Weak evidence, supplemented with common sense for reduction in postoperative pulmonary complications

A clinical decision report appraising: Kaminski PN, Forgiarini LA, Jr., Andrade CF. Early respiratory therapy reduces postoperative atelectasis in children undergoing lung resection. Respir Care. 2013;58(5):805-809. https://doi.org/10.4187/respcare.01870 for prevention of postoperative pulmonary complications following thoracic surgery for a patient who is not able to participate in incentive spirometry

Managing clinical uncertainty: an ethnographic study of the impact of critical care outreach on end‐of‐life transitions in ward‐based critically ill patients with a life‐limiting illness

© 2018 Crown copyright. Journal of Clinical Nursing © 2018 John Wiley & Sons LtdRapid response teams, such as critical care outreach teams, have prominent roles in managing end-of-life transitions in critical illness, often questioning appropriateness of treatment escalation. Clinical uncertainty presents clinicians with dilemmas in how and when to escalate or de-escalate treatment. Aims and objectives: To explore how critical care outreach team decision-making processes affect the management of transition points for critically ill, ward-based patients with a life-limiting illness. Methods: An ethnographic study across two hospitals observed transition points and decisions to de-escalate treatment, through the lens of critical care outreach. In-depth interviews were carried out to elucidate rationales for practices witnessed in observations. Detailed field notes were taken and placed in a descriptive account. Ethnographic data were analysed, categorised and organised into themes using thematic analysis. Findings: Data were collected over 74 weeks, encompassing 32 observation periods with 20 staff, totalling more than 150 hr. Ten formal staff interviews and 20 informal staff interviews were undertaken. Three main themes emerged: early decision-making and the role of critical care outreach; communicating end-of-life transitions; end-of-life care and the input of critical care outreach. Findings suggest there is a negotiation to achieve smooth transitions for individual patients, between critical care outreach, and parent or ward medical teams. This process of negotiation is subject to many factors that either hinder or facilitate timely transitions. Conclusions: Critical care outreach teams have an important role in shared decision-making. Associated emotional costs relate to conflict with parent medical teams, and working as lone practitioners. The cultural contexts in which teams work have a significant effect on their interactions and agency. Relevance to practice: There needs to be a cultural shift towards early and open discussion of treatment goals and limitations of medical treatment, particularly when facing serious illness. With training and competencies, outreach nurses are well placed to facilitate these discussions.Peer reviewe

Campylobacter jejuni bacteremia in the setting of pancytopenia

Introduction: Campylobacter species are a common infectious cause of acute diarrhea worldwide. Small gram-negative bacteria, Campylobacter species are commonly transmitted fecal-orally and frequently found nonpathogenically in the guts of animals including chickens, creating a risk for frequent animal-human transmission. Campylobacter jejuni, one of the most important Campylobacter species for human health, typically produces a watery or inflammatory diarrhea. It is common in developing countries and outbreaks are often linked to contaminated water, unpasteurized milk, undercooked poultry, and contact with animals or infected persons. C. jejuni is a fastidious, gram-negative spiral-shaped rod which is best detected by culture but can also be seen on microscopic examination of a stool sample of a symptomatic patient with enteritis. Microscopy typically also reveals red blood cells or neutrophils. Culture is usually performed using a selective agar with sheep blood, vancomycin, amphotericin B, cephalothin, polymyxin B, and trimethoprim, incubated at 42 degrees with 5-10% oxygen, 1-10% carbon dioxide, and some hydrogen. C. jejuni typically presents in adults with diarrhea, commonly associated with abdominal pain and a high fever. The diarrhea is usually watery but frequently becomes bloody. Symptoms usually peak for 24-48 hours before gradually resolving, but some cases can last up to a week. While antibiotics are not typically necessary, as the course is short, they are commonly used in more severe or prolonged cases or in cases where the patient has immunosuppression or immunodeficiency. Infection can spread to contiguous organs, including the pancreas or gallbladder, and bacteremia can lead to seeding of distant organs, though bacteremia is rare and usually occurs only in immunocompromised patients. Complications of infection can include Guillain-Barre syndrome, reactive arthritis, and spontaneous abortion. Case description: Our patient is a 57-year-old woman with a past medical history of decompensated NASH cirrhosis and type II diabetes mellitus currently undergoing workup for a pancytopenia who presented to our emergency department with low-grade fever two days after bone marrow biopsy. She was found to have a two-day history of explosive watery yellow stool without any nausea, vomiting, or abdominal discomfort. Her temperature was 38.1 degrees Celsius with an increase in white blood cells to 4,000 from her baseline of 3,000, with minor increases in creatinine and liver enzymes stable as per her baseline. On CT, she had mild duodenitis. Influenza and Clostridium difficile workup were negative. Stool and blood cultures were taken and she was started on IV vancomycin and cefepime for her neutropenic fever. Stool culture came back positive for C. jejuni and blood cultures later came back positive for the same, demonstrating curved gram-negative bacteria. Due to her neutropenia and her existing once-weekly ciprofloxacin dosing for spontaneous bacterial peritonitis prophylaxis, she was treated azithromycin for a total of 7 days. During her inpatient stay, her bone marrow biopsy also came back and appeared normal. She was discharged to follow up on the pancytopenia with her usual doctors, continuing her SBP prophylaxis and counseled on common complications of C. jejuni. Discussion: Bacteremia is an uncommon consequence of C. jejuni enteritis, though it is also likely underreported due to difficulty in culturing and lack of indication in many patients. Risk of bacteremia increases with immunocompromise, but patients who are not immunocompromised may also be affected. C. jejuni can evade host defenses with several virulence factors, including flagella, cytotoxin, and serum resistance. Risk is also increased with old age and male gender, as well. While most cases may go unnoticed due to the short, self-limiting course of the diarrheal illness, an increased suspicion in patients with immunocompromise may be warranted.https://scholarlycommons.henryford.com/merf2020caserpt/1128/thumbnail.jp

Modeling Urban Form in City Simulations

One way of planning for a region's future transportation infrastructure and capacity needs is to forecast travel demand. Integrated land use-transportation modeling tools do this in a way that is sensitive to how the performance of a transportation system affects peoples' decisions of where to live and firms' decisions of where to locate. As such, they are helpful tools for analyzing different transportation and land use policy scenarios. The transportation system is a factor in how new urban areas develop. Policies attempt to regulate dispersed urban development, known as urban sprawl, however integrated modeling frameworks can only evaluate those policies that affect the extent of non-urban land legislated as developable, or those within urban areas. Incorporating other policies relating to sprawl into integrated models is limited by their ability to represent geometric changes to the landscape; those associated with the transition of non-urban land to residential use. Building on current methods for representing geometric landscape changes, this thesis is about models and algorithms for representing the specific forms these changes can take. There are a number of algorithms, taking distinct approaches to subdividing blocks into parcels and generating roads, suggesting different algorithms are better for generating different forms. There is little guidance on when to use which algorithm, potentially resulting in sub-optimal geometric representation of future urban areas. This thesis outlines a process for representing the spatial distribution of urban form in future urban areas within integrated models. To this end, it has estimated a model for predicting the spatial distribution of road network patterns in future residential neighborhoods and identified the block subdivision algorithm most suited to subdividing each of the possible road network patterns. Results can serve as guidelines for deciding which algorithms to use on which road network types. They also present a possible way of estimating the type of future road network in a local area as a function of slope of terrain, period of development, proximity to a river and adjacency to a road network of the same type, among others. This knowledge could help improve the accuracy of population predictions and potentially be implemented within the modeling process of integrated models once these are better able to represent geometric changes to the landscape

Does cancer research focus on areas of importance to patients?

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.The majority of research ideas are proposed by clinicians or scientists and little is currently known about which areas of research patients feel are important. We performed a 4 week pilot patient survey at the Royal Marsden (a specialist cancer centre) to investigate patients' views on priorities for cancer research. A total of 780 patients completed the survey and the top research priorities were identified as: detection and prevention of cancer, scientific understanding, curative treatment and personalised treatment. The top research priorities were remarkably consistent across age, gender and a variety of tumour types. We believe that patients' views should be considered alongside those of clinicians and researchers when devising research proposals and strategies.Peer reviewedFinal Published versio

Actin–myosin network reorganization breaks symmetry at the cell rear to spontaneously initiate polarized cell motility

We have analyzed the spontaneous symmetry breaking and initiation of actin-based motility in keratocytes (fish epithelial cells). In stationary keratocytes, the actin network flow was inwards and radially symmetric. Immediately before motility initiation, the actin network flow increased at the prospective cell rear and reoriented in the perinuclear region, aligning with the prospective axis of movement. Changes in actin network flow at the cell front were detectable only after cell polarization. Inhibition of myosin II or Rho kinase disrupted actin network organization and flow in the perinuclear region and decreased the motility initiation frequency, whereas increasing myosin II activity with calyculin A increased the motility initiation frequency. Local stimulation of myosin activity in stationary cells by the local application of calyculin A induced directed motility initiation away from the site of stimulation. Together, these results indicate that large-scale actin–myosin network reorganization and contractility at the cell rear initiate spontaneous symmetry breaking and polarized motility of keratocytes

Hepatitis B Therapy in Pregnancy

All decisions about initiating, continuing, or stopping therapy of the hepatitis B virus (HBV) during pregnancy must include an analysis of the risks and benefits for mother and fetus. The trimester of the pregnancy and the stage of the mother’s liver disease are important factors. Treatment in the third trimester may be initiated to aid in preventing perinatal transmission, which appears to be most pronounced in mothers with high viral loads. Consideration of initiating treatment in the third trimester should occur after a high viral load is documented in the latter part of the second trimester, to allow adequate time for initiation of antiviral therapy with significant viral suppression before delivery. This discussion should include the topic of breastfeeding, because it is generally not recommended while receiving antiviral therapy. Currently, lamivudine and tenofovir appear to be the therapeutic options with the most reasonable safety data in pregnancy

Differential Regulation of Adhesion Complex Turnover by ROCK1 and ROCK2

ROCK1 and ROCK2 are serine/threonine kinases that function downstream of the small GTP-binding protein RhoA. Rho signalling via ROCK regulates a number of cellular functions including organisation of the actin cytoskeleton, cell adhesion and cell migration.In this study we use RNAi to specifically knockdown ROCK1 and ROCK2 and analyse their role in assembly of adhesion complexes in human epidermal keratinocytes. We observe that loss of ROCK1 inhibits signalling via focal adhesion kinase resulting in a failure of immature adhesion complexes to form mature stable focal adhesions. In contrast, loss of ROCK2 expression results in a significant reduction in adhesion complex turnover leading to formation of large, stable focal adhesions. Interestingly, loss of either ROCK1 or ROCK2 expression significantly impairs cell migration indicating both ROCK isoforms are required for normal keratinocyte migration.ROCK1 and ROCK2 have distinct and separate roles in adhesion complex assembly and turnover in human epidermal keratinocytes

Beliefs About Medication and Uptake of Preventive Therapy in Women at Increased Risk of Breast Cancer: Results From a Multicenter Prospective Study

Introduction Uptake of preventive therapies for breast cancer is low. We examined whether women at increased risk of breast cancer can be categorized into groups with similar medication beliefs, and whether belief group membership was prospectively associated with uptake of preventive therapy. Patients and Methods Women (n = 732) attending an appointment to discuss breast cancer risk were approached; 408 (55.7%) completed the Beliefs About Medicines and the Perceived Sensitivity to Medicines questionnaires. Uptake of tamoxifen at 3 months was reported in 258 (63.2%). The optimal number of belief groups were identified using latent profile analysis. Results Uptake of tamoxifen was 14.7% (38/258). One in 5 women (19.4%; 78/402) reported a strong need for tamoxifen. The model fit statistics supported a 2-group model. Both groups held weak beliefs about their need for tamoxifen for current and future health. Group 2 (38%; 154/406 of the sample) reported stronger concerns about tamoxifen and medicines in general, and stronger perceived sensitivity to the negative effects of medicines compared with group 1 (62%; 252/406). Women with low necessity and lower concerns (group 1) were more likely to initiate tamoxifen (18.3%; 33/180) than those with low necessity and higher concerns (group 2) (6.4%; 5/78). After adjusting for demographic and clinical factors, the odds ratio was 3.37 (95% confidence interval, 1.08-10.51; P = .036). Conclusion Uptake of breast cancer preventive therapy was low. A subgroup of women reported low need for preventive therapy and strong medication concerns. These women were less likely to initiate tamoxifen. Medication beliefs are targets for supporting informed decision-making