The inclusion of delirium in version 2 of the National Early Warning Score will substantially increase the alerts for escalating levels of care: findings from a retrospective database study of emergency medical admissions in two hospitals

YesBackground The National Early Warning Score (NEWS) is being replaced with NEWS2 which adds 3 points for new confusion or delirium. We estimated the impact of adding delirium on the number of medium/high level alerts that are triggers to escalate care. Methods Analysis of emergency medical admissions in two acute hospitals (York Hospital (YH) and Northern Lincolnshire and Goole NHS Foundation Trust hospitals (NH)) in England. Twenty per cent were randomly assigned to have delirium. Results The number of emergency admissions (YH: 35584; NH: 35795), mortality (YH: 5.7%; NH: 5.5%), index NEWS (YH: 2.5; NH: 2.1) and numbers of NEWS recorded (YH: 879193; NH: 884072) were similar in each hospital. The mean number of patients with medium level alerts per day increased from 55.3 (NEWS) to 69.5 (NEWS2), a 25.7% increase in YH and 64.1 (NEWS) to 77.4 (NEWS2), a 20.7% increase in NH. The mean number of patients with high level alerts per day increased from 27.3 (NEWS) to 34.4 (NEWS2), a 26.0% increase in YH and 29.9 (NEWS) to 37.7 (NEWS2), a 26.1% increase in NH. Conclusions The addition of delirium in NEWS2 will have a substantial increase in medium and high level alerts in hospitalised emergency medical patients. Rigorous evaluation of NEWS2 is required before widespread implementation because the extent to which staff can cope with this increase without adverse consequences remains unknown

An Interprofessional End of Life Simulation Using a Movie/Discussion Format

An Interprofessional End of Life Simulation Using a Movie/Discussion Format Sigma Theta Tau International Nursing Research Congress Cape Town, South Africa July 25, 2016 Mary Val Palumbo, DNP, MSN, BS, APRN, GNP-BC1 Christina S. Melvin, MS, BS, PHCNS, BC, CHPN1 Nancy P. LeMieux, MSN, BSEd, RN1 Deborah A. O\u27Rouke, PhD, MA, MClSc, BSc, PT2 Jean Beatson, EdD, MS, RN3 Patricia A. Prelock, PhD, MA, BS, CCC-SLP, BCS-CL4 Kelly A. Melekis, PhD, MSW, LMSW5 Mary Alice Favro, MA, BS, CCC-SLP6 Vicki Hart, PhD7 (1)Department of Nursing, University of Vermont, Burlington, VT (2)Dept. of Rehabilitation and Movement Science, University of Vermont, Burlington, VT (3)Vermont Interdisciplinary Leadership Education for Health Professionals Program, University Of Vermont, Burlington, VT (4)Department of Communication Sciences & Disorders, University of Vermont, Burlington, VT (5)Department of Social Work, University of Vermont, Burlington, VT (6)Department of Communication Sciences and Disorders, University of Vermont, Burlington, VT, VT (7)Office of Health Promotion Research, University of Vermont, Burlington, VT Purpose: The interprofessional team’s role in end of life care provides a unique opportunity for an educational simulation. Novel ways to teach this content to a large number of students were needed. This research evaluated a palliative care interprofessional educational activity for healthcare students from six disciplines using an in-person movie/discussion format. Methods: Healthcare provider assessment visits and a death scene were pilot tested in actual simulations using twenty four students with standardized patients portraying a patient with ALS and his husband. Scripts were written from recordings of these simulations and were used in the dialogue of the movie which had standardized patient actors playing the patient, husband, sister and the student healthcare providers. The movie portrayed a patient with ALS and his husband in five scenes: assessment of patient and family needs by nursing, physical therapy, social work and speech language pathology; and a death scene. The movie was then edited to be used for discussion by large student groups. An evaluation survey was developed with 14 questions scored on a Likert scale and related to Interprofessional Competency Domains of 1. Values/Ethics, 2. Roles/Responsibilities, 3. Interprofessional communication, and 4. Teams/teamwork. These competencies provided a structure for the evaluation questions, and a review by faculty in each discipline also provided content validity. Reliability of the survey instrument was not tested or established. Graduate nurse practitioner, medical, communication sciences and disorders, social work and physical therapy students as well as undergraduate nursing students participated together in end of life movie discussions in four sessions held in a classroom equipped with tables of six. Survey responses were compared across disciplines and across the four interprofessional competency domains using a Chi-square test and adjusting for multiple comparisons. Significant differences were established at p Results: Student evaluations of the end of life simulations were consistently positive. Eighty percent of the participants (n=162) strongly agreed that they recognize the necessity of utilizing a healthcare team when providing care for patients at the end of life. All participants agreed that they would continue to forge relationships with other healthcare professionals to improve care for elders. Physical therapy students were consistently had the most positive responses; however, significant differences were only observed in three of the 14 questions. There were no significant differences between disciplines across the four interprofessional competency domains. A summary of qualitative data from the open ended questions will be also be presented. Conclusion: Interprofessional end of life care can be simulated in a carefully planned activity. The value of the experience was expressed by all students. Nurse practitioner students valued being able to practice supervising a palliative care team and facilitating the team discussion. Other students appreciated a safe place to discuss how to care for a dying patient and their family. Regarding the evaluation, small sample sizes in some disciplines may have limited the ability to detect significant differences between groups. Production of a movie and the discussion of the different scenes helped lower the cost of the simulation and scale up the activity for use with large groups of students. Interprofessional education requires innovative pedagogy that must be evaluated and disseminated. Consistent evaluation of interprofessional practice competency domains must be included in all educational activities

Complete Genome Sequence of Serotype III Streptococcus agalactiae Sequence Type 17 Strain 874391.

Here we report the complete genome sequence of Streptococcus agalactiae strain 874391. This serotype III isolate is a member of the hypervirulent sequence type 17 (ST-17) lineage that causes a disproportionate number of cases of invasive disease in humans and mammals. A brief historical context of the strain is discussed

Adjuvant endocrine therapy for premenopausal women with early breast cancer

Adjuvant endocrine therapy is a pivotal component of treatment for premenopausal women with early-stage hormone receptor-positive breast cancer. Currently, the standard endocrine therapy for premenopausal women is tamoxifen; a role for ovarian suppression or ablation has also been identified. Uncertainty remains about the optimal use of endocrine therapy in this setting. The role of ovarian suppression with tamoxifen or aromatase inhibitor, the optimal duration of adjuvant endocrine therapy and the utility of biomarkers and pharmacogenetic studies to select therapy are questions worthy of further investigation

Increased S-nitrosylation and proteasomal degradation of caspase-3 during infection contribute to the persistence of adherent invasive escherichia coli (AIEC) in immune cells

Adherent invasive Escherichia coli (AIEC) have been implicated as a causative agent of Crohn's disease (CD) due to their isolation from the intestines of CD sufferers and their ability to persist in macrophages inducing granulomas. The rapid intracellular multiplication of AIEC sets it apart from other enteric pathogens such as Salmonella Typhimurium which after limited replication induce programmed cell death (PCD). Understanding the response of infected cells to the increased AIEC bacterial load and associated metabolic stress may offer insights into AIEC pathogenesis and its association with CD. Here we show that AIEC persistence within macrophages and dendritic cells is facilitated by increased proteasomal degradation of caspase-3. In addition S-nitrosylation of pro- and active forms of caspase-3, which can inhibit the enzymes activity, is increased in AIEC infected macrophages. This S-nitrosylated caspase-3 was seen to accumulate upon inhibition of the proteasome indicating an additional role for S-nitrosylation in inducing caspase-3 degradation in a manner independent of ubiquitination. In addition to the autophagic genetic defects that are linked to CD, this delay in apoptosis mediated in AIEC infected cells through increased degradation of caspase-3, may be an essential factor in its prolonged persistence in CD patients

Respiratory mechanics assessment for reverse-triggered breathing cycles using pressure reconstruction

Monitoring patient-specific respiratory mechanics can be used to guide mechanical ventilation (MV) therapy in critically ill patients. However, many patients can exhibit spontaneous breathing (SB) efforts during ventilator supported breaths, altering airway pressure waveforms and hindering model-based (or other) identification of the true, underlying respiratory mechanics necessary to guide MV. This study aims to accurately assess respiratory mechanics for breathing cycles masked by SB efforts. A cumulative pressure reconstruction method is used to ameliorate SB by identifying SB affected waveforms and reconstructing unaffected pressure waveforms for respiratory mechanics identification using a single-compartment model. Performance is compared to conventional identification without reconstruction, where identified values from reconstructed waveforms should be less variable. Results are validated with 9485 breaths affected by SB, including periods of muscle paralysis that eliminates SB, as a validation test set where reconstruction should have no effect. In this analysis, the patients are their own control, with versus without reconstruction, as assessed by breath-to-breath variation using the non-parametric coefficient of variation (CV) of respiratory mechanics. Pressure reconstruction successfully estimates more consistent respiratory mechanics. CV of estimated respiratory elastance is reduced up to 78% compared to conventional identification (p < 0.05). Pressure reconstruction is comparable (p > 0.05) to conventional identification during paralysis, and generally performs better as paralysis weakens, validating the algorithm’s purpose. Pressure reconstruction provides less-affected pressure waveforms, ameliorating the effect of SB, resulting in more accurate respiratory mechanics identification. Thus providing the opportunity to use respiratory mechanics to guide mechanical ventilation without additional muscle relaxants, simplifying clinical care and reducing risk

The host metabolite D-serine contributes to bacterial niche specificity through gene selection

Escherichia coli comprise a diverse array of both commensals and niche-specific pathotypes. The ability to cause disease results from both carriage of specific virulence factors and regulatory control of these via environmental stimuli. Moreover, host metabolites further refine the response of bacteria to their environment and can dramatically affect the outcome of the host–pathogen interaction. Here, we demonstrate that the host metabolite, D-serine, selectively affects gene expression in E. coli O157:H7. Transcriptomic profiling showed exposure to D-serine results in activation of the SOS response and suppresses expression of the Type 3 Secretion System (T3SS) used to attach to host cells. We also show that concurrent carriage of both the D-serine tolerance locus (dsdCXA) and the locus of enterocyte effacement pathogenicity island encoding a T3SS is extremely rare, a genotype that we attribute to an ‘evolutionary incompatibility’ between the two loci. This study demonstrates the importance of co-operation between both core and pathogenic genetic elements in defining niche specificity

Global dissemination of a multidrug resistant Escherichia coli clone.

Escherichia coli sequence type 131 (ST131) is a globally disseminated, multidrug resistant (MDR) clone responsible for a high proportion of urinary tract and bloodstream infections. The rapid emergence and successful spread of E. coli ST131 is strongly associated with several factors, including resistance to fluoroquinolones, high virulence gene content, the possession of the type 1 fimbriae FimH30 allele, and the production of the CTX-M-15 extended spectrum β-lactamase (ESBL). Here, we used genome sequencing to examine the molecular epidemiology of a collection of E. coli ST131 strains isolated from six distinct geographical locations across the world spanning 2000-2011. The global phylogeny of E. coli ST131, determined from whole-genome sequence data, revealed a single lineage of E. coli ST131 distinct from other extraintestinal E. coli strains within the B2 phylogroup. Three closely related E. coli ST131 sublineages were identified, with little association to geographic origin. The majority of single-nucleotide variants associated with each of the sublineages were due to recombination in regions adjacent to mobile genetic elements (MGEs). The most prevalent sublineage of ST131 strains was characterized by fluoroquinolone resistance, and a distinct virulence factor and MGE profile. Four different variants of the CTX-M ESBL-resistance gene were identified in our ST131 strains, with acquisition of CTX-M-15 representing a defining feature of a discrete but geographically dispersed ST131 sublineage. This study confirms the global dispersal of a single E. coli ST131 clone and demonstrates the role of MGEs and recombination in the evolution of this important MDR pathogen