Effect of implementing a heart failure admission care bundle on hospital readmission and mortality rates: interrupted time series study

This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: N-terminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFT-Evidence approach to quality improvement was used. During implementation, July 2015–July 2017, 1169 patients received the intervention. An interrupted time series design was used to evaluate impact on patient outcomes, including 15 618 admissions for 8951 patients. Mixed-effects multiple Poisson and log-linear regression models were fitted for count and continuous outcomes, respectively. Effect sizes are slope change ratios pre-intervention and post-intervention. The intervention was associated with reductions in emergency readmissions between 7 and 90 days (0.98, 95% CI 0.97 to 1.00), although not readmissions between 0 and 7 days post-discharge. Improvements were seen in in-hospital mortality (0.96, 95% CI 0.95 to 0.98), and there was no change in trend for hospital length of stay. Care process changes were also evaluated. Compliance with NT-proBNP testing was already high in 2014/2015 (162 of 163, 99.4%) and decreased slightly, with increased numbers audited, to 2016/2017 (1082 of 1101, 98.2%). Over this period, rates of echocardiography (84.7–98.9%) and specialist input (51.6–90.4%) improved. Care quality and outcomes can be improved for patients with acute heart failure using a care bundle approach. A systematic approach to quality improvement, and robust evaluation design, can be beneficial in supporting successful improvement and learning

Genesis and development of an interfluvial peatland in the central Congo Basin since the Late Pleistocene

The central Congo Basin contains the largest known peatland complex in the tropics. Here we present a detailed multi-proxy record from a peat core, CEN-17.4, from the centre of a 45 km wide interfluvial peatland (Ekolongouma), the first record of its kind from the central Congo peatlands. We use pollen, charcoal, sedimentological and geochemical data to reconstruct the site's history from the late Pleistocene to the present day. Peat began accumulating at the centre of the peatland ∼19,600 cal BP (∼17,500–20,400 cal BP, 95% confidence interval), and between ∼9500 (9430–9535 cal BP) and 10,500 (10,310–10,660 cal BP) cal BP towards the margins. Pollen data from the peatland centre show that an initial grass- and sedge-dominated vegetation, which burned frequently, was replaced by a Manilkara-type dominated flooded forest at ∼12,640 cal BP, replaced in turn by a more mixed swamp forest at ∼9670 cal BP. Mixed swamp forest vegetation has persisted to the present day, with variations in composition and canopy openness likely caused at least in part by changes in palaeo-precipitation. Stable isotope data (δDn-C29-v&icecorr) indicate a large reduction in precipitation beginning ∼5000 and peaking ∼2000 cal BP, associated with the near-complete mineralization of several metres of previously accumulated peat and with a transition to a drier, more heliophilic swamp forest assemblage, likely with a more open canopy. Although the peatland and associated vegetation recovered from this perturbation, the strong response to this climatic event underlines the ecosystem's sensitivity to changes in precipitation. We find no conclusive evidence for anthropogenic activity in our record; charcoal is abundant only in the Pleistocene part of the record and may reflect natural rather than anthropogenic fires. We conclude that autogenic succession and variation in the amount and seasonality of precipitation have been the most important drivers of ecological change in this peatland since the late Pleistocene

‘I can die today, I can die tomorrow’: lay perceptions of sickle cell disease in Kumasi, Ghana at a point of transition

Objective. To describe the lay meanings of sickle cell disease (SCD) in the Ashanti region of Ghana

Phosphoinositide 3 kinase signalling may affect multiple steps during herpes simplex virus type-1 entry

Early interactions of herpes simplex virus type-1 (HSV-1) with cells lead to cytoskeletal changes facilitating filopodia formation and membrane fusion. Here, we demonstrate that phosphoinositide 3 kinase (PI3K) signalling may affect multiple steps during HSV-1 entry. An inhibitor of PI3K (LY294002) blocked HSV-1 entry and the blockage was cell-type- and gD receptor-independent. Entry inhibition was also observed with primary cultures of the human corneal fibroblasts and unrelated β- and γ-herpesviruses. Immunofluorescence analysis demonstrated that LY294002 negatively affected HSV-1-induced filopodia formation. Similar effects of the inhibitor were seen on HSV-1 glycoprotein-induced cell-to-cell fusion. Cells expressing HSV-1 glycoproteins (gB, gD, gH and gL) showed significantly less fusion with target cells in the presence of the inhibitor. Expression of a dominant-negative PI3K mutant negatively affected both entry and fusion. We also show that inhibition of PI3K signalling also affected RhoA activation required for HSV-1 entry into certain cell types

Learning to live with Parkinson’s disease in the family unit:an interpretative phenomenological analysis of well-being

We investigated family members’ lived experience of Parkinson’s disease (PD) aiming to investigate opportunities for well-being. A lifeworld-led approach to healthcare was adopted. Interpretative phenomenological analysis was used to explore in-depth interviews with people living with PD and their partners. The analysis generated four themes: It’s more than just an illness revealed the existential challenge of diagnosis; Like a bird with a broken wing emphasizing the need to adapt to increasing immobility through embodied agency; Being together with PD exploring the kinship within couples and belonging experienced through support groups; and Carpe diem! illuminated the significance of time and fractured future orientation created by diagnosis. Findings were interpreted using an existential-phenomenological theory of well-being. We highlighted how partners shared the impact of PD in their own ontological challenges. Further research with different types of families and in different situations is required to identify services required to facilitate the process of learning to live with PD. Care and support for the family unit needs to provide emotional support to manage threats to identity and agency alongside problem-solving for bodily changes. Adopting a lifeworld-led healthcare approach would increase opportunities for well-being within the PD illness journey

Participation of the PI-3K/Akt-NF-κB signaling pathways in hypoxia-induced mitogenic factor-stimulated Flk-1 expression in endothelial cells

BACKGROUND: Hypoxia-induced mitogenic factor (HIMF), a lung-specific growth factor, promotes vascular tubule formation in a matrigel plug model. We initially found that HIMF enhances vascular endothelial growth factor (VEGF) expression in lung epithelial cells. In present work, we tested whether HIMF modulates expression of fetal liver kinase-1 (Flk-1) in endothelial cells, and dissected the possible signaling pathways that link HIMF to Flk-1 upregulation. METHODS: Recombinant HIMF protein was intratracheally instilled into adult mouse lungs, Flk-1 expression was examined by immunohistochemistry and Western blot. The promoter-luciferase reporter assay and real-time RT-PCR were performed to examine the effects of HIMF on Flk-1 expression in mouse endothelial cell line SVEC 4–10. The activation of NF-kappa B (NF-κB) and phosphorylation of Akt, IKK, and IκBα were examined by luciferase assay and Western blot, respectively. RESULTS: Intratracheal instillation of HIMF protein resulted in a significant increase of Flk-1 production in lung tissues. Stimulation of SVEC 4–10 cells by HIMF resulted in increased phosphorylation of IKK and IκBα, leading to activation of NF-κB. Blocking NF-κB signaling pathway by dominant-negative mutants of IKK and IκBα suppressed HIMF-induced Flk-1 upregulation. Mutation or deletion of NF-κB binding site within Flk-1 promoter also abolished HIMF-induced Flk-1 expression in SVEC 4–10 cells. Furthermore, HIMF strongly induced phosphorylation of Akt. A dominant-negative mutant of PI-3K, Δp85, as well as PI-3K inhibitor LY294002, blocked HIMF-induced NF-κB activation and attenuated Flk-1 production. CONCLUSION: These results suggest that HIMF upregulates Flk-1 expression in endothelial cells in a PI-3K/Akt-NF-κB signaling pathway-dependent manner, and may play critical roles in pulmonary angiogenesis

Development and validation of a visual grading scale for assessing image quality of AP pelvis radiographic images

OBJECTIVE: Apply psychometric theory to develop and validate a visual grading scale for assessing visual perception of AP pelvis digital image quality. METHODS: Psychometric theory was used to guide scale development. Seven phantom and 7 cadaver images of visually and objectively predetermined quality were used to help assess scale reliability and validity. 151 volunteers scored phantom images; 184 volunteers scored cadaver images. Factor analysis and Cronbach’s alpha were used to assess scale validity and reliability. RESULTS: A 24 item scale was produced. Aggregated mean volunteer scores for each image correlated with the rank order of the visually and objectively predetermined image qualities. Scale items had good inter-item correlation (≥0.2) and high factor loadings (≥0.3). Cronbach's alpha (reliability) revealed that the scale has acceptable levels of internal reliability for both phantom and cadaver images (α= 0.8 and 0.9, respectively). Factor analysis suggested the scale is multidimensional (assessing multiple quality themes). CONCLUSION: This study represents the first full development and validation of a visual image quality scale using psychometric theory. It is likely that this scale will have clinical, training and research applications. ADVANCES IN KNOWLEDGE: This article presents data to create and validate visual grading scales for radiographic examinations. The visual grading scale, for AP pelvis examinations, can act as a validated tool for future research, teaching and clinical evaluations of image quality