvement in immune responses was absent in patients with an increase in the proportion of MDSC.

CONCLUSIONS

Inhibition of VEGF signaling may improve differentiation of dendritic cells in cancer patients. However, it was not sufficient to improve immune responses. This shows multifaceted nature of immune deficiency and points out to the need for complex approach to modulation of immune reactivity in cancer.

Mesenteric cysts: a rare cause of abdominal pain

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The epidermal growth factor receptor as a target for colorectal cancer therapy

The epidermal growth factor receptor (EGFR) is the prototypical member of the erbB receptor family. The EGFR axis is activated by a variety of ligands that are crucial in the formation and propagation of many tumors, including colorectal cancer, through their effects on cell signaling pathways, cellular proliferation, control of apoptosis, and angiogenesis. The importance of the EGFR axis in tumorigenesis and tumor progression makes it an attractive target for the development of anticancer therapies. A variety of targeting strategies to exploit the role of EGFR in tumors have been employed. The most highly developed of these anti-EGFR approaches are the monoclonal antibodies and the tyrosine kinase inhibitors (TKIs). Clinical evaluations of these compounds have yielded some promising results. The role of the EGFR axis in colorectal cancer formation and progression is reviewed and the clinical development of these anticancer EGFR-targeted drugs is reviewed and updated.

Biomedicine on the spatial periphery: the (re)production of a metaphorical landscape by rural health care practitioners in northern California

I examine the use of spatial concepts by rural health care practitioners in Northern California and suggest that rural and urban spatial metaphors are important means of expressing and (re)producing problems associated with their search for legitimacy and moral authority within a field of relations defined by biomedicine. I present three broad ways in which spatial metaphors are used by rural health care practitioners to continuously enact a "metaphorical landscape." I situate this landscape in the context of a hierarchical field of relations within biomedicine, which is itself underpinned by a distinct urban bias and the uneven distribution of material and technological resources. I suggest that this landscape is partly the result of the rural health care practitioners' position within this field of relations and partly the result of implicit and historically situated frameworks of spatial meanings derived from capitalism.

The paradigm shift: behavioral home care

Home care agencies looking to compete in today's competitive market must learn to target their services to market niches and to keep their eyes on marketplace trends. This article examines the changes occurring in behavioral home care and how agencies can tailor their services to their communities.

Percutaneous insertion of peritoneal shunt catheters with use of the Veress needle. Technical note

A safe percutaneous method of insertion of peritoneal shunt catheters is described. The method is based on the use of the Veress needle.

Surgical and medical experience with 734 premature infants with patient ductus arteriosus

During the past 5 years, patent ductus arteriosus (PDA) presented in 734 preterm infants (less than 2.5 kg and 37 weeks gestation) of 2,532 admissions (29%). The ductus presented with murmur, bounding pulses, and often congestive heart failure. Medical treatment consisted of the following: fluid restriction, furosemide, respiratory support, and rarely digoxin. The patients who were unresponsive to medical treatment had surgical ligation (306 of 734 or 42%). The patients who had ductal ligation were smaller, i .e., 82% of the surgical patients weighed less than 1.5 kg as compared to 38% of the medical patients. Of those patients weighing less than 1.5 kg, the surgical and medical groups were compared and the following observations made: The incidence of respiratory distress syndrome was greater in the surgical group (86% or 216 of 252 patients versus 69% or 111 of 161 medical patients, p less than 0.001) and the long-term survival was better (89% or 224 of 252 surgical patients versus 77% or 124 of 161 medical patients, p less than 0.005). In addition, the average duration of intubation was shorter in this surgical subgroup (8.9 versus 13.6 days). Significant left atrial enlargement and echocardiographic left atrial/aortic (LA/Ao) ratios of greater than 1.5:1 occurred in 58% or 171 of 290 surgical patients versus 32% or 59 of 190 medical patients (p less than 0.001). During the first 3 years of this study (medical treatment averaged 5 days), the duration of intubation in the surgical patients averaged 15.2 days; by comparison, in the last 2 years of this study (medical treatment averaged 1 to 2 days), the duration of intubation was 6.5 days (p less than 0.001). Necrotizing enterocolitis (NEC) occurred in 11% or 46 of 428 medical patients versus 0.3% (one of 305 patients) in the ligated group postoperatively (p less than 0.001). Late deaths were related to lung disease, central nervous system problems, NEC, and so on. From this study, it was determined that ligation of a significant PDA is associated with (1) zero surgical risk, (2) a reduced incidence of NEC, (3) reduced duration of intubation, especially with early ligation, and (4) improvement in late survival. Thus the surgical approach is our treatment of choice for a refractory PDA.

Surgical repair of coarctation of the aorta in infants less than six months of age: including the question of pulmonary artery banding

High mortality rates (20% to 60%) have been reported in the repair of coarctation of the aorta in infancy. During a 4 year period, 34 infants less than 6 months of age had coarctation repair (two prior to 1976). Eleven were less than 2 weeks of age, nine were 2 weeks to 1 month, eight were 1 to 2 months, and six were 2 to 6 months. Associated lesions were patent ductus arteriosus (PDA) (82%), ventricular septal defect (VSD) (53%), and other intracardiac lesions (35%). Twenty-three patients (67%) had emergency operations; the other procedures were semielective. The indications for operation included congestive cardiac failure (91%), acidosis (32%), hypertension (29%), cardiogenic shock (26%), and cardiac arrest (18%). There was one operative death (2.9%) in a patient with severe pulmonary valve insufficiency and multiple VSDs. There was one late death a 4 months (Taussig-Bing complex). Primary repair was used in 15, patch-graft angioplasty in 19 (left subclavian artery in nine, left common carotid in one, and Dacron or pericardial patch in nine). Two (6%) required reoperation for recurrent coarctation (follow-up 3 to 36 months with a mean of 25.8). Of 15 patients with a large VSD, six had pulmonary artery banding with two deaths (one operative and one late), two had debanding plus VSD repair, and two are awaiting operation. The remaining nine patients did not have banding (no operative or late deaths), four patients required late VSD closure, two VSDs closed spontaneously, two VSDs became smaller, and one patient is awaiting VSD closure. The infrequent need for pulmonary artery banding may be partly due to "physiological banding" seen at Denver's high altitude. The VSD spontaneously closed or became smaller in 44% of nonbanded patients. The low operative mortality can be ascribed to (1) aggressive medical therapy, (2) emergency catheterization and repair, (3) avoidance of hypothermia, and (4) adequate relief of the coarctation.

Values and policy conceptions of health policy elites in the United States, the United Kingdom, and the Federal Republic of Germany

This essay presents data on the thinking of health policy elites in the United States, the United Kingdom and the Federal Republic of Germany. These three national groups are compared in terms of the values they perceive health policy should serve and their conceptions of appropriate policies for realizing these values. The different values and policy conceptions are then related to various propositions as to why social policies differ across nations, particularly to the hypothesis that social policies differ as a consequence of elite values and attitudes.

Autotransfusion--a technique for the trauma patient

The use of autotransfusion--the retrieval and reinfusion of shed blood--has been demonstrated to be a beneficial therapeutic modality for the trauma patient. The use of autotransfusion is indicated for major blood losses of the patient who experiences blunt or penetrating trauma and has an external or a cavitational bleeding source. Advantages and disadvantages are numerous. It does appear that because of the low incidence of complications and the many advantages, autotransfusion will become a widespread resuscitative technique for use with the trauma patient. The procedure also has clinical application for those other than trauma patients. The nursing implications suggested by this new modality are many, including legal considerations, safety factors, protocol adoption, and new nursing roles. Perhaps the most positive benefit to nursing is the opportunity for clinical nursing staff (ER and OR) to become involved in nursing research that they can apply directly to their clinical setting.