Analysis of Factors and Medical Errors Involved in Patient Complaints in a European Emergency Department

Introduction: Patients’ complaints from Emergency Departments (ED) are frequent and can be used as a quality assurance indicator. Objective: Factors contributing to patients’ complaints (PCs) in the emergency department were analyzed.  Methods: It was a retrospective cohort study, the qualitative variables of patients’ complaints visiting ED of a university hospital were compared with Chi-Square and t test tests. Results: Eighty-five PC were analyzed. The factors contributing to PC were: communication (n=26), length of stay (LOS) (n=24), diagnostic errors (n=21), comfort and privacy issues (n=7), pain management (n=6), inappropriate treatment (n=6), delay of care and billing issues (n=3). PCs were more frequent when patients were managed by residents, during night shifts, weekends, Saturdays, Mondays, January and June. Moreover, the factors contributing to diagnostic errors were due to poor communication, non-adherence to guidelines and lack of systematic proofreading of X-rays. In 98% of cases, disputes were resolved by apology and explanation and three cases resulted in financial compensation. Conclusion: Poor communication, LOS and medical errors are factors contributing to PCs. Improving communication, resolving issues leading to slow health care provision, adequate staffing and supervision of trainees may reduce PCs

Rôle de la niche mésenchymateuse dans la régulation du phénotype SP des progéniteurs hématopoïétiques humains

L hématopoïèse est un processus finement régulé pour permettre sa pérennité et son adaptation aux contraintes physiologiques et pathologiques. Ce potentiel repose en grande partie sur les capacités de quiescence, auto-renouvellement, division asymétrique et multipotence des cellules souches hématopoïétiques (CSH). Les CSH et progéniteurs hématopoïétiques (CSPH) sont principalement régulés de façon extrinsèque au sein des niches hématopoïétiques médullaires et cette régulation fait intervenir, des contacts intercellulaires et des facteurs diffusibles. Le phénotype side-population (SP), secondaire à l efflux actif d un colorant fluorescent (Hoechst 33342) par des pompes de type multidrugresistance, est une caractéristique des cellules souches de la plupart des tissus. Au sein de l hématopoïèse, le phénotype SP est un excellent moyen pour identifier les CSH murines et est associé à leur quiescence et à leur adhésion à la niche endostéale, mais sa valeur comme marqueur des CSH est plus discutée chez l homme. Les cellules SP, de par leur nature, sont également étudiées en oncologie, et sont associées aux cellules tumorales les plus résistantes et les plus tumorogènes. La compréhension des mécanismes régulant la fonctionnalité SP devrait permettre d ouvrir des pistes en physiologie quand à la compréhension de la régulation des CSPH par les niches mésenchymateuses et en pathologie pour cibler les mécanismes de chimiorésistance.Dans ce travail nous montrons pour la première fois chez l homme que l acquisition du phénotype SP est un phénomène dynamique et versatile sous le contrôle du stroma médullaire. Le stroma médullaire est en effet capable de maintenir le phénotype SP de CSPH médullaires et d induire le phénotype SP de CSPH circulants. L acquisition du phénotype SP par les cellules circulantes nécessite à la fois un nichage au sein du stroma et des facteurs diffusibles. Les cellules circulantes capables d acquérir le phénotype SP contiennent des CSPH au regard de (i) leur expression du CD34, (ii) leur richesse en cellules quiescentes, (iii) leur capacité clonogénique et proliférative en cultures secondaires, (iv) leur expression des gènes de nichage et de souchitude , (v) leur capacité de migration en réponse à un gradient de CXCL12, (vi) leur activité LT-SRC in vivo. De plus nous avons mis en évidence, au sein de ces CSPH SP+CD34+ révélés par le stroma médullaire, une sous-population CD44-/faible qui pourrait contenir les cellules plus immatures en raison de sa quiescence et de l intensité de son efflux du Hoechst 33342. Les études mécanistiques montrent que l acquisition du phénotype SP par les cellules circulantes est sous la dépendance de l intégrine VLA-4 et du CD44. La transduction du signal implique des protéines G et la famille des Src-kinases. Nous montrons également que le stroma médullaire peut induire/maintenir/amplifier la fonctionnalité SP de blastes circulants de leucémie aigüe myéloblastique de façon ß1-intégrine dépendante et que cette fonctionnalité est associée à une capacité d efflux de Mitoxantrone. Ce mécanisme de modulation de l activité d ABC-transporteurs par l adhésion au stroma correspond à un mécanisme encore jamais décrit de CAM-DR.Hematopoiesis is a finely tuned process to allow its long-term efficiency and its adaptation to various physiological and pathological stresses. Hematopoietic stem cell (HSC) is the keystone of hematopoiesis through its multipotency, quiescence, asymmetrical division and self-renewing properties. HSC bone marrow (BM) niches mainly regulate hematopoietic stem and progenitor cells (HSPC) through intercellular contacts and diffusible factors. Side-population (SP) cells are characterized by their capability to actively efflux Hoechst 33342 dye through multidrug resistance-like pumps. SP phenotype is a characteristic of stem cells in many tissues and especially, it is a stringent criterion to purify murine HSCs. In mice, this phenotype has been demonstrated to be related to quiescence and resistance to drugs/environmental stresses and to be controlled by endosteal niche adhesion. SP cells are also studied in oncology and are associated to chemo-resistance and tumor initiating capacity. At steady state, SP cells are mainly present in the BM and are mostly absent from the circulation except in stress conditions, raising the hypothesis of the versatility of the SP functionality. Therefore, studying SP phenotype regulation is of importance to understand how BM niches regulate HSPC and how to interfere with cancer cells chemo-resistance.In this work, we demonstrate for the first time and in human that SP phenotype acquisition is a dynamic phenomenon under control of stromal BM cells. Stromal cells from healthy donors maintain SP phenotype of BM HSPC and promote SP phenotype acquisition in circulating ones. SP phenotype promotion depends of stroma nesting and of diffusible factors secretion. This stroma-induced circulating SP cell fraction contains HSPC, as ascertained by (i) CD34 expression, (ii) proportion of cells in G0, (iii) clonogenic and proliferative potential, (iv) nesting and stemness gene expression, (v) CXCL12-related migration capability and (vi) LT-SRC activity. Moreover, we describe an SP+CD34+CD44-/low sub-population that could contain most immature HSPCs with regards to their quiescence and Hoechst efflux intensity. Mechanistic studies show that the stoma-mediated SP promoting effect is VLA-4/ 4ß1-integrin and CD44 dependent, and implicate G-protein and Src-kinase pathways. We also demonstrate that BM stroma from healthy donors can induce/maintain/amplify in a ß1-integrin dependent manner an SP sub-population with mitoxantrone efflux capability in blast cells from acute myeloid leukemia. The existence of a similar mechanism in circulating leukemic blasts suggests the possibility to interfere with the chemo-resistant phenotype of blast cells through integrin/CD44 axis blockade.PARIS11-SCD-Bib. électronique (914719901) / SudocSudocFranceF

Protein kinase B controls transcriptional programs that direct cytotoxic T cell fate but is dispensable for T cell metabolism

SummaryIn cytotoxic T cells (CTL), Akt, also known as protein kinase B, is activated by the T cell antigen receptor (TCR) and the cytokine interleukin 2 (IL-2). Akt can control cell metabolism in many cell types but whether this role is important for CTL function has not been determined. Here we have shown that Akt does not mediate IL-2- or TCR-induced cell metabolic responses; rather, this role is assumed by other Akt-related kinases. There is, however, a nonredundant role for sustained and strong activation of Akt in CTL to coordinate the TCR- and IL-2-induced transcriptional programs that control expression of key cytolytic effector molecules, adhesion molecules, and cytokine and chemokine receptors that distinguish effector versus memory and naive T cells. Akt is thus dispensable for metabolism, but the strength and duration of Akt activity dictates the CTL transcriptional program and determines CTL fate

Phosphoinositide-dependent kinase 1 controls migration and malignant transformation but not cell growth and proliferation in PTEN-null lymphocytes

In normal T cell progenitors, phosphoinositide-dependent kinase l (PDK1)–mediated phosphorylation and activation of protein kinase B (PKB) is essential for the phosphorylation and inactivation of Foxo family transcription factors, and also controls T cell growth and proliferation. The current study has characterized the role of PDK1 in the pathology caused by deletion of the tumor suppressor phosphatase and tensin homologue deleted on chromosome 10 (PTEN). PDK1 is shown to be essential for lymphomagenesis caused by deletion of PTEN in T cell progenitors. However, PTEN deletion bypasses the normal PDK1-controlled signaling pathways that determine thymocyte growth and proliferation. PDK1 does have important functions in PTEN-null thymocytes, notably to control the PKB–Foxo signaling axis and to direct the repertoire of adhesion and chemokine receptors expressed by PTEN-null T cells. The results thus provide two novel insights concerning pathological signaling caused by PTEN loss in lymphocytes. First, PTEN deletion bypasses the normal PDK1-controlled metabolic checkpoints that determine cell growth and proliferation. Second, PDK1 determines the cohort of chemokine and adhesion receptors expressed by PTEN-null cells, thereby controlling their migratory capacity

Annealing-free Si3N4 frequency combs for monolithic integration with Si photonics

International audienceSilicon-nitride-on-insulator (SiNOI) is an attractive platform for optical frequency comb generation in the telecommunication band because of the low two-photon absorption and free carrier induced nonlinear loss when compared with crystalline silicon. However, the high-temperature annealing that has been used so far for demonstrating Si3N4-based frequency combs made the co-integration with silicon-based optoelectronics elusive, thus reducing dramatically its effective complementary metal oxide semiconductor (CMOS) compatibility. We report here on the fabrication and testing of annealing-free SiNOI nonlinear photonic circuits. In particular, we have developed a process to fabricate low-loss, annealing-free, and crack-free Si3N4 740-nm-thick films for Kerr-based nonlinear photonics featuring a full process compatibility with front-end silicon photonics. Experimental evidence shows that micro-resonators using such annealing-free silicon nitride films are capable of generating a frequency comb spanning 1300-2100 nm via optical parametrical oscillation based on four-wave mixing. This work constitutes a decisive step toward time-stable power-efficient Kerr-based broadband sources featuring full process compatibility with Si photonic integrated circuits (Si-PICs) on CMOS-.lines

Stepwise Optimization of the Procedure for Assessment of Circulating Progenitor Cells in Patients with Myocardial Infarction

The number and functional activity of circulating progenitor cells (CPCs) is altered in diabetic patients. Furthermore, reduced CPC count has been shown to independently predict cardiovascular events. Validation of CPCs as a biomarker for cardiovascular risk stratification requires rigorous methodology. Before a standard operation protocol (SOP) can be designed for such a trial, a variety of technical issues have to be addressed fundamentally, which include the appropriate type of red blood cell lysis buffer, FMO or isotype controls to identify rare cell populations from background noise, optimal antibody dilutions and conditions of sample storage. We herein propose improvements in critical steps of CPC isolation, antigenic characterization and determination of functional competence for final application in a prospective investigation of CPCs as a biomarker of outcome following acute myocardial infarction.In this validation study, we refined the standard operating procedure (SOP) for flow cytometry characterisation and functional analysis of CPCs from the first 18 patients of the Progenitor Cell Response after Myocardial Infarction Study (ProMIS). ProMIS aims to verify the prognostic value of CPCs in patients with either ST elevation or non-ST elevation myocardial infarction with or without diabetes mellitus, using cardiac magnetic resonance imaging (MRI) for assessment of ventricular function as a primary endpoint. Results indicate crucial steps for SOP implementation, namely timely cell isolation after sampling, use of appropriate lysis buffer to separate blood cell types and minimize the acquisition events during flow cytometry, adoption of proper fluorophore combination and antibody titration for multiple antigenic detection and introduction of counting beads for precise quantification of functional CPC activity in migration assay.With systematic specification of factors influencing the enumeration of CPC by flow cytometry, the abundance and migration capacity of CPCs can be correctly assessed. Adoption of validated SOP is essential for refined comparison of patients with different comorbidities in the analysis of risk stratification

Probiotic modulation of dendritic cell function is influenced by ageing

Dendritic cells (DCs) are critical for the generation of T-cell responses. DC function may be modulated by probiotics, which confer health benefits in immunocompromised individuals, such as the elderly. This study investigated the effects of four probiotics, Bifidobacterium longum bv. infantis CCUG 52486, B. longum SP 07/3, L. rhamnosus GG (L.GG) and L. casei Shirota (LcS) on DC function in an allogeneic mixed leucocyte reaction (MLR) model, using DCs and T-cells from young and older donors in different combinations. All four probiotics enhanced expression of CD40, CD80 and CCR7 on both young and older DCs, but enhanced cytokine production (TGF-β, TNF-α) by old DCs only. LcS induced IL-12 and IFNγ production by DC to a greater degree than other strains, while Bifidobacterium longum bv. infantis CCUG 52486 favoured IL-10 production. Stimulation of young T cells in an allogeneic MLR with DC was enhanced by probiotic pretreatment of old DCs, which demonstrated greater activation (CD25) than untreated controls. However, pretreatment of young or old DCs with LPS or probiotics failed to enhance the proliferation of T-cells derived from older donors. In conclusion, this study demonstrates that ageing increases the responsiveness of DCs to probiotics, but this is not sufficient to overcome the impact of immunosenescence in the MLR