Robot-Assisted Radical Cystectomy in the Management of Bladder Cancer

The application of robotic technology to laparoscopic surgery has the potential to revolutionize the entire field of urology. The use of robotic-assisted radical cystectomy has been demonstrated in the literature only within the past 3 years, as much of the reconstruction and urinary diversion techniques associated with radical cystectomy are considered more technically challenging than other procedures. Here we review the available literature pertaining to this procedure, which consists of a limited number of case reports, case series, and pilot or feasibility studies. While theses results seem to point towards less blood loss, lower transfusion rates, and shorter hospital stays compared to open radical cystectomy, definitive conclusions and recommendations cannot yet be made because of a lack of larger and/or prospective studies or randomized trials

A Comparison of Quality of Care in Critical Access Hospitals and Other Rural Hospitals

Purpose: The United States has about 2100 rural hospitals. Approximately 1300 are Critical Access Hospitals (CAHs) with 25 beds or less. CAHs receive cost-based reimbursement through the federal Flex program with the goal to improve quality and access to health care. Reports on quality of care (QOC) and factors that influence quality in CAHs are mixed. This study compared QOC and factors that influence QOC in CAHs and other rural hospitals. Sample: 385 staff nurses in 6 CAHs and 9 other rural hospitals in North Carolina and Virginia. Method: Descriptive cross-sectional design using nurse surveys aggregated to the hospital level, data from provider of services file, and the United States Department of Agriculture, Economic Research files. Variables on community, hospital, and nursing unit characteristics, the nurse work environment, nurse rated QOC and community perception of hospital quality were compared using t-test or chi-square. Findings: There were no differences in the majority of factors influencing QOC. A culture of safety, the nurse work environment, and QOC were rated high in all hospitals. Compared to other rural hospitals CAHs tend to be located in communities with better economic status and their nurses had more years of nursing experience. More nurses in CAHs felt their community recognized their hospital as a good place for minor health issues and would recommend the hospital to family and friends. Conclusions: The high ratings of QOC were accompanied with the presence of safety cultures and work environments rated as highly as in Magnet hospitals. The lower poverty levels in communities with CAHs suggest possible community financial benefits from CAHs. More studies are warranted to explore these relationships. Further reporting to public quality indicator databases by all CAHs should be encouraged and QOC measures relevant for small rural hospitals should be developed

Diffusing an Innovation: Clinician Perceptions of Continuous Predictive Analytics Monitoring in Intensive Care

Background The purpose of this article is to describe neonatal intensive care unit clinician perceptions of a continuous predictive analytics technology and how those perceptions influenced clinician adoption. Adopting and integrating new technology into care is notoriously slow and difficult; realizing expected gains remain a challenge. Methods Semistructured interviews from a cross-section of neonatal physicians (n ¼ 14) and nurses (n ¼ 8) from a single U.S. medical center were collected 18 months following the conclusion of the predictive monitoring technology randomized control trial. Following qualitative descriptive analysis, innovation attributes from Diffusion of Innovation Theory-guided thematic development. Results Results suggest that the combination of physical location as well as lack of integration into work flow or methods of using data in care decisionmaking may have delayed clinicians from routinely paying attention to the data. Once data were routinely collected, documented, and reported during patient rounds and patient handoffs, clinicians came to view data as another vital sign. Through clinicians’ observation of senior physicians and nurses, and ongoing dialogue about data trends and patient status, clinicians learned how to integrate these data in care decision making (e.g., differential diagnosis) and came to value the technology as beneficial to care delivery. Discussion The use of newly created predictive technologies that provide early warning of illness may require implementation strategies that acknowledge the risk–benefit of treatment cliniciansmust balance and take advantage of existing clinician trainingmethods

Accurate and Rapid Identification of the Burkholderia pseudomallei Near-Neighbour, Burkholderia ubonensis, Using Real-Time PCR

Burkholderia ubonensis is an environmental bacterium belonging to the Burkholderia cepacia complex (Bcc), a group of genetically related organisms that are associated with opportunistic but generally nonfatal infections in healthy individuals. In contrast, the near-neighbour species Burkholderia pseudomallei causes melioidosis, a disease that can be fatal in up to 95% of cases if left untreated. B. ubonensis is frequently misidentified as B. pseudomallei from soil samples using selective culturing on Ashdown’s medium, reflecting both the shared environmental niche and morphological similarities of these species. Additionally, B. ubonensis shows potential as an important biocontrol agent in B. pseudomallei-endemic regions as certain strains possess antagonistic properties towards B. pseudomallei. Current methods for characterising B. ubonensis are laborious, time-consuming and costly, and as such this bacterium remains poorly studied. The aim of our study was to develop a rapid and inexpensive real-time PCR-based assay specific for B. ubonensis. We demonstrate that a novel B. ubonensis-specific assay, Bu550, accurately differentiates B. ubonensis from B. pseudomallei and other species that grow on selective Ashdown’s agar. We anticipate that Bu550 will catalyse research on B. ubonensis by enabling rapid identification of this organism from Ashdown’s-positive colonies that are not B. pseudomallei

Epistasis, core-genome disharmony, and adaptation in recombining bacteria

Recombination of short DNA fragments via horizontal gene transfer (HGT) can introduce beneficial alleles, create genomic disharmony through negative epistasis, and create adaptive gene combinations through positive epistasis. For non-core (accessory) genes, the negative epistatic cost is likely to be minimal because the incoming genes have not co-evolved with the recipient genome and are frequently observed as tightly linked cassettes with major effects. By contrast, interspecific recombination in the core genome is expected to be rare because disruptive allelic replacement is likely to introduce negative epistasis. Why then is homologous recombination common in the core of bacterial genomes? To understand this enigma, we take advantage of an exceptional model system, the common enteric pathogens Campylobacter jejuni and C. coli that are known for very high magnitude interspecies gene flow in the core genome. As expected, HGT does indeed disrupt co-adapted allele pairings, indirect evidence of negative epistasis. However, multiple HGT events enable recovery of the genome’s co-adaption between introgressing alleles, even in core metabolism genes (e.g., formate dehydrogenase). These findings demonstrate that, even for complex traits, genetic coalitions can be decoupled, transferred, and independently reinstated in a new genetic background—facilitating transition between fitness peaks. In this example, the two-step recombinational process is associated with C. coli that are adapted to the agricultural niche

Home and Community Based Medicaid Waivers for Children with Medical Complexity

Funded by the Lucile Packard Foundation for Children's Healt