The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus

<p>Abstract</p> <p>Background</p> <p>Ongoing care for chronic conditions such as diabetes is best provided by a range of health professionals working together. There are challenges in achieving this where collaboration crosses organisational and sector boundaries. The aim of this article is to explore the influence of power dynamics and trust on collaboration between health professionals involved in the management of diabetes and their impact on patient experiences.</p> <p>Methods</p> <p>A qualitative case study conducted in a rural city in Australia. Forty five health service providers from nineteen organisations (including fee-for-service practices and block funded public sector services) and eight patients from two services were purposively recruited. Data was collected through semi-structured interviews that were audio-taped and transcribed. A thematic analysis approach was used using a two-level coding scheme and cross-case comparisons.</p> <p>Results</p> <p>Three themes emerged in relation to power dynamics between health professionals: their use of power to protect their autonomy, power dynamics between private and public sector providers, and reducing their dependency on other health professionals to maintain their power. Despite the intention of government policies to support more shared decision-making, there is little evidence that this is happening. The major trust themes related to role perceptions, demonstrated competence, and the importance of good communication for the development of trust over time. The interaction between trust and role perceptions went beyond understanding each other's roles and professional identity. The level of trust related to the acceptance of each other's roles. The delivery of primary and community-based health services that crosses organisational boundaries adds a layer of complexity to interprofessional relationships. The roles of and role boundaries between and within professional groups and services are changing. The uncertainty and vulnerability associated with these changes has affected the level of trust and mistrust.</p> <p>Conclusions</p> <p>Collaboration across organisational boundaries remains challenging. Power dynamics and trust affect the strategic choices made by each health professional about whether to collaborate, with whom, and to what level. These decisions directly influenced patient experiences. Unlike the difficulties in shifting the balance of power in interprofessional relationships, trust and respect can be fostered through a mix of interventions aimed at building personal relationships and establishing agreed rules that govern collaborative care and that are perceived as fair.</p

Huntingtin proteolysis releases non-polyQ fragments that cause toxicity through dynamin 1 dysregulation

Cleavage of mutant huntingtin (HTT) is an essential process in Huntington's disease (HD), an inherited neurodegenerative disorder. Cleavage generates N-ter fragments that contain the polyQ stretch and whose nuclear toxicity is well established. However, the functional defects induced by cleavage of full-length HTT remain elusive. Moreover, the contribution of non-polyQ C-terminal fragments is unknown. Using time- and site-specific control of full-length HTT proteolysis, we show that specific cleavages are required to disrupt intramolecular interactions within HTT and to cause toxicity in cells and flies. Surprisingly, in addition to the canonical pathogenic N-ter fragments, the C-ter fragments generated, that do not contain the polyQ stretch, induced toxicity via dilation of the endoplasmic reticulum (ER) and increased ER stress. C-ter HTT bound to dynamin 1 and subsequently impaired its activity at ER membranes. Our findings support a role for HTT on dynamin 1 function and ER homoeostasis. Proteolysis-induced alteration of this function may be relevant to disease. Synopsis The development of a time and site-specifically controlled cleavage of the mutant huntingtin protein reveals a pathogenic mechanism induced by the non-polyQ-containing fragments that are generated upon proteolysis during disease progression. Huntingtin proteolysis generates N-ter fragments that contain the toxic polyQ stretch but also the corresponding C-ter fragments. N-ter to C-ter intramolecular interactions present in full-length huntingtin are abrogated by sequential cleavages. Whereas the N-ter polyQ fragments translocate into the nucleus, the non-polyQ C-ter huntingtin fragments remain in the cytoplasm and cause ER dilation, stress and cell death. C-ter huntingtin fragments bind and inactivate dynamin 1 at the ER thus causing ER dilation and toxicity. Site-specifically controlled cleavage of the mutant huntingtin protein reveals a pathogenic mechanism induced by non-polyQ-containing fragments that are generated upon proteolysis during disease progression.</p

multicenter cohort study

Publisher Copyright: © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.Objective: Monochorionic (MC) triplet pregnancies are extremely rare and information on these pregnancies and their complications is limited. We aimed to investigate the risk of early and late pregnancy complications, perinatal outcome and the timing and methods of fetal intervention in these pregnancies. Methods: This was a multicenter retrospective cohort study of MC triamniotic (TA) triplet pregnancies managed in 21 participating centers around the world from 2007 onwards. Data on maternal age, mode of conception, diagnosis of major fetal structural anomalies or aneuploidy, gestational age (GA) at diagnosis of anomalies, twin-to-twin transfusion syndrome (TTTS), twin anemia–polycythemia sequence (TAPS), twin reversed arterial perfusion (TRAP) sequence and or selective fetal growth restriction (sFGR) were retrieved from patient records. Data on antenatal interventions were collected, including data on selective fetal reduction (three to two or three to one), laser surgery and any other active fetal intervention (including amniodrainage). Data on perinatal outcome were collected, including numbers of live birth, intrauterine demise, neonatal death, perinatal death and termination of fetus or pregnancy (TOP). Neonatal data such as GA at birth, birth weight, admission to neonatal intensive care unit and neonatal morbidity were also collected. Perinatal outcomes were assessed according to whether the pregnancy was managed expectantly or underwent fetal intervention. Results: Of an initial cohort of 174 MCTA triplet pregnancies, 11 underwent early TOP, three had an early miscarriage, six were lost to follow-up and one was ongoing at the time of writing. Thus, the study cohort included 153 pregnancies, of which the majority (92.8%) were managed expectantly. The incidence of pregnancy affected by one or more fetal structural abnormality was 13.7% (21/153) and that of TRAP sequence was 5.2% (8/153). The most common antenatal complication related to chorionicity was TTTS, which affected just over one quarter (27.6%; 42/152, after removing a pregnancy with TOP < 24 weeks for fetal anomalies) of the pregnancies, followed by sFGR (16.4%; 25/152), while TAPS (spontaneous or post TTTS with or without laser treatment) occurred in only 4.6% (7/152) of pregnancies. No monochorionicity-related antenatal complication was recorded in 49.3% (75/152) of pregnancies. Survival was apparently associated largely with the development of these complications: there was at least one survivor beyond the neonatal period in 85.1% (57/67) of pregnancies without antenatal complications, in 100% (25/25) of those complicated by sFGR and in 47.6% (20/42) of those complicated by TTTS. The overall rate of preterm birth prior to 28 weeks was 14.5% (18/124) and that prior to 32 weeks' gestation was 49.2% (61/124). Conclusion: Monochorionicity-related complications, which can impact adversely perinatal outcome, occur in almost half of MCTA triplet pregnancies, creating a challenge with regard to counseling, surveillance and management.publishersversionpublishe

Exercise versus usual care after non-reconstructive breast cancer surgery (UK PROSPER): multicentre randomised controlled trial and economic evaluation

Objective To evaluate whether a structured exercise programme improved functional and health related quality of life outcomes compared with usual care for women at high risk of upper limb disability after breast cancer surgery. Design Multicentre, pragmatic, superiority, randomised controlled trial with economic evaluation. Setting 17 UK National Health Service cancer centres. Participants 392 women undergoing breast cancer surgery, at risk of postoperative upper limb morbidity, randomised (1:1) to usual care with structured exercise (n=196) or usual care alone (n=196). Interventions Usual care (information leaflets) only or usual care plus a physiotherapy led exercise programme, incorporating stretching, strengthening, physical activity, and behavioural change techniques to support adherence to exercise, introduced at 7-10 days postoperatively, with two further appointments at one and three months. Main outcome measures Disability of Arm, Hand and Shoulder (DASH) questionnaire at 12 months, analysed by intention to treat. Secondary outcomes included DASH subscales, pain, complications, health related quality of life, and resource use, from a health and personal social services perspective. Results Between 26 January 2016 and 31 July 2017, 951 patients were screened and 392 (mean age 58.1 years) were randomly allocated, with 382 (97%) eligible for intention to treat analysis. 181 (95%) of 191 participants allocated to exercise attended at least one appointment. Upper limb function improved after exercise compared with usual care (mean DASH 16.3 (SD 17.6) for exercise (n=132); 23.7 (22.9) usual care (n=138); adjusted mean difference 7.81, 95% confidence interval 3.17 to 12.44; P=0.001). Secondary outcomes favoured exercise over usual care, with lower pain intensity at 12 months (adjusted mean difference on numerical rating scale −0.68, −1.23 to −0.12; P=0.02) and fewer arm disability symptoms at 12 months (adjusted mean difference on Functional Assessment of Cancer Therapy-Breast+4 (FACT-B+4) −2.02, −3.11 to −0.93; P=0.001). No increase in complications, lymphoedema, or adverse events was noted in participants allocated to exercise. Exercise accrued lower costs per patient (on average −£387 (€457; $533) (95% confidence interval −£2491 to £1718; 2015 pricing) and was cost effective compared with usual care. Conclusions The PROSPER exercise programme was clinically effective and cost effective and reduced upper limb disability one year after breast cancer treatment in patients at risk of treatment related postoperative complications

Plasmonics applied to optical modulation and single molecules detection by fluorescence correlation spectroscopy

Des études préliminaires ont été menées sur un modulateur plasmonique pour des applications télécoms et sur un réseau de nanopointes recouvertes d'or pour des applications biomédicales. Nous proposons d'utiliser des modulateurs plasmoniques tout optique basés sur des nanoparticules métalliques déposées sur des films métalliques minces afin d'assurer la conversion des signaux électriques en signaux optiques par variation de l'intensité de la lumière transmise. L'originalité de ce projet provient de l'utilisation simultanée de plasmons de surface localisés et propagatifs pour produire la fonction optique. Cette géométrie offre de nombreux avantages par rapport aux systèmes actuellement proposés : réalisation simple, capacité d'intégration haute densité et efficacité de modulation. Une partie de ce travail de thèse a consisté à étudier ce type de modulateur en microscopie à fuites radiatives. L'étude de la réponse optique de nanoparticules d'or déposées sur des films métalliques minces a permis d'obtenir des amplifications de la transmission de lumière à travers ces films. Nous avons également développé une nouvelle technique de fluorescence couplant la spectroscopie de corrélation de fluorescence (FCS) avec des substrats plasmoniques nanostructurés afin de pouvoir caractériser des biomolécules in vivo en réduisant le volume d'observation. Les substrats plasmoniques utilisés sont des réseaux de pointes nanométriques recouvertes d'or. Des mesures de FCS sur des fluorophores diffusant à proximité de ces substrats ont été effectuées. Les résultats obtenus n'ont malheureusement pas été concluants : en réflexion (laser d'excitation réfléchi sur les substrats plasmoniques), le signal émis par les fluorophores n'a pas pu être discriminé de celui émis par les substrats. Récemment, des résultats prometteurs ont cependant été obtenus dans une autre configuration (lumière injectée et collectée par les fibres optiques des substrats).Preliminary studies were carried on a plasmonic modulator for telecomunication applications and on a gold nanotips array for biomedical applications.PARIS7-Bibliothèque centrale (751132105) / SudocSudocFranceF

Intracolony variability in winter feeding and migration strategies of Atlantic puffins and black‑legged kittiwakes

Polar ecosystems are subjected to many stressors, including climate change, that impact their overall functioning. Seabirds are good bioindicators of these systems as they readily respond to changes in environmental conditions. To quantify how environmental changes afect their life history, data on seabird diet, spatial distribution and body condition are needed to reveal the underlying mechanisms. We explored possible drivers of the winter distribution of single-colony populations of Atlantic pufns Fratercula arctica and black-legged kittiwakes Rissa tridactyla, two of the most numerous seabird species in the North Atlantic. Based on carbon and nitrogen stable isotopic data from feathers moulted during winter migration, we identifed three groups of Atlantic pufns and two groups of black-legged kittiwakes occupying diferent isotopic niches. We then used geolocator tracking data for the same birds to determine if these groups refected parallel diferences in the location of moulting grounds rather than diferences in their diet. We found that the isotopic niches of the three Atlantic pufn groups likely resulted from their use of diferent habitats during winter moult. In contrast, the isotopic niches of the two black-legged kittiwake groups were more likely a result of diferences in their diet, as both groups were distributed in the same area. These fndings suggest that diferent winter feeding and/or migration strategies may play a role in shaping the body condition of individuals for their following breeding season. We discuss the role of environmental conditions encountered by seabirds during winter migration to further elucidate such intracolony divergence in strategies. As polar ecosystems experience rapid changes in environmental conditions, the approach presented here may provide valuable information for the development of efective conservation measures (taking both intra- and intercolony variability into account), and to better predict future impacts of climate change

Influence of ultrasound determination of fetal head position on mode of delivery: A pragmatic randomized trial

International audienceObjective To evaluate the influence of ultrasound determination of fetal head position on mode of delivery. Methods This was a pragmatic open-label randomized controlled trial that included women with a singleton pregnancy in the vertex presentation at ≥ 37 weeks' gestation, cervical dilation ≥ 8 cm and who received epidural anesthesia. Women were assigned randomly to undergo either digital vaginal examination (VE group) or both digital vaginal and ultrasound examinations (VE+US group) to determine fetal head position. When the ultrasound and digital vaginal findings were inconsistent in the VE+US group, the ultrasound result was used for clinical management. The primary outcome assessed was operative delivery (Cesarean or instrumental vaginal delivery), and maternal and fetal morbidity were also assessed. Results The VE and VE+US groups included 959 and 944 women, respectively. The overall rate of operative delivery was significantly higher in the VE+US group than in the VE group: 33.7% vs 27.1%, respectively (relative risk (RR), 1.24 (95% CI, 1.08-1.43)), as was the rate of Cesarean delivery: 7.8% vs 4.9%, respectively (RR, 1.60 (95% CI, 1.12-2.28)). The rate of instrumental vaginal delivery was also higher, albeit not significantly: 25.8% in the VE+US group vs 22.2% in the VE group (RR, 1.16 (95% CI, 0.99-1.37)). Neonatal outcomes did not differ between the two groups. When analysis was restricted to instrumental vaginal deliveries only, maternal and neonatal morbidity outcomes were similar in both groups. Conclusion Correction of fetal occiput position, determined initially by digital vaginal examination, using systematic ultrasound examination did not improve management of labor and increased the rate of operative delivery without decreasing maternal and neonatal morbidity. Copyrigh