Outcomes following oesophagectomy in patients with oesophageal cancer: a secondary analysis of the ICNARC Case Mix Programme Database

Introduction: This report describes the case mix and outcomes of patients with oesophageal cancer admitted to adult critical care units following elective oesophageal surgery in England, Wales and Northern Ireland. Methods: Admissions to critical care following elective oesophageal surgery for malignancy were identified using data from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database. Information on admissions between December 1995 and September 2007 were extracted and the association between in-hospital mortality and patient characteristics on admission to critical care was assessed using multiple logistic regression analysis. The performance of three prognostic models (Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II and the ICNARC physiology score) was also evaluated. Results: Between 1995 and 2007, there were 7227 admissions to 181 critical care units following oesophageal surgery for malignancy. Overall mortality in critical care was 4.4% and in-hospital mortality was 11%, although both declined steadily over time. Eight hundred and seventy-three (12.2%) patients were readmitted to critical care, most commonly for respiratory complications (49%) and surgical complications (25%). Readmitted patients had a critical care unit mortality of 24.7% and in-hospital mortality of 33.9%. Overall in-hospital mortality was associated with patient age, and various physiological measurements on admission to critical care (partial pressure of arterial oxygen (PaO2):fraction of inspired oxygen (FiO2) ratio, lowest arterial pH, mechanical ventilation, serum albumin, urea and creatinine). The three prognostic models evaluated performed poorly in measures of discrimination, calibration and goodness of fit. Conclusions: Surgery for oesophageal malignancy continues to be associated with significant morbidity and mortality. Age and organ dysfunction in the early postoperative period are associated with an increased risk of death. Postoperative serum albumin is confirmed as an additional prognostic factor. More work is required to determine how this knowledge may improve clinical management

Optical Design of the WFIRST Phase-A Wide Field Instrument

The WFIRST Wide-Field Infrared Survey Telescope TMA optical design provides 0.28-sq degrees FOV at 0.11 pixel scale to the Wide Field Instrument, operating between 0.48-2.0 micrometers, including a spectrograph mode (1.0-2.0 micrometers). An Integral Field Channel provides 2-D discrete spectroscopy at 0.15 & 0.3 sampling

Workforce development to provide person-centered care

OBJECTIVES: Describe the development of a competent workforce committed to providing patient-centered care to persons with dementia and/or depression and their caregivers; to report on qualitative analyses of our workforce's case reports about their experiences; and to present lessons learned about developing and implementing a collaborative care community-based model using our new workforce that we call care coordinator assistants (CCAs). METHOD: Sixteen CCAs were recruited and trained in person-centered care, use of mobile office, electronic medical record system, community resources, and team member support. CCAs wrote case reports quarterly that were analyzed for patient-centered care themes. RESULTS: Qualitative analysis of 73 cases using NVivo software identified six patient-centered care themes: (1) patient familiarity/understanding; (2) patient interest/engagement encouraged; (3) flexibility and continuity of care; (4) caregiver support/engagement; (5) effective utilization/integration of training; and (6) teamwork. Most frequently reported themes were patient familiarity - 91.8% of case reports included reference to patient familiarity, 67.1% included references to teamwork and 61.6% of case reports included the theme flexibility/continuity of care. CCAs made a mean number of 15.7 (SD = 15.6) visits, with most visits for coordination of care services, followed by home visits and phone visits to over 1200 patients in 12 months. DISCUSSION: Person-centered care can be effectively implemented by well-trained CCAs in the community

Which imaging modality is superior for prediction of response to neoadjuvant chemotherapy in patients with triple negative breast cancer?

Background and Objectives. Triple negative breast cancer (TNBC) has been shown to be generally chemosensitive. We sought to investigate the utility of mammography (MMG), ultrasonography (US), and breast magnetic resonance imaging (MRI) in predicting residual disease following neoadjuvant chemotherapy for TNBC. Methods. We identified 148 patients with 151 Stage I–III TNBC treated with neoadjuvant chemotherapy. Residual tumor size was estimated by MMG, US, and/or MRI prior to surgical intervention and compared to the subsequent pathologic residual tumor size. Data were compared using chi-squared test. Results. Of 151 tumors, 44 (29%) did not have imaging performed prior to surgical treatment. Thirty-eight (25%) tumors underwent a pathologic complete response (pCR), while 113 (75%) had residual invasive disease. The imaging modality was accurate to within 1 cm of the final pathologic residual disease in 74 (69%) cases and within 2 cm in 94 (88%) cases. Groups were similar with regards to patient age, race, tumor size and grade, and clinical stage (). Accuracy to within 1 cm was the highest for US (83%) and the lowest for MMG (56%) (). Conclusions. Breast US and MRI were more accurate than MMG in predicting residual tumor size following neoadjuvant chemotherapy in patients with TNBC. None of the imaging modalities were predictive of a pCR

Randomized double-blind placebo-controlled trial of 40 mg/day of atorvastatin in reducing the severity of sepsis in ward patients (ASEPSIS Trial)

Introduction: Several observational studies suggest that statins modulate the pathophysiology of sepsis and may prevent its progression. The aim of this study was to determine if the acute administration of atorvastatin reduces sepsis progression in statin naïve patients hospitalized with sepsis. Methods: A single centre phase II randomized double-blind placebo-controlled trial. Patients with sepsis were randomized to atorvastatin 40 mg daily or placebo for the duration of their hospital stay up to a maximum of 28-days. The primary end-point was the rate of sepsis progressing to severe sepsis during hospitalization. Results: 100 patients were randomized, 49 to the treatment with atorvastatin and 51 to placebo. Patients in the atorvastatin group had a significantly lower conversion rate to severe sepsis compared to placebo (4% vs. 24% p = 0.007.), with a number needed to treat of 5. No significant difference in length of hospital stay, critical care unit admissions, 28-day and 12-month readmissions or mortality was observed. Plasma cholesterol and albumin creatinine ratios were significantly lower at day 4 in the atorvastatin group (p < 0.0001 and p = 0.049 respectively). No difference in adverse events between the two groups was observed (p = 0.238). Conclusions: Acute administration of atorvastatin in patients with sepsis may prevent sepsis progression. Further multi-centre trials are required to verify these findings. Trial Registration: International Standard Randomized Control Trial Registry ISRCTN64637517

Care coordinator assistants: Job satisfaction and the importance of teamwork in delivering person-centered dementia care

As the prevalence of persons with dementia increases, a larger, trained, and skilled healthcare workforce is needed. Attention has been given to models of person-centered care as a standard for dementia care. One promising role to deliver person-centered care is the care coordinator assistant. An inquiry about care coordinator assistant’s job satisfaction is reasonable to consider for retention and quality improvement purposes. We evaluated care coordinator assistant’s job satisfaction quantitatively and qualitatively. This study was part of a Centers for Medicare & Medicaid Services Health Care Innovation Award to the Indiana University School of Medicine. Sixteen care coordinator assistants, predominately female, African American or Caucasian, college graduates with a mean age of 43.1 years participated. Care coordinator assistants wrote quarterly case reports to share stories, lessons learned, and/or the impact of their job and completed the revised Job Satisfaction Inventory and Job in General scales during the second year of the Centers for Medicare & Medicaid Services award. For the Job Descriptive Index subscales promotion, supervision, and coworkers and Job in General, care coordinator assistants scored similar to normative means. Care coordinator assistants reported significantly higher satisfaction on the work subscale and significantly lower satisfaction on the pay subscale compared to normative data. Care coordinator assistants completed 119 quarterly case reports. Job satisfaction and teamwork were recurring themes in case reports, referenced in 47.1% and 60.5% of case reports, respectively. To address the demands of increasing dementia diagnoses, care coordinator assistants can constitute a compassionate, competent, and satisfied workforce. Training care coordinator assistants to work together in a team to address the needs of persons with dementia and caregivers provides a viable model of workforce development necessary to meet the growing demands of this population

Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial

Background: Approximately a third of women receiving pethidine for labour pain subsequently require an epidural, which provides effective pain relief but increases the risk of instrumental delivery. Remifentanil patient controlled analgesia (PCA) in labour is an alternative to pethidine, but not widely utilized. We sought to determine epidural rates amongst women using remifentanil PCA compared to pethidine.Methods: We conducted a randomised, parallel, open-label trial in 14 UK maternity units. Women at term gestation, in labour with a singleton cephalic presentation, requesting opioid pain relief, were randomly assigned (1:1) to remifentanil PCA (40μg bolus with a two minute “lock-out”) or intramuscular pethidine (100mg, four-hourly, up to 400mg). Web-based or telephone randomisation minimised allocations by parity, age, ethnicity and mode of labour onset. The primary outcome was the proportion of women who received epidural analgesia after enrolment. To detect a reduction in epidural conversion from 30% to 15% with 90% power, with a 15% anticipated attrition from urgent delivery by emergency caesarean section, required 400 women. Primary analyses were unadjusted and by intention-to-treat. ISRCTN29654603.Findings: Between May 13, 2014, and Sept 2, 2016, 201 women were randomly assigned to the remifentanil PCA group and 200 to the pethidine group. One participant in the pethidine group withdrew consent, leaving 199 for analyses. The proportions of epidural conversion were 19% (39 of 201) in the remifentanil PCA group and 41% (81 of 199) in the pethidine group (risk ratio 0·48, 95% CI 0·34–0·66; p less 0·0001). There were no serious adverse events or drug reactions directly attributable to either analgesic during the study.Interpretation: Intravenous remifentanil PCA halved the proportion of epidural conversions compared with intramuscular pethidine. This finding challenges routine pethidine use as standard of care in labour

Characterisation of two quorum sensing systems in the endophytic Serratia plymuthica strain G3: differential control of motility and biofilm formation according to life-style

<p>Abstract</p> <p>Background</p> <p><it>N</it>-acylhomoserine lactone (AHL)-based quorum sensing (QS) systems have been described in many plant-associated Gram-negative bacteria to control certain beneficial phenotypic traits, such as production of biocontrol factors and plant growth promotion. However, the role of AHL-mediated signalling in the endophytic strains of plant-associated <it>Serratia </it>is still poorly understood. An endophytic <it>Serratia </it>sp. G3 with biocontrol potential and high levels of AHL signal production was isolated from the stems of wheat and the role of QS in this isolate was determined.</p> <p>Results</p> <p>Strain G3 classified as <it>Serratia plymuthica </it>based on 16S rRNA was subjected to phylogenetic analysis. Using primers to conserved sequences of <it>luxIR </it>homologues from the <it>Serratia </it>genus, <it>splIR </it>and <it>spsIR </it>from the chromosome of strain G3 were cloned and sequenced. AHL profiles from strain G3 and <it>Escherichia coli </it>DH5α expressing <it>splI </it>or <it>spsI </it>from recombinant plasmids were identified by liquid chromatography-tandem mass spectrometry. This revealed that the most abundant AHL signals produced by SplI in <it>E. coli </it>were <it>N</it>-3-oxo-hexanoylhomoserine lactone (3-oxo-C6-HSL), <it>N</it>-3-oxo-heptanoylhomoserine lactone (3-oxo-C7-HSL), <it>N</it>-3-hydroxy-hexanoylhomoserine lactone (3-hydroxy-C6-HSL), <it>N</it>-hexanoylhomoserine lactone (C6-HSL), and <it>N</it>-heptanoyl homoserine lactone (C7-HSL); whereas SpsI was primarily responsible for the synthesis of <it>N</it>-butyrylhomoserine lactone (C4-HSL) and <it>N</it>-pentanoylhomoserine lactone (C5-HSL). Furthermore, a quorum quenching analysis by heterologous expression of the <it>Bacillus </it>A24 AiiA lactonase in strain G3 enabled the identification of the AHL-regulated biocontrol-related traits. Depletion of AHLs with this lactonase resulted in altered adhesion and biofilm formation using a microtiter plate assay and flow cells coupled with confocal laser scanning microscopy respectively. This was different from the closely related <it>S. plymuthica </it>strains HRO-C48 and RVH1, where biofilm formation for both strains is AHL-independent. In addition, QS in G3 positively regulated antifungal activity, production of exoenzymes, but negatively regulated production of indol-3-acetic acid (IAA), which is in agreement with previous reports in strain HRO-C48. However, in contrast to HRO-C48, swimming motility was not controlled by AHL-mediated QS.</p> <p>Conclusions</p> <p>This is the first report of the characterisation of two AHL-based quorum sensing systems in the same isolate of the genus <it>Serratia</it>. Our results show that the QS network is involved in the global regulation of biocontrol-related traits in the endophytic strain G3. However, although free-living and endophytic <it>S. plymuthica </it>share some conservation on QS phenotypic regulation, the control of motility and biofilm formation seems to be strain-specific and possible linked to the life-style of this organism.</p

Direct numerical simulation of a tip-leakage flow in a planar duct with a longitudinal slit

A planar duct flow configuration with a cross-flow injected from a longitudinal slit close to the upper wall of the duct is studied by using a direct numerical simulation approach to explore the underlying flow mechanism in relation to the tip-leakage vortex (TLV), which is one of the most important flow phenomena in turbomachinery. Major characteristics of TLV in a rotor of turbomachinery are identified in the current flow model. The analysis of mean and instantaneous flow fields reveals that the interaction between the main (axial) flow and jet (cross) flow is the primary source of the generation of the TLV. The evolution of the TLV is then investigated, and a vortex breakup phenomenon is identified. The evolution of TLV can be divided into three phases, i.e. the formation phase, the break-up phase, and the diffusion phase. Mean streamlines and turbulence kinetic energy (TKE) budgets are analysed, showing that the high TKE central spot in the formation phase is due to the interaction between highly swirling vortex filaments and mean velocity gradient. In the outer part of the TLV, the TKE is mainly produced in the shear-layer and transported towards the centre by the turbulence transport

Using H-alpha Morphology and Surface Brightness Fluctuations to Age-Date Star Clusters in M83

We use new WFC3 observations of the nearby grand design spiral galaxy M83 to develop two independent methods for estimating the ages of young star clusters. The first method uses the physical extent and morphology of Halpha emission to estimate the ages of clusters younger than tau ~10 Myr. It is based on the simple premise that the gas in very young (tau < few Myr) clusters is largely coincident with the cluster stars, is in a small, ring-like structure surrounding the stars in slightly older clusters (e.g., tau ~5 Myr), and is in a larger ring-like bubble for still older clusters (i.e., ~5-10 Myr). The second method is based on an observed relation between pixel-to-pixel flux variations within clusters and their ages. This method relies on the fact that the brightest individual stars in a cluster are most prominent at ages around 10 Myr, and fall below the detection limit (i.e., M_V < -3.5) for ages older than about 100 Myr. These two methods are the basis for a new morphological classification system which can be used to estimate the ages of star clusters based on their appearance. We compare previous age estimates of clusters in M83 determined from fitting UBVI Halpha measurements using predictions from stellar evolutionary models with our new morphological categories and find good agreement at the ~95% level. The scatter within categories is ~0.1 dex in log tau for young clusters (10 Myr) clusters. A by-product of this study is the identification of 22 "single-star" HII regions in M83, with central stars having ages ~4 Myr.Comment: 33 pages, 10 figures, 3 tables; published in March Ap